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Chest Pain Severity Rating Is a Poor Predictive Tool in the Diagnosis of ST-Segment Elevation Myocardial Infarction. Crit Pathw Cardiol 2021; 20:88-92. [PMID: 32947377 DOI: 10.1097/hpc.0000000000000241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Current ST-segment elevation myocardial infarction (STEMI) guidelines require persistent electrocardiogram ST-segment elevation, cardiac enzyme changes, and symptoms of myocardial ischemia. Chest pain is the determinant symptom, often measured using an 11-point scale (0-10). Greater severity of chest pain is presumed to be associated with a stronger likelihood of a true positive STEMI diagnosis. This retrospective observational cohort study considered consecutive STEMI patients from May 02, 2009 to December 31, 2018. Analysis of standard STEMI metrics included positive electrocardiogram-to-device and first medical contact-to-device times, presence of comorbidities, false-positive diagnosis, 30-day and 1-year mortality, and 30-day readmission. Chest pain severity was assessed upon admission to the primary percutaneous coronary intervention hospital. We analyzed 1409 STEMI activations (69% male, 66.3 years old ± 13.7 years). Of these, 251 (17.8%) had no obstructive lesion, consistent with false-positive STEMI. Four hundred sixty-six (33.1%) reported chest pain rating of 0 on admission, 378 (26.8%) reported mild pain (1-3), 300 (21.3%) moderate (4-6), and 265 (18.8%) severe (7-10). Patients presenting without chest pain had a significantly higher rate of false-positive STEMI diagnosis. Increasing chest pain severity was associated with decreased time from first medical contact to device, and decreased in-hospital, 30-day and 1-year mortality. Severity of chest pain on admission did not correlate to the likelihood of a true-positive STEMI diagnosis, although it was associated with improved patient prognosis, in the form of improved outcomes, and shorter times to reperfusion.
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Akgol Gur ST, Betos Kocak M, Kocak AO, Vural M, Akbas I, Dogruyol S, Kerget B, Cakir Z. Effectiveness of Modified HEART Score in Predicting Major Adverse Cardiac Events. Eurasian J Med 2021; 53:57-61. [PMID: 33716532 DOI: 10.5152/eurasianjmed.2021.20341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective The most important problem for emergency physicians in patients presenting with chest pain is deciding whether to discharge the patient or not. Therefore, many scoring systems have been developed to help with this decision making process. We aim to achieve a modified HEART value by combining the VAS value with the HEART score. Materials and Methods Data were collected on age, sex, duration of the symptoms, pain severity using a 10-point visual analog scale (VAS), and the presence of a major adverse cardiac event (MACE). The HEART score was calculated and modified (mHEART) by adding 1 point to the total HEART score for a VAS score of ≥7. Results During the study period, 4781 patients were admitted, and 293 participants were analyzed. Of the patients, 34(11.6%) experienced MACE within a month after the encounter. The mean VAS scores were 5.65±1.44. However, 77(26.3%) patients had VAS scores ≥7. Taking 3 as the threshold, 42(14.3%) patients had HEART scores of 4 and above, where 47(16.0%) had mHEART scores ≥4. The mHEART scoring demonstrated better test indicators than the HEART score. According to the HEART score, 6(2.3%) of the 251 patients predicted as negative would develop MACE, but this number decreased to 1(0.4%) in 246 using the mHEART score. Conclusion Although the HEART score performs reasonably well in discriminating patients who are MACE negative, it is possible to further improve the score by adding the VAS item. After validation by other studies, we would suggest modifying the HEART score by including the VAS item.
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Affiliation(s)
- Sultan Tuna Akgol Gur
- Department of Emergency Medicine, Ataturk University School of Medicine, Erzurum, Turkey
| | - Meryem Betos Kocak
- Department of Family Medicine, Sukrupasa Family Health Center, Erzurum, Turkey
| | - Abdullah Osman Kocak
- Department of Emergency Medicine, Ataturk University School of Medicine, Erzurum, Turkey
| | - Mert Vural
- Department of Emergency Medicine, Ataturk University School of Medicine, Erzurum, Turkey
| | - Ilker Akbas
- Department of Emergency Medicine, Bingol State Hospital, Bingol, Turkey
| | - Sinem Dogruyol
- Department of Emergency Medicine, Manisa Merkez Efendi State Hospital, Manisa, Turkey
| | - Bugra Kerget
- Department of Pulmonary Diseases, Ataturk University School of Medicine, Erzurum, Turkey
| | - Zeynep Cakir
- Department of Emergency Medicine, Ataturk University School of Medicine, Erzurum, Turkey
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Abstract
Introduction: Incidence of chest pain and discomfort varies in general population between 2 % and 5 %. Total prehospital delay involves two components: the time it takes for patients to recognise their symptoms as severe and seek medical attention, ie the decision-making time, and the time from seeking help to hospital admission, ie the transport time. Scope of the study was to analyse time loss in patients with chest pain hesitating to contact healthcare services, as well as distribution of acute myocardial infarction (AMI) and angina pectoris (AP) among them. Methods: Retrospective analysis of medical records of physicians working at the emergency medical services (EMS) Department of the City of Belgrade, Serbia, from 20 April 2006 to 22 July 2013 on a total of 5,310 completed field interventions. When placing a call to the EMS, 10.43 % of patients cited chest pain as a major symptom. After deducting all those ones who denied having the symptom on examination thereafter and those for whom there were no data, 349 patients remained, ie 6.57 % of the total number of calls available for analysis. Results: The average time between the onset of chest pain and the decision to call the EMS was 11.97 h, median 2 h and mode 1 h. Patient's minimum prehospital delay was 2 min and the maximum was 20 days. Most patients who experienced chest pain or discomfort waited less than an hour before calling the EMS. Most commonly diagnoses made for a symptom of chest pain were AMI and AP, ie AMI with 12.32 % of the total diagnoses, as well as the elevated arterial pressure. There were more female patients, with no difference found among the age groups. Conclusion: For the majority of patients with chest pain and discomfort presented in this paper the decision-making time was up to one hour, with cardiovascular causes being the at the top of the list.
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Wibring K, Herlitz J, Lingman M, Bång A. Symptom description in patients with chest pain-A qualitative analysis of emergency medical calls involving high-risk conditions. J Clin Nurs 2019; 28:2844-2857. [PMID: 30938902 DOI: 10.1111/jocn.14867] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/14/2019] [Accepted: 03/23/2019] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To explore the symptoms descriptions and situational information provided by patients during ongoing chest pain events caused by a high-risk condition. BACKGROUND Chest pain is a common symptom in patients contacting emergency dispatch centres. Only 15% of these patients are later classified as suffering from a high-risk condition. Prehospital personnel are largely dependent on symptom characteristics when trying to identify these patients. DESIGN Qualitative descriptive. METHODS Manifest content analysis of 56 emergency medical calls involving patients with chest pain was carried out. A stratified purposive sampling was used to obtain calls concerning patients with high-risk conditions. These calls were then listened to and transcribed. Thereafter, meaning units were identified and coded and finally categorised. Consolidated criteria for reporting qualitative studies guidelines have been applied. RESULTS A wide range of situational information and symptoms descriptions was found. Pain and affected breathing were dominating aspects, but other situational information and several other symptoms were also reported. The situational information and these symptoms were classified into seven categories: Pain narrative, Affected breathing, Bodily reactions, Time, Bodily whereabouts, Fear and concern and Situation management. The seven categories consisted of 17 subcategories. CONCLUSIONS Patients with chest pain caused by a high-risk condition present a wide range of symptoms which are described in a variety of ways. They describe different kinds of chest pain accompanied by pain from other parts of the body. Breathing difficulties and bodily reactions such as muscle weakness are also reported. The variety of symptoms and the absence of a typical symptomatology make risk stratification on the basis of symptoms alone difficult. RELEVANCE TO CLINICAL PRACTICE This study highlights the importance of an open mind when assessing patients with chest pain and the requirement of a decision support tool in order to improve risk stratification in these patients.
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Affiliation(s)
- Kristoffer Wibring
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.,Department of Ambulance and Prehospital Care, Region Halland, Sweden
| | - Johan Herlitz
- The Prehospital Research Center Western Sweden, University of Borås, Borås, Sweden
| | - Markus Lingman
- Halland Hospital, Region Halland, Sweden.,Department of Molecular and Clinical Medicine/Cardiology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Angela Bång
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
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Morphine and Ticagrelor Interaction in Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction: ATLANTIC-Morphine. Am J Cardiovasc Drugs 2019; 19:173-183. [PMID: 30353444 DOI: 10.1007/s40256-018-0305-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Morphine adversely impacts the action of oral adenosine diphosphate (ADP)-receptor blockers in ST-segment elevation myocardial infarction (STEMI) patients, and is possibly associated with differing patient characteristics. This retrospective analysis investigated whether interaction between morphine use and pre-percutaneous coronary intervention (pre-PCI) ST-segment elevation resolution in STEMI patients in the ATLANTIC study was associated with differences in patient characteristics and management. METHODS ATLANTIC was an international, multicenter, randomized study of treatment in the acute ambulance/hospital setting where STEMI patients received ticagrelor 180 mg ± morphine. Patient characteristics, cardiovascular history, risk factors, management, and outcomes were recorded. RESULTS Opioids (97.6% morphine) were used in 921 out of 1862 patients (49.5%). There were no significant differences in age, sex or cardiovascular history, but more morphine-treated patients had anterior myocardial infarction and left-main disease. Time from chest pain to electrocardiogram and ticagrelor loading was shorter with morphine (both p = 0.01) but not total ischemic time. Morphine-treated patients more frequently received glycoprotein IIb/IIIa inhibitors (p = 0.002), thromboaspiration and stent implantation (both p < 0.001). No significant difference between the two groups was found regarding pre-PCI ≥ 70% ST-segment elevation resolution, death, myocardial infarction, stroke, urgent revascularization and definitive acute stent thrombosis. More morphine-treated patients had an absence of pre-PCI Thrombolysis in Myocardial Infarction (TIMI) 3 flow (85.8% vs. 79.7%; p = 0.001) and more had TIMI major bleeding (1.1% vs. 0.1%; p = 0.02). CONCLUSIONS Morphine-treatment was associated with increased GP IIb/IIIa inhibitor use, less pre-PCI TIMI 3 flow, and more bleeding. Judicious morphine use is advised with non-opioid analgesics preferred for non-severe acute pain. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT01347580.
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Holmberg M, Andersson H, Winge K, Lundberg C, Karlsson T, Herlitz J, Wireklint Sundström B. Association between the reported intensity of an acute symptom at first prehospital assessment and the subsequent outcome: a study on patients with acute chest pain and presumed acute coronary syndrome. BMC Cardiovasc Disord 2018; 18:216. [PMID: 30486789 PMCID: PMC6260754 DOI: 10.1186/s12872-018-0957-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 11/16/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND To decrease the morbidity burden of cardiovascular disease and to avoid the development of potentially preventable complications, early assessment and treatment of acute coronary syndrome (ACS) are important. The aim of this study has therefore been to explore the possible association between patients' estimated intensity of chest pain when first seen by the ambulance crew in suspected ACS, and the subsequent outcome before and after arrival in hospital. METHODS Data was collected both prospectively and retrospectively. The inclusion criteria were chest pain raising suspicion of ACS and a reported intensity of pain ≥4 on the visual analogue scale. RESULTS All in all, 1603 patients were included in the study. Increased intensity of chest pain was related to: 1) more heart-related complications before hospital admission; 2) a higher proportion of heart failure, anxiety and chest pain after hospital admission; 3) a higher proportion of acute myocardial infarction and 4) a prolonged hospitalisation. However, there was no significant association with mortality neither in 30 days nor in three years. Adjustment for possible confounders including age, a history of smoking and heart failure showed similar results. CONCLUSION The estimated intensity of chest pain reported by the patients on admission by the ambulance team was associated with the risk of complications prior to hospital admission, heart failure, anxiety and chest pain after hospital admission, the final diagnosis and the number of days in hospital. TRIAL REGISTRATION ClinicalTrials.gov 151:2008/4564 Identifier: NCT00792181. Registred 17 November 2008 'retrospectively registered'.
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Affiliation(s)
- Mats Holmberg
- Department of Ambulance Service, Sörmland County Council, Eskilstuna, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Eskilstuna, Sweden
- PreHospen – Centre for Prehospital Research, University of Borås, Borås, Sweden
| | - Henrik Andersson
- PreHospen – Centre for Prehospital Research, University of Borås, Borås, Sweden
- Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Karin Winge
- Ambulance Department, South Älvsborgs Hospital, Borås, Sweden
| | | | - Thomas Karlsson
- Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johan Herlitz
- PreHospen – Centre for Prehospital Research, University of Borås, Borås, Sweden
- Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Birgitta Wireklint Sundström
- PreHospen – Centre for Prehospital Research, University of Borås, Borås, Sweden
- Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
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Joury AU, Hersi AS, Alfaleh H, Alhabib KF, Kashour TS. Baseline characteristics, management practices, and long-term outcomes among patients with first presentation acute myocardial infarction in the Second Gulf Registry of Acute Coronary Events (Gulf RACE-II). J Saudi Heart Assoc 2018; 30:233-239. [PMID: 29983497 PMCID: PMC6026399 DOI: 10.1016/j.jsha.2018.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/31/2018] [Accepted: 03/07/2018] [Indexed: 11/25/2022] Open
Abstract
Background and objectives Limited data are available highlighting the different clinical aspects of acute coronary syndrome (ACS) patients, especially in Gulf countries. In this study, we aimed to compare patients who presented with acute myocardial infarction (AMI) as the first presentation of patients who have a history of ACS in terms of initial presentation, medical history, laboratory findings, and overall mortality. Methods We used the Second Gulf Registry of Acute Coronary Events (Gulf RACE-II), which is a multinational observational study of 7930 ACS patients. Results Among all patients, 4723 (59.6%) patients presented with AMI. First presentation AMI patients were older (mean age, 55 years vs. 53 years; p < 0.001) and had lower risk factors than patients with a history of ACS. Higher laboratory readings of cardiac markers and all aspects of mortality were significantly higher among patients with first presentation AMI. After adjustments for baseline variables, congestive heart failure [odds ratio (OR) = 1.08; 95% confidence interval (CI), 0.73–1.57], reinfarction (OR = 1.16; 95% CI, 0.58–2.30), cardiogenic shock (OR = 1.51; 95% CI, 0.74–3.08), stroke (OR = 2.30; 95% CI, 0.29–17.99), and overall mortality (OR = 1.16; 95% CI = 0.74–1.83) were independent predictive factors for first presentation AMI. Conclusions First presentation AMI patients tend to be older and to have lower rates of risk factors. Adverse clinical outcomes such as congestive heart failure, reinfarction, cardiogenic shock, and stroke were higher among patients with first presentation AMI compared to patients with a history of ACS.
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Affiliation(s)
- Abdulaziz U. Joury
- King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi ArabiaaSaudi Arabia
- King Salman Heart Center, King Fahd Medical City, Riyadh, Saudi ArabiabSaudi Arabia
| | - Ahmed S. Hersi
- King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi ArabiaaSaudi Arabia
| | - Hussam Alfaleh
- King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi ArabiaaSaudi Arabia
| | - Khalid F. Alhabib
- King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi ArabiaaSaudi Arabia
| | - Tarek Seifaw Kashour
- King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi ArabiaaSaudi Arabia
- Corresponding author at: P.O. Box 7805, Riyadh 11472, Saudi Arabia.
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Nonnenmacher CL, Pires AUB, Moraes VM, Lucena ADF. Factors that influence care priority for chest pain patients using the manchester triage system. J Clin Nurs 2018; 27:e940-e950. [PMID: 28793384 DOI: 10.1111/jocn.14011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2017] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To analyse crucial factors for determining care priority for patients with acute myocardial infarction based on the Manchester Triage System. BACKGROUND Triage is the first potentially critical step in the care of myocardial infarction patients. However, there are still very few studies on the factors interfering in the lack of care priority for these patients, impacting their treatment and prognosis. DESIGN Retrospective cohort study with 217 patients in the emergency department of a Brazilian hospital. METHODS Data were collected from patients' records with a primary diagnosis of myocardial infarction, from March 2014-February 2015. Patients were divided into two groups for statistical analysis: high priority (immediate and very urgent) and low priority (urgent, standard and nonurgent). RESULTS Most of the patients were male, with a mean age of 62.1 years, with a prevalence of high blood pressure and smoking as risk factors. Lower care priority level was assigned to 116 (53.4%) patients. Sixty-four (29.5%) patients had ST-segment elevation acute myocardial infarction, and 29 (45.3%) of these patients were assigned lower care priority level. Coughing, abdominal pain, onset of symptoms over 24 hr ago and pain of mild to moderate intensity were clinical predictors associated with lower care priority level. Sweating and high blood pressure were associated with high care priority level. Lower care priority level was associated with increased door-to-electrocardiogram and door-to-troponin times. There was no significant difference between the two groups for door-to-needle and door-to-balloon times. CONCLUSIONS Most of the patients with myocardial infarction were classified as low care priority, showing triage failure either due to symptom variability or need for professional qualification in clinical data collection and interpretation. RELEVANCE TO CLINICAL PRACTICE The results may support clinical evaluation, bringing chest pain assessment into focus.
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Affiliation(s)
- Carine Lais Nonnenmacher
- Group of Study and Research on Nursing Care for Adults and Older Adults (GEPECADI-CNPq), Porto Alegre, RS, Brazil
| | - Ananda Ughini Bertoldo Pires
- Group of Study and Research on Nursing Care for Adults and Older Adults (GEPECADI-CNPq), Porto Alegre, RS, Brazil.,School of Nursing, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Vítor Monteiro Moraes
- Group of Study and Research on Nursing Care for Adults and Older Adults (GEPECADI-CNPq), Porto Alegre, RS, Brazil.,School of Nursing, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Amália de Fátima Lucena
- Group of Study and Research on Nursing Care for Adults and Older Adults (GEPECADI-CNPq), Porto Alegre, RS, Brazil.,School of Nursing, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Committee of Nursing Process, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
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Frisch A, Heidle KJ, Frisch SO, Ata A, Kramer B, Colleran C, Carlson JN. Factors associated with advanced cardiac care in prehospital chest pain patients. Am J Emerg Med 2017; 36:1182-1187. [PMID: 29217178 DOI: 10.1016/j.ajem.2017.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 11/15/2017] [Accepted: 12/01/2017] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Many patients transported by emergency medical services (EMS) may require advanced cardiac care but do not have ST-segment elevation (STEMI) on the initial prehospital EKG. We sought to identify factors associated with the need for advanced cardiac care in undifferentiated EMS patients reporting chest pain in the absence of STEMI on EKG. METHODS We performed a retrospective analysis of all adult patients, reporting atraumatic chest pain from a single EMS agency, presenting to a single, urban hospital over a 10-year period. Patients with STEMI on prehospital electrocardiogram were excluded. Patient demographics, chest pain characteristics and prehospital factors were abstracted for all patients. We identified those patients that required advanced cardiac care and performed regression analysis to determine associated factors. RESULTS A total of 956 charts were analyzed. Of this total, 193 patients (20.2%) met the primary composite outcome. Of the outcome group, 185 patients (95.9%) had coronary artery disease documented on cardiac catheterization, 22 patients (11.4%) underwent CABG, and seven patients (3.6%) died in the hospital. Most significant variables (multivariable IRR) included age (1.02), male gender (1.65), history of MI (1.47), PCI (1.66), hyperlipidemia (1.40), diaphoresis (1.51), home aspirin (1.53), and improvement with EMS treatment (1.60). CONCLUSION We have identified several factors that could be considered when risk stratifying prehospital patients reporting chest pain. While potentially predictive, the factors are broad and support the need for other objective factors that could augment prediction of patients who may benefit from early advanced cardiac care.
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Affiliation(s)
- Adam Frisch
- UPMC, Department of Emergency Medicine, Pittsburgh, PA, United States.
| | - Kenneth J Heidle
- Allegheny Health Network, Department of Emergency Medicine, Erie, PA, United States.
| | - Stephanie O Frisch
- University of Pittsburgh School of Nursing, Pittsburgh, PA, United States.
| | - Ashar Ata
- Albany Medical Center, Department of Emergency Medicine, Albany, NY, United States.
| | - Brandon Kramer
- Allegheny Health Network, Department of Emergency Medicine, Erie, PA, United States.
| | - Caroline Colleran
- Allegheny Health Network, Department of Emergency Medicine, Erie, PA, United States.
| | - Jestin N Carlson
- Allegheny Health Network, Department of Emergency Medicine, Erie, PA, United States.
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Wibring K, Herlitz J, Christensson L, Lingman M, Bång A. Prehospital factors associated with an acute life-threatening condition in non-traumatic chest pain patients - A systematic review. Int J Cardiol 2016; 219:373-9. [PMID: 27352210 DOI: 10.1016/j.ijcard.2016.06.066] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/19/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chest pain is a common symptom among patients contacting the emergency medical services (EMS). Risk stratification of these patients is warranted before arrival in hospital, regarding likelihood of an acute life-threatening condition (LTC). AIM To identify factors associated with an increased risk of acute LTC among patients who call the EMS due to non-traumatic chest pain. METHODS Several databases were searched for relevant articles. Identified articles were quality-assessed using the Scottish Intercollegiate Guidelines Network checklists. Extracted data was analysed using a semi-quantitative synthesis evaluating the level of evidence of each identified factor. RESULTS In total, 10 of 1245 identified studies were included. These studies provided strong evidence for an increased risk of an acute LTC with increasing age, male gender, elevated heart rate, low systolic blood pressure and ST elevation or ST depression on a 12-lead ECG. The level of evidence regarding the history of myocardial infarction, angina pectoris or presence of a Q wave or a Left Bundle Branch Block on the ECG was moderate. The evidence was inconclusive regarding dyspnoea, cold sweat/paleness, nausea/vomiting, history of chronic heart failure, smoking, Right Bundle Branch Block or T-inversions on the ECG. CONCLUSIONS Factors reflecting age, gender, myocardial ischemia and a compromised cardiovascular system predicted an increased risk of an acute life-threatening condition in the prehospital setting in cases of acute chest pain. These factors may form the basis for prehospital risk stratification in acute chest pain.
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Affiliation(s)
- Kristoffer Wibring
- Department of Ambulance and Prehospital Care, Region Halland, Sweden; School of Health Sciences, Department of Nursing, Jönköping University, Jönköping, Sweden.
| | - Johan Herlitz
- The Pre-hospital Research Centre of Western Sweden, Prehospen, University College of Borås, Borås, Sweden
| | - Lennart Christensson
- School of Health Sciences, Department of Nursing, Jönköping University, Jönköping, Sweden
| | | | - Angela Bång
- The Pre-hospital Research Centre of Western Sweden, Prehospen, University College of Borås, Borås, Sweden
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Thomas SH, Mumma S, Satterwhite A, Haas T, Arthur AO, Todd KH, Mace S, Diercks DB, Pollack CV. Variation Between Physicians and Mid-level Providers in Opioid Treatment for Musculoskeletal Pain in the Emergency Department. J Emerg Med 2015; 49:415-23. [PMID: 26238183 DOI: 10.1016/j.jemermed.2015.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 05/25/2015] [Accepted: 05/31/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Effective, appropriate, and safe opioid analgesia administration in the Emergency Department (ED) is a complex issue, with risks of both over- and underutilization of medications. OBJECTIVE To assess for possible association between practitioner status (physician [MD] vs. mid-level provider [MLP]) and use of opioids for in-ED treatment of musculoskeletal pain (MSP). METHODS This was a secondary, hypothesis-generating analysis of a subset of subjects who had ED analgesia noted as part of entry into a prospective registry trial of outpatient analgesia. The study was conducted at 12 U.S. academic EDs, 10 of which utilized MLPs. Patients were enrolled as a convenience sample from September 2012 through February 2014. Study patients were adults (>17 years of age) with acute MSP and eligibility for both nonsteroidal antiinflammatory drugs and opioids at ED discharge. The intervention of interest was whether patients received opioid therapy in the ED prior to discharge. RESULTS MDs were significantly more likely to order opioids than MLPs for ED patients with MSP. The association between MD/MLP status and likelihood of treatment with opioids was similar in both classical logistic regression (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.1-4.5, p = 0.019) and in propensity-adjusted modeling (OR 2.1, 95% CI 1.0-4.5, p = 0.049). CONCLUSIONS In preliminary analysis, MD/MLP status was significantly associated with likelihood of provider treatment of MSP with opioids. A follow-up study is warranted to confirm the results of this hypothesis-testing analysis and to inform efforts toward consistency in opioid therapy in the ED.
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Affiliation(s)
- Stephen H Thomas
- Department of Emergency Medicine, University of Oklahoma College of Medicine, Tulsa, Oklahoma
| | - Shannon Mumma
- Department of Emergency Medicine, University of Oklahoma College of Medicine, Tulsa, Oklahoma
| | - Amanda Satterwhite
- Department of Emergency Medicine, University of Oklahoma College of Medicine, Tulsa, Oklahoma
| | - Tyler Haas
- Department of Emergency Medicine, University of Oklahoma College of Medicine, Tulsa, Oklahoma
| | - Annette O Arthur
- Department of Emergency Medicine, University of Oklahoma College of Medicine, Tulsa, Oklahoma
| | - Knox H Todd
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sharon Mace
- Department of Emergency Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Deborah B Diercks
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, California
| | - Charles V Pollack
- Department of Emergency Medicine, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania
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