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Trent SA, Allen LA, Regensteiner JG, Huebschmann AG. Toward Personalized and Equitable Chest Pain Pathways: Considerations Related to Sex and Gender Differences. J Womens Health (Larchmt) 2024. [PMID: 38607925 DOI: 10.1089/jwh.2024.0242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024] Open
Affiliation(s)
- Stacy A Trent
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Ludeman Family Center for Women's Health Research, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Judith G Regensteiner
- Ludeman Family Center for Women's Health Research, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Amy G Huebschmann
- Ludeman Family Center for Women's Health Research, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
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Ola O, Sandoval Y, Jaffe AS. The Reply. Am J Med 2024; 137:e78. [PMID: 38604723 DOI: 10.1016/j.amjmed.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 04/13/2024]
Affiliation(s)
- Olatunde Ola
- Department of Cardiovascular Diseases, Marshall University School of Medicine, Huntington, WVa, USA
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minneapolis, Minn, USA; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn, USA
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn, USA.
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Ho AFW, Yau CE, Ho JSY, Lim SH, Ibrahim I, Kuan WS, Ooi SBS, Chan MY, Sia CH, Mosterd A, Gijsberts CM, de Hoog VC, Bank IEM, Doevendans PA, de Kleijn DPV. Predictors of major adverse cardiac events among patients with chest pain and low HEART score in the emergency department. Int J Cardiol 2024; 395:131573. [PMID: 37931658 DOI: 10.1016/j.ijcard.2023.131573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/08/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023]
Abstract
AIM For patients who present to the emergency departments (ED) with undifferentiated chest pain, the risk of major adverse cardiac events (MACE) may be underestimated in low-HEART score patients. We aimed to identify characteristics of patients who were classified as low risk by HEART score but subsequently developed MACE at 6 weeks. METHODS We studied a multiethnic cohort of patients who presented with chest pain arousing suspicion of acute coronary syndrome to EDs in the Netherlands and Singapore. Patients were risk-stratified using HEART score and followed up for MACE at 6 weeks. Risk factors of developing MACE despite low HEART scores (scores 0-3) were identified using logistic and Cox regression models. RESULTS Among 1376 (39.8%) patients with low HEART scores, 63 (4.6%) developed MACE at 6 weeks. More males (53/806, 6.6%) than females (10/570, 2.8%) with low HEART score developed MACE. There was no difference in outcomes between ethnic groups. Among low-HEART score patients with 2 points for history, 21% developed MACE. Among low-HEART score patients with 1 point for troponin, 50% developed MACE, while 100% of those with 2 points for troponin developed MACE. After adjusting for HEART score and potential confounders, male sex was independently associated with increased odds (OR 4.12, 95%CI 2.14-8.78) and hazards (HR 3.93, 95%CI 1.98-7.79) of developing MACE despite low HEART score. CONCLUSION Male sex, highly suspicious history and elevated troponin were disproportionately associated with MACE. These characteristics should prompt clinicians to consider further investigation before discharge.
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Affiliation(s)
- Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore; Pre-hospital & Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore, Singapore; Centre for Population Health Research and Implementation, SingHealth Regional Health System, Singapore, Singapore.
| | - Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jamie Sin-Ying Ho
- Department of Cardiology, National University Hospital, Singapore, Singapore
| | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Irwani Ibrahim
- Emergency Medicine Department, National University Hospital, Singapore, Singapore
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, Singapore, Singapore
| | | | - Mark Y Chan
- Department of Cardiology, National University Hospital, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Hospital, Singapore, Singapore
| | - Arend Mosterd
- Department of Cardiology, Meander Medical Centre, Amersfoort, the Netherlands
| | - Crystel M Gijsberts
- Department of Experimental Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Vince C de Hoog
- Department of Experimental Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ingrid E M Bank
- Department of Experimental Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pieter A Doevendans
- Department of Experimental Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
| | - Dominique P V de Kleijn
- Department of Experimental Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
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Titus BR, Ream KS, Rehman T, Allen LA. Sex-disparities in chest pain workup: a retrospective cohort review of a university based clinical decision pathway. BMC Cardiovasc Disord 2023; 23:620. [PMID: 38114900 PMCID: PMC10729513 DOI: 10.1186/s12872-023-03610-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 11/13/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Females have historically lower rates of cardiovascular testing when compared to males. Clinical decision pathways (CDP) that utilize standardized risk-stratification methods may balance this disparity. We sought to determine whether clinical decision pathways could minimize sex-based differences in the non-invasive workup of chest pain in the emergency department (ED). Moreover, we evaluated whether the HEART score would minimize sex-based differences in risk-stratification. METHODS We conducted a retrospective cohort review of adult ED encounters for chest pain where CDP was employed. Primary outcome was any occurrence of non-invasive imaging (coronary CTA, stress imaging), invasive testing, intervention (PCI or CABG), or death. Secondary outcomes were 30-day major adverse cardiac events (MACE). We stratified HEART scores and primary/secondary outcomes by sex. RESULTS A total of 1078 charts met criteria for review. Mean age at presentation was 59 years. Females represented 47% of the population. Low, intermediate, and high-risk patients as determined by the HEART score were 17%, 65%, and 18% of the population, respectively, without any significant differences between males and females. Non-invasive testing was similar between males and females when stratified by risk. Males categorized as high risk underwent more coronary angiogram (33% vs. 16%, p = 0.01) and PCI (18% vs. 8%, p = 0.04) than high risk females, but this was not seen in patients categorized as low or intermediate risk. Males experienced more MACE than females (8% vs. 3%, p = 0.001). CONCLUSIONS We identified no sex-based differences in risk-stratification or non-invasive testing when the CDP was used. High risk males, however, underwent more coronary angiogram and PCI than high risk females, and consequently males experienced more overall MACE than females. This disparity may be explained by sex-based differences in the pathophysiology driving each patient's presentation.
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Affiliation(s)
- Benjamin R Titus
- Internal Medicine Residency, University of Colorado, Aurora, United States.
| | - Karen S Ream
- Division of Cardiology, University of Colorado, Aurora, United States
| | - Tehreem Rehman
- Department of Emergency Medicine, Mount Sinai Hospital, New York City, United States
| | - Larry A Allen
- Division of Cardiology, University of Colorado, Aurora, United States
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Aarts GWA, Camaro C, Rodwell L, Adang EMM, van Hout R, Brok G, Hoare A, de Pooter FPC, de Wit W, Cramer GE, van Kimmenade RRJ, Ouwendijk E, Rutten M, Zegers E, van Geuns RJM, Gomes MER, Damman P, van Royen N. Differences in risk and costs between prehospital identified low-risk men and women with chest pain. Open Heart 2023; 10:e002390. [PMID: 38011992 PMCID: PMC10685936 DOI: 10.1136/openhrt-2023-002390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/26/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVE Prehospital rule-out of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in low-risk patient with a point-of-care troponin measurement reduces healthcare costs with similar safety to standard transfer to the hospital. Risk stratification is performed identical for men and women, despite important differences in clinical presentation, risk factors and age between men and women with NSTE-ACS. Our aim was to compare safety and healthcare costs between men and women in prehospital identified low-risk patients with suspected NSTE-ACS. METHODS In the Acute Rule-out of non-ST-segment elevation acute coronary syndrome in the (pre)hospital setting by HEART (History, ECG, Age, Risk factors and Troponin) score assessment and a single poInt of CAre troponin randomised trial, the HEAR (History, ECG, Age and Risk factors) score was assessed by ambulance paramedics in suspected NSTE-ACS patients. Low-risk patients (HEAR score ≤3) were included. In this substudy, men and women were compared. Primary endpoint was 30-day major adverse cardiac events (MACE), secondary endpoints were 30-day healthcare costs and the scores for the HEAR score components. RESULTS A total of 863 patients were included, of which 495 (57.4%) were women. Follow-up was completed in all patients. In the total population, MACE occurred in 6.8% of the men and 1.6% of the women (risk ratio (RR) 4.2 (95% CI 1.9 to 9.2, p<0.001)). In patients with ruled-out ACS (97% of the total population), MACE occurred in 1.4% of the men and in 0.2% of the women (RR 7.0 (95% CI 2.0 to 14.2, p<0.001). Mean healthcare costs were €504.55 (95% CI €242.22 to €766.87, p<0.001) higher in men, mainly related to MACE. CONCLUSIONS In a prehospital population of low-risk suspected NSTE-ACS patients, 30-day incidence of MACE and MACE-related healthcare costs were significantly higher in men than in women. TRIAL REGISTRATION NUMBER NCT05466591.
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Affiliation(s)
| | - Cyril Camaro
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - Laura Rodwell
- Department for Health Evidence, Radboudumc Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Eddy M M Adang
- Department for Health Evidence, Radboudumc Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Roger van Hout
- Ambulance Service, Safety Region Gelderland-Zuid, Nijmegen, The Netherlands
| | - Gijs Brok
- Ambulance Service, Safety Region Gelderland-Zuid, Nijmegen, The Netherlands
| | - Anouk Hoare
- Ambulance Service, Witte Kruis, Houten, The Netherlands
| | - Frank P C de Pooter
- Ambulance Service Noord- en Oost-Gelderland, Witte Kruis, Elburg, The Netherlands
| | - Walter de Wit
- Ambulance Service Zeeland, Witte Kruis, Goes, The Netherlands
| | | | | | - Eva Ouwendijk
- General Practitioner Centre Nijmegen and Boxmeer, Nijmegen, The Netherlands
| | - Martijn Rutten
- General Practitioner Cooperative Noord-Limburg, Venlo, The Netherlands
| | - Erwin Zegers
- Department of Cardiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - Marc E R Gomes
- Department of Cardiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Peter Damman
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
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Thomas YT, Jarman AF, Faynshtayn NG, Buehler GB, Andrabi S, McGregor AJ. Achieving Equity in Emergency Medicine Quality Measures Requires a Sex and Gender Lens. J Emerg Med 2023; 65:e60-e65. [PMID: 37331918 PMCID: PMC10505242 DOI: 10.1016/j.jemermed.2023.03.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 03/07/2023] [Accepted: 03/11/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Quality measures within Emergency Medicine (EM) were developed to standardize and improve care. Their development has been limited by lack of consideration of sex- and gender-based differences. Research has suggested that sex and gender can impact clinical care and treatment. Inclusion of sex and gender differences is needed to create EM quality measures that are equitable to all. OBJECTIVE The aim of the review is to provide a brief history of EM quality measures and the value of considering sex- and gender-based evidence in their development to ensure equity, using acute myocardial infarction (AMI) as an example. DISCUSSION Current quality measures related to AMI, such as time-to-electrocardiogram and door-to-balloon time in percutaneous coronary intervention, may have important and modifiable disparities when stratified by sex. Even when presenting with signs and symptoms of AMI, women experience delayed time to diagnosis and treatment. Few studies have considered interventions to mitigate these differences. However, the data available suggest that sex-based disparities can be minimized by implementation of strategies such as a quality control checklist. CONCLUSIONS Quality measures were created to deliver high-quality, evidence-based, and standardized care, but without the inclusion of sex and gender metrics, they may not advance care to an equitable level.
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Affiliation(s)
- Ynhi T Thomas
- Henry J.N. Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas.
| | - Angela F Jarman
- Department of Emergency Medicine, University of California-Davis, Sacramento, California
| | | | - Greg B Buehler
- Henry J.N. Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Sara Andrabi
- Henry J.N. Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Alyson J McGregor
- Department of Emergency Medicine, Prisma Health, University of South Carolina School of Medicine Greenville, Greenville, South Carolina
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Akman G, Hökenek NM, Yusufoğlu K, Akman D, Haği O, Bayramoğlu B, Yavuz BG, Çolak Ş. T-MACS score vs HEART score identification of major adverse cardiac events in the emergency department. Am J Emerg Med 2023; 64:21-25. [PMID: 36435006 DOI: 10.1016/j.ajem.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/06/2022] [Accepted: 11/09/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Ischemic heart disease is the leading cause of mortality worldwide, and its prevalence is rising. OBJECTIVE The goal of this study was to evaluate the HEART and T-MACS scores for predicting major cardiac events (MACE) in patients presenting to the emergency department with chest pain. METHOD This study was single center and prospectively conducted. The demographic information, T-MACS and HEART scores of the participants were recorded and calculated. Acute myocardial infarction (AMI), mortality, and the need for coronary revascularization were considered as major adverse cardiac events (MACEs). The statistical analysis was carried out using SPSS (IBM Statistics, New York) version 24, and significance was determined at the p < 0.05 level. RESULTS The 514 patients included in our study had a mean age of 52.01 ± 19.10 years, with 55.3% were female and 44.7% was male. A total of 78(%15.1) cases were diagnosed with AMI. Fifty patients (%9.7) underwent percutaneous coronary intervention, 12 (%2.3) patients underwent coronary artery by-pass graft, and 8 (%1.5) patients died within a one-month period. The sensitivity and negative predictive values of the T-MACS score for the very low risk classification were 93.90% (86.3%-98.0%) and 97.7% (94.7%-99.0%), respectively, and the sensitivity and negative predictive values of the HEART score for the low risk classification were 89.59% (77.3%-93.1%) and 96.6% (94.2%-98.0%), respectively. The specificity and positive predictive values for the high risk classification were 99.77% (98.7%-100%) and 97.2% (82.9%-99.6%), respectively for the T-MACS score and 95.14% (92.7%-97%) and 63.2% (51.4%-73.5%), respectively for the HEART score. CONCLUSION The T-MACS score was shown to be more accurate than the HEART score in predicting low risk (very low risk for the T-MACS score), high risk, and anticipated one-month risk for MACE in patients coming to the emergency department with chest pain.
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Affiliation(s)
- Gürkan Akman
- Department of Emergency Medicine, University of Health Sciences, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Nihat Müjdat Hökenek
- Department of Emergency Medicine, University of Health Sciences, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey.
| | - Kaan Yusufoğlu
- Department of Emergency Medicine, University of Health Sciences, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Damla Akman
- Department of Anaesthesiology and Reanimation, Osmancık State Hospital, Çorum, Turkey
| | - Orhan Haği
- Department of Emergency Medicine, Sanliurfa Provincial Health Directorate, Sanliurfa Training and Research Hospital, Sanliurfa, Turkey
| | - Burcu Bayramoğlu
- Department of Emergency Medicine, University of Health Sciences, Sancaktepe Şehit Prof. Dr. İlhan Varank Training and Research Hospital, Istanbul, Turkey
| | - Burcu Genç Yavuz
- Department of Emergency Medicine, University of Health Sciences, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Şahin Çolak
- Department of Emergency Medicine, University of Health Sciences, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
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Kaur G, Chand S, Rai D, Baibhav B, Blankstein R, Mukherjee D, Levy P, Gulati M. Contemporary Risk Stratification of Acute Coronary Syndrome. US Cardiology Review 2022. [DOI: 10.15420/usc.2022.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Chest pain is one of the most common presenting concerns of patients seeking care in the emergency department, and the underlying etiology can range from acute coronary syndrome to various other non-cardiac causes. Initial evaluation should focus on characterizing symptoms and identifying risk factors, but further risk stratification using clinical decision pathways and biomarkers (cardiac troponin) is essential. The 2021 American Heart Association/American College of Cardiology guidelines for the evaluation and diagnosis of chest pain represent the first ever guidelines for the evaluation of patients with acute chest pain. The contemporary risk stratification methods described in these guidelines allow for the identification of patient subgroups: patients who do not require further testing, patients who should proceed directly to the cath lab, and patients who will benefit from further anatomic or functional testing. In this review, we describe contemporary risk stratification methods for acute coronary syndrome and summarize the recommendations put forth by the guidelines.
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Affiliation(s)
- Gurleen Kaur
- Department of Internal Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Swati Chand
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Devesh Rai
- Department of Cardiology, Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY
| | - Bipul Baibhav
- Department of Cardiology, Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY
| | - Ron Blankstein
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Texas Tech University Health Sciences Center at El Paso, El Paso, TX
| | - Phillip Levy
- Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - Martha Gulati
- Department of Cardiology, Barbra Streisand Women’s Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
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Appelman Y, Doevendans P. Applying the HEART score is safe and saves. Neth Heart J 2022. [PMID: 35788897 DOI: 10.1007/s12471-022-01710-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 10/26/2022] Open
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Gelber A, Drescher M, Shiber S. Sex Differences in Identifying Chest Pain as Being of Cardiac Origin Using the HEART Pathway in the Emergency Department. J Womens Health (Larchmt) 2022; 31:926-931. [PMID: 35501966 DOI: 10.1089/jwh.2021.0453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives: The HEART Pathway is a diagnostic protocol designed to identify low-risk patients with chest pain who can be safely discharged from the emergency department (ED) without hospitalization. Studies have reported a negative bias in identifying myocardial ischemia in females versus males and a different clinical pattern of cardiac ischemia across genders. This study sought to determine if the HEART Pathway recommendations are affected by negative bias in females. Design: A retrospective cohort study was conducted in the ED of an academic tertiary medical center. Admission/discharge decisions made by physicians in male and female patients presenting with chest pain in 4/2014-7/2019 were compared with HEART Pathway protocol predictions. Probabilities were estimated with logistic regression analysis, and odds ratios and 95% confidence intervals were calculated. Results: The cohort included 772 patients, 485 male (63%) and 287 female (37%), of median age 54 years. On the basis of their presenting symptoms, 278 patients (36%) were admitted by the ED physician and 494 (64%) were discharged. Using the HEART Pathway protocol, 227 patients (29.4%) would be expected to be admitted and 545 (70.6%) discharged. The real-life admission rate was higher than possible with the HEART Protocol (p = 0.001). In a regression model, male sex was a significant factor favoring admission among the patients for whom the HEART Pathway predicted admission (p = 0.007). Conclusions: As the HEART Pathway is a validated risk-stratification tool, there is a high likelihood that serious coronary artery disease may be overlooked in women, even those who seek timely medical assistance.
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Affiliation(s)
- Aviv Gelber
- Emergency Department, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
| | - Michael Drescher
- Emergency Department, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shachaf Shiber
- Emergency Department, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Candel BG, Dap S, Raven W, Lameijer H, Gaakeer MI, de Jonge E, de Groot B. Sex differences in clinical presentation and risk stratification in the Emergency Department: An observational multicenter cohort study. Eur J Intern Med 2022; 95:74-79. [PMID: 34521584 DOI: 10.1016/j.ejim.2021.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/02/2021] [Accepted: 09/05/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to investigate whether sex differences exist in disease presentations, disease severity and (case-mix adjusted) outcomes in the Emergency Department (ED). METHODS Observational multicenter cohort study using the Netherlands Emergency Department Evaluation Database (NEED), including patients ≥ 18 years of three Dutch EDs. Multivariable logistic regression was used to study the associations between sex and outcome measures in-hospital mortality and Intensive Care Unit/Medium Care Unit (ICU/MCU) admission in ED patients and in subgroups triage categories and presenting complaints. RESULTS Of 148,825 patients, 72,554 (48.8%) were females. Patient characteristics at ED presentation and diagnoses (such as pneumonia, cerebral infarction, and fractures) were comparable between sexes at ED presentation. In-hospital mortality was 2.2% in males and 1.7% in females. ICU/MCU admission was 4.7% in males and 3.1% in females. Males had higher unadjusted (OR 1.34(1.25-1.45)) and adjusted (AOR 1.34(1.24-1.46)) risks for mortality, and unadjusted (OR 1.54(1.46-1.63)) and adjusted (AOR 1.46(1.37-1.56)) risks for ICU/MCU admission. Males had higher adjusted mortality and ICU/MCU admission for all triage categories, and with almost all presenting complaints except for headache. CONCLUSIONS Although patient characteristics at ED presentation for both sexes are comparable, males are at higher unadjusted and adjusted risk for adverse outcomes. Males have higher risks in all triage categories and with almost all presenting complaints. Future studies should investigate reasons for higher risk in male ED patients.
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Affiliation(s)
- Bart Gj Candel
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands; Department of Emergency Medicine, Máxima Medical Center, De Run 4600, Veldhoven, DB 5504, the Netherlands.
| | - Saimi Dap
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Center Leeuwarden, Henri Dunantweg 2, Leeuwarden, AD 8934, the Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Adrz Hospital, 's-Gravenpolderseweg 114, Goes, RA 4462, the Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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Sagel D, Vlaar PJ, van Roosmalen R, Waardenburg I, Nieuwland W, Lettinga R, van Barneveld R, Jorna E, Kijlstra R, van Well C, Oomen A, Bartels L, Anthonio R, Hagens V, Hofma S, Gu Y, Drenth D, Addink R, van Asselt T, van der Meer P, Lipsic E, Juarez Orozco L, van der Harst P. Prehospital risk stratification in patients with chest pain. Emerg Med J 2021; 38:814-819. [PMID: 34373266 PMCID: PMC8551969 DOI: 10.1136/emermed-2020-210212] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/10/2021] [Indexed: 11/17/2022]
Abstract
Objectives The History, ECG, Age, Risk Factors and Troponin (HEART) Score is a decision support tool applied by physicians in the emergency department developed to risk stratify low-risk patients presenting with chest pain. We assessed the potential value of this tool in prehospital setting, when applied by emergency medical services (EMS), and derived and validated a tool adapted to the prehospital setting in order to determine if it could assist with decisions regarding conveyance to a hospital. Methods In 2017, EMS personnel prospectively determined the HEART Score, including point-of-care (POC) troponin measurements, in patients presenting with chest pain, in the north of the Netherlands. The primary endpoint was a major adverse cardiac event (MACE), consisting of acute myocardial infarction or death, within 3 days. The components of the HEART Score were evaluated for their discriminatory value, cut-offs were calibrated for the prehospital setting and sex was substituted for cardiac risk factors to develop a prehospital HEART (preHEART) Score. This score was validated in an independent prospective cohort of 435 patients in 2018. Results Among 1208 patients prospectively recruited in the first cohort, 123 patients (10.2%) developed a MACE. The HEART Score had a negative predictive value (NPV) of 98.4% (96.4–99.3), a positive predictive value (PPV) of 35.5% (31.8–39.3) and an area under the receiver operating characteristic curve (AUC) of 0.81 (0.78–0.85). The preHEART Score had an NPV of 99.3% (98.1–99.8), a PPV of 49.4% (42.0–56.9) and an AUC of 0.85 (0.82–0.88), outperforming the HEART Score or POC troponin measurements on their own. Similar results were found in a validation cohort. Conclusions The HEART Score can be used in the prehospital setting to assist with conveyance decisions and choice of hospitals; however, the preHEART Score outperforms both the HEART Score and single POC troponin measurements when applied by EMS personnel in the prehospital setting.
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Affiliation(s)
- Dennis Sagel
- Expirimental Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Pieter Jan Vlaar
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Ingmar Waardenburg
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wybe Nieuwland
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Roelof Lettinga
- Department of Anthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert van Barneveld
- Department of Emergency Medical Services, University Medical Center Groningen, Groningen, The Netherlands
| | - Edward Jorna
- Department of Anesthesiology, Hospital Nij Smellinghe, Drachten, The Netherlands
| | - Roelof Kijlstra
- Emergency Medical Services, Kijlstra ambulance zorg, Drachten, The Netherlands
| | - Carien van Well
- Emergency Medical Services, Kijlstra ambulance zorg, Drachten, The Netherlands
| | - Antoon Oomen
- Cardiology, Antonius Hospital Sneek, Sneek, The Netherlands
| | - Louis Bartels
- Department of Cardiology, Martini Ziekenhuis, Groningen, The Netherlands
| | - Rutger Anthonio
- Cardiology, Treant Zorggroep Locatie Scheper, Emmen, The Netherlands
| | - Vincent Hagens
- Department of Cardiology, Ommelander Hospital Groningen, Scheemda, The Netherlands
| | - Sjoerd Hofma
- Department of Cardiology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Youlan Gu
- Department of Cardiology, Hospital Nij Smellinghe, Drachten, The Netherlands
| | - Derk Drenth
- Avicenna General Practice Paterswolde, Paterswolde, The Netherlands
| | - Ryanne Addink
- Middelstum General Practice, Middelstum, The Netherlands
| | - Thea van Asselt
- Department of Epidemiolgy, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Eric Lipsic
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Luis Juarez Orozco
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Pim van der Harst
- Expirimental Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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Preciado SM, Sharp AL, Sun BC, Baecker A, Wu YL, Lee MS, Shen E, Ferencik M, Natsui S, Kawatkar AA, Park SJ, Redberg RF. Evaluating Sex Disparities in the Emergency Department Management of Patients With Suspected Acute Coronary Syndrome. Ann Emerg Med 2021; 77:416-424. [PMID: 33358395 PMCID: PMC8005458 DOI: 10.1016/j.annemergmed.2020.10.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 10/02/2020] [Accepted: 10/28/2020] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE We compare clinical management and outcomes of emergency department (ED) encounters by sex after implementation of a clinical care pathway in 15 community EDs that standardized recommendations based on patient risk, using the History, ECG, Age, Risk Factors, and Troponin (HEART) score. METHODS This was a retrospective analysis of adult ED encounters evaluated for suspected acute coronary syndrome with a documented HEART score from May 20, 2016, to December 1, 2017. The primary outcomes were hospitalization or 30-day stress testing. Secondary outcomes included 30-day acute myocardial infarction or all-cause death (major adverse cardiac event). A generalized estimating equation regression model was used to compare the odds of hospitalization or stress testing by sex; we report HEART scores (0 to 10) stratified by sex and describing major adverse cardiac events. RESULTS A total of 34,715 adult ED encounters met the inclusion criteria (56.0% women). A higher proportion of women were classified as low risk (60.5% versus 52.4%; odds ratio [OR] 1.39; 95% confidence interval [CI] 1.33 to 1.45). Women were hospitalized or received stress testing less frequently than men for low HEART scores (18.8% versus 22.8%; OR 0.79; 95% CI 0.73 to 0.84) and intermediate ones (46.7% versus 49.7%; OR 0.88; 95% CI 0.83 to 0.95), but similarly for high-risk ones (74.1% versus 74.4%; OR 0.99; 95% CI 0.77 to 1.28). Women had 18% lower odds of hospitalization or noninvasive cardiac testing (OR 0.82; 95% CI 0.78 to 0.86), even after adjusting for HEART score and comorbidities. Men had higher risks of major adverse cardiac events than women for all HEART score categories but the risk for men was significantly higher among low-risk HEART scores (0.4% versus 0.1%). CONCLUSION Women with low-risk HEART scores are hospitalized or stress tested less than men, which is likely appropriate, and women have better outcomes than men. Use of the HEART score has the potential to reduce sex disparities in acute coronary syndrome care.
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Affiliation(s)
- Salena M Preciado
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Adam L Sharp
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Benjamin C Sun
- Department of Emergency Medicine, University of Pennsylvania, Leonard Davis Institute, Philadelphia, PA
| | - Aileen Baecker
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Yi-Lin Wu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Ming-Sum Lee
- Division of Cardiology, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, CA
| | - Ernest Shen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR
| | - Shaw Natsui
- New York City Health + Hospitals, New York, NY
| | - Aniket A Kawatkar
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Stacy J Park
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Rita F Redberg
- Division of Cardiology, University of California-San Francisco, San Francisco, CA.
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15
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Holmes KA, Posey RA, Wang H. The value of using the HEART score among cocaine associated chest pain patients in the emergency department - A closer look. Am J Emerg Med 2020; 46:729-730. [PMID: 33148470 DOI: 10.1016/j.ajem.2020.09.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/24/2020] [Accepted: 09/25/2020] [Indexed: 01/29/2023] Open
Affiliation(s)
- Katherine A Holmes
- Department of Emergency Medicine, JPS Health Network, 1500 S. Main St., Fort Worth, TX 76104, United States of America.
| | - Rachel A Posey
- Department of Emergency Medicine, JPS Health Network, 1500 S. Main St., Fort Worth, TX 76104, United States of America.
| | - Hao Wang
- Department of Emergency Medicine, JPS Health Network, 1500 S. Main St., Fort Worth, TX 76104, United States of America.
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Spiegel R, Sutherland M, Brown R, Honasoge A, Witting M. Clinically relevant adverse cardiovascular events in intermediate heart score patients admitted to the hospital following a negative emergency department evaluation. Am J Emerg Med 2021; 46:469-75. [PMID: 33176952 DOI: 10.1016/j.ajem.2020.10.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/22/2020] [Accepted: 10/26/2020] [Indexed: 12/26/2022] Open
Abstract
STUDY HYPOTHESIS Study objective: To estimate the frequency of clinically relevant adverse cardiac events (CRACE) in patients admitted to the hospital for chest pain with an intermediate HEART score (4, 5, 6), non-diagnostic EKG, and a negative initial troponin. METHODS We conducted a retrospective analysis of all patients admitted to the University of Maryland Medical Center (UMMC) from May 2016 to May 2019 with an intermediate HEART score (4, 5, or 6), a non-diagnostic EKG, and a negative initial troponin. Our primary outcome was the rate of inpatient clinically relevant adverse cardiac events (CRACE), composite of life-threatening dysrhythmia, inpatient STEMI, cardiac or respiratory arrest, and all-cause mortality during hospitalization. RESULTS A total of 1118 patients met our inclusion criteria, 6 of whom had CRACE. Overall the rate of CRACE was 0.5% (95% CI, 0.2-1.2%). Six patients (0.5%, 95% CI, 0.2%-1.2%) experienced inpatient NSTEMIs, 212 patients (19%, 95% CI, 17-21%) underwent provocative testing during their inpatient stay, 5 patients received a stent or CABG, and 5 patients had false positive non-invasive testing and underwent a negative cardiac catheterization. CONCLUSIONS In this cohort of admitted patients with a documented intermediate-risk HEART score, nonischemic EKG, and negative initial troponin, the occurrence of CRACE during the index hospitalization was 0.5%.
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Dekker M, Waissi F, van Bennekom J, Silvis MJM, Timmerman N, Schoneveld AH, Grobbee DE, de Winter RJ, Mosterd A, Timmers L, de Kleijn DPV. Extracellular Vesicle cystatin c is associated with unstable angina in troponin negative patients with acute chest pain. PLoS One 2020; 15:e0237036. [PMID: 32756583 PMCID: PMC7406038 DOI: 10.1371/journal.pone.0237036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/17/2020] [Indexed: 01/12/2023] Open
Abstract
Background Despite the use of high-sensitive cardiac troponin there remains a group of high-sensitive cardiac troponin negative patients with unstable angina with a non-neglectable risk for future adverse cardiovascular events, emphasising the need for additional risk stratification. Plasma extracellular vesicles are small bilayer membrane vesicles known for their potential role as biomarker source. Their role in unstable angina remains unexplored. We investigate if extracellular vesicle proteins are associated with unstable angina in patients with chest pain and low high-sensitive cardiac troponin. Methods The MINERVA study included patients presenting with acute chest pain but no acute coronary syndrome. We performed an exploratory retrospective case-control analysis among 269 patients. Cases were defined as patients with low high-sensitive cardiac troponin and proven ischemia. Patients without ischemia were selected as controls. Blood samples were fractionated to analyse the EV proteins in three plasma-subfractions: TEX, HDL and LDL. Protein levels were quantified using electrochemiluminescence immunoassay. Results Lower levels of (adjusted) EV cystatin c in the TEX subfraction were associated with having unstable angina (OR 0.93 95% CI 0.88–0.99). Conclusion In patients with acute chest pain but low high-sensitive cardiac troponin, lower levels of plasma extracellular vesicle cystatin c are associated with having unstable angina. This finding is hypothesis generating only considering the small sample size and needs to be confirmed in larger cohort studies, but still identifies extracellular vesicle proteins as source for additional risk stratification.
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Affiliation(s)
- Mirthe Dekker
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Farahnaz Waissi
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Joelle van Bennekom
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Max J. M. Silvis
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Nathalie Timmerman
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Arjan H. Schoneveld
- Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Diederick E. Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Robbert J. de Winter
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Arend Mosterd
- Department of Cardiology, Meander Medical Centre Amersfoort, Amersfoort, the Netherlands
| | - Leo Timmers
- Department of Cardiology, St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - Dominique P. V. de Kleijn
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
- * E-mail:
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Prasad P, Sharma AN, Vipparla NS, Majid M, Daniela A, Howell SJ, Wilson MD, Amsterdam EA. Identification and Management of Intermediate Risk Patients in the Chest Pain Unit. Crit Pathw Cardiol 2020; 19:26-9. [PMID: 31633498 DOI: 10.1097/HPC.0000000000000202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We examined low risk (LR) patients admitted to our chest pain unit (CPU) with negative cardiac injury markers, normal electrocardiogram, and clinical stability. We hypothesized that there is a sub-group of intermediate risk (IR) patients within the larger LR population. METHODS Criteria for IR were the aforementioned 3 indicators of LR and ≥1 of the following: (1) known coronary artery disease (CAD), (2) men ≥45 yo, women ≥55 yo, and (3) ≥3 cardiac risk factors. We compared patient characteristics, use of pre-discharge testing (PDT), and major adverse cardiac events (MACE). RESULTS IR patients numbered 371, whereas LR patients totaled 70. IR patients were older (61 vs 46 years), more had known CAD (28 vs. 0%), had a higher median number of risk factors (2 vs. 1) and were less likely to be women (49 vs. 81%), all P < 0.0001. IR patients received a greater median number of tests compared with LR patients (1 vs. 0, P < 0.0001). CONCLUSIONS Among the IR group, 16 patients (4%) had a cardiac event at the index CPU visit, 2 (0.5%) experienced MACE at 30-day follow-up, and 2 (0.5%) had MACE at 6 months follow-up. No LR patients had MACE at any point in the study. Thus, the majority of CPU patients are IR, have more risk factors than LR group, and are more likely to receive PDT. IR patients were managed safely in a CPU, while maintaining low rates of MACE post-discharge.
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20
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Fernando SM, Tran A, Cheng W, Rochwerg B, Taljaard M, Thiruganasambandamoorthy V, Kyeremanteng K, Perry JJ. Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac Events in Patients Presenting With Chest Pain: A Systematic Review and Meta-analysis. Acad Emerg Med 2019; 26:140-151. [PMID: 30375097 DOI: 10.1111/acem.13649] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/04/2018] [Accepted: 08/13/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The HEART score has been proposed for emergency department (ED) prediction of major adverse cardiac events (MACE). We sought to summarize all studies assessing the prognostic accuracy of the HEART score for prediction of MACE in adult ED patients presenting with chest pain. METHODS We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception through May 2018 and included studies using the HEART score for the prediction of short-term MACE in adult patients presenting to the ED with chest pain. The main outcome was short-term (i.e., 30-day or 6-week) incidence of MACE. We secondarily evaluated the prognostic accuracy of the HEART score for prediction of mortality and myocardial infarction (MI). Where available, accuracy of the Thrombolysis in Myocardial Infarction (TIMI) score was determined. RESULTS We included 30 studies (n = 44,202) in analysis. A HEART score above the low-risk threshold (≥4) had a sensitivity of 95.9% (95% confidence interval [CI] = 93.3%-97.5%) and specificity of 44.6% (95% CI = 38.8%-50.5%) for MACE. A high-risk HEART score (≥7) had a sensitivity of 39.5% (95% CI = 31.6%-48.1%) and specificity of 95.0% (95% CI = 92.6%-96.6%) for MACE, whereas a TIMI score above the low-risk threshold (≥2) had a sensitivity of 87.8% (95% CI = 80.2%-92.8%) and specificity of 48.1% (95% CI = 38.9%-57.5%) for MACE. A high-risk TIMI score (≥6) was 2.8% sensitive (95% CI = 0.8%-9.6%), but 99.6% (95% CI = 98.5%-99.9%) specific for MACE. A HEART score ≥ 4 had a sensitivity of 95.0% (95% CI = 87.2%-98.2%) for prediction of mortality and 97.5% (95% CI = 93.7%-99.0%) for prediction of MI. CONCLUSIONS The HEART score has excellent performance for prediction of MACE (particularly mortality and MI) in chest pain patients and should be the primary clinical decision instrument used for the risk stratification of this patient population.
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Affiliation(s)
- Shannon M. Fernando
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario
- Division of Critical Care; Department of Medicine; University of Ottawa; Ottawa Ontario
| | - Alexandre Tran
- School of Epidemiology and Public Health; University of Ottawa; Ottawa Ontario
- Department of Surgery; University of Ottawa; Ottawa Ontario
| | - Wei Cheng
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Ontario
| | - Bram Rochwerg
- Department of Medicine; Division of Critical Care, and Department of Health Research Methods, Evidence, and Impact; McMaster University; Hamilton Ontario Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health; University of Ottawa; Ottawa Ontario
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Ontario
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario
- School of Epidemiology and Public Health; University of Ottawa; Ottawa Ontario
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Ontario
| | - Kwadwo Kyeremanteng
- Division of Critical Care; Department of Medicine; University of Ottawa; Ottawa Ontario
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Ontario
| | - Jeffrey J. Perry
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario
- School of Epidemiology and Public Health; University of Ottawa; Ottawa Ontario
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Ontario
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Abstract
Nowadays, measurement of cardiac troponins (cTn) in patient plasma is central for diagnosis of patients with acute coronary syndrome (ACS). High-sensitivity (hs) immunoassays have been developed that can very precisely record slightly elevated and rising plasma concentrations of cTn very early after onset of clinical symptoms. Algorithms integrate measurements of hs-cTn at onset of clinical symptoms of acute myocardial infarction (AMI), and 1 or 3 h after onset, to rule-in and rule-out AMI patients. More and more point-of-care (POC) cTn assays conquer the diagnostic market, but thorough clinical validation studies are required before potential implementation of such POC tests into hospital settings. This review provides an overview of the technical aspects, as well as diagnostic and prognostic use of cardiac troponins in AMI patients and in the healthy population.
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McGregor AJ, Beauchamp GA, Wira CR, Perman SM, Safdar B. Sex as a Biological Variable in Emergency Medicine Research and Clinical Practice: A Brief Narrative Review. West J Emerg Med 2017; 18:1079-1090. [PMID: 29085541 PMCID: PMC5654878 DOI: 10.5811/westjem.2017.8.34997] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/18/2017] [Accepted: 08/21/2017] [Indexed: 12/16/2022] Open
Abstract
The National Institutes of Health recently highlighted the significant role of sex as a biological variable (SABV) in research design, outcome and reproducibility, mandating that this variable be accounted for in all its funded research studies. This move has resulted in a rapidly increasing body of literature on SABV with important implications for changing the clinical practice of emergency medicine (EM). Translation of this new knowledge to the bedside requires an understanding of how sex-based research will ultimately impact patient care. We use three case-based scenarios in acute myocardial infarction, acute ischemic stroke and important considerations in pharmacologic therapy administration to highlight available data on SABV in evidence-based research to provide the EM community with an important foundation for future integration of patient sex in the delivery of emergency care as gaps in research are filled.
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Affiliation(s)
- Alyson J McGregor
- Warren Alpert Medical School of Brown University, Department of Emergency Medicine, Division of Sex and Gender in Emergency Medicine, Providence, Rhode Island
| | - Gillian A Beauchamp
- Oregon Health & Science University, Department of Emergency Medicine, Portland, Oregon
| | - Charles R Wira
- Yale University School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
| | - Sarah M Perman
- University of Colorado, School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Basmah Safdar
- Yale University School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
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