The elder patient with suspected acute coronary syndromes in the emergency department

Does Advanced Age Reduce the Typicality of Clinical Presentation in Patients with Acute Chest Pain Related to Coronary Artery Disease?

Fundamento

De acordo com o pensamento diagnóstico tradicional, indivíduos muito idosos estão mais predispostos a desenvolver sintomas atípicos em síndromes coronarianas agudas.

Objetivo

Testar a hipótese de que indivíduos muito idosos estão mais predispostos a manifestações de dor torácica atípica devido à doença arterial coronariana obstrutiva (DAC).

Métodos

O Registro de dor torácica inclui pacientes internados com dor torácica aguda. Primeiramente, foi construído o índice de tipicidade dessa manifestação clínica: a soma de 12 características de sintomas (8 sintomas típicos e 4 sintomas atípicos). No subgrupo de pacientes com etiologia coronariana, o índice de tipicidade foi comparado entre octogenários e não octogenários. A significância estatística foi definida por p<0,05.

Resultados

958 pacientes foram incluídos no registro, sendo que 486 (51%) tinham etiologia supostamente coronariana. Nesse grupo, 59 (12%) octogenários (idade 84±3,5; 50% homens) foram comparados a 427 pacientes com idade <80 (60±12 anos; 71% homens). O índice de tipicidade em octogenários foi 3,42±1,92, que é semelhante ao de não octogenários (3,44±1,74; p=0,092 na análise univariada e p=0,80 após ajuste para sexo pela análise de variância — ANOVA). Também não houve diferença estatisticamente significativa quando a amostra foi dividida em idade mediana (62 anos; 3,41±1,77 vs. 3,49 ± 1,77; p=0,61). Não houve associação linear estatisticamente significativa entre idade e índice de tipicidade (r=- 0,05; p=0,24). A análise de regressão logística para predição de DAC na amostra geral de 958 pacientes não mostrou interação do índice de tipicidade com a idade numérica (p=0,94), octogenários (p=0,22) ou idade acima da mediana (p=0,74).

Conclusão

Em pacientes com dor torácica aguda de etiologia coronariana, a idade avançada não influencia o quadro clínico típico.

Higher Frequency of Undetected Acute Coronary Syndrome in Elderly Patients with Chest Pain Who Visited the Emergency Department: A Large-Cohort Retrospective Study

Background

Acute coronary syndrome (ACS) is a critical disease encountered in the emergency department (ED). Despite the development of diagnostic tools, it may be difficult to diagnose ACS because of atypical symptoms and equivocal test results. We investigated the difference in the rates of revisit and undetected ACS between adult and elderly patients who visited the ED with chest pain.

Method

Data from 11,323 patients who visited the ED with chest pain at university hospitals in Korea were retrospectively analyzed. The cohort was categorized into two age groups: the adult (30–64 years) and elderly (>65 years). Baseline characteristic data (age, sex, vital signs, triage category, etc.) were obtained. We selected patients who revisited the ED within 30 d and investigated whether ACS was diagnosed.

Result

The revisit rate was higher in the elderly (12%) than in the adult group (8.3%). The rate of undetected ACS among the revisited patients was 2.91% (18/7,186) in adults and 6.08% (16/1,998) in elderly patients.

Conclusion

Elderly patients with chest pain had an increased rate of ED revisits and undetected ACS than adult patients. We recommend that old patients should be hospitalized to observe the progression of cardiac complaints or receive short-term follow-up.

Diagnostic Accuracy of History and Physical Examination for Predicting Major Adverse Cardiac Events Within 30 Days in Patients With Acute Chest Pain

BACKGROUND

The cornerstones in the assessment of emergency department (ED) patients with suspected acute coronary syndrome (ACS) are patient history and physical examination, electrocardiogram, and cardiac troponins. Although there are several prior studies on this subject, they have in some cases produced inconsistent results.

OBJECTIVE

The aim of this study was to evaluate the diagnostic and prognostic accuracy of elements of patient history and the physical examination in ED chest pain patients for predicting major adverse cardiac events (MACE) within 30 days.

METHODS

This was a prospective observational study that included 1167 ED patients with nontraumatic chest pain. We collected clinical data during the initial ED assessment of the patients. Our primary outcome was 30-day MACE.

RESULTS

Pain radiating to both arms increased the probability of 30-day MACE (positive likelihood ratio [LR+] 2.7), whereas episodic chest pain lasting seconds (LR+ 0.0) and >24 h (LR+ 0.1) markedly decreased the risk. In the physical examination, pulmonary rales (LR+ 3.0) increased the risk of 30-day MACE, while pain reproduced by palpation (LR+ 0.3) decreased the risk. Among cardiac risk factors, a history of diabetes (LR+ 3.0) and peripheral arterial disease (LR+ 2.7) were the most predictive factors.

CONCLUSIONS

No clinical findings reliably ruled in 30-day MACE, whereas episodic chest pain lasting seconds and pain lasting more than 24 h markedly decreased the risk of 30-day MACE. Consequently, these two findings can be adjuncts in ruling out 30-day MACE.

Age is associated with increased mortality in the RETTS-A triage scale

Background

Triage is widely used in the emergency department (ED) in order to identify the patient’s level of urgency and often based on the patient’s chief complaint and vital signs. Age has been shown to be independently associated with short term mortality following an ED visit. However, the most commonly used ED triage tools do not include age as an independent core variable. The aim of this study was to investigate the relationship between age and 7- and 30-day mortality across the triage priority level groups according to Rapid Emergency Triage and Treatment System – Adult (RETTS-A), the most widely used triage tool in Sweden.

Methods

In this cohort, we included all adult patients visiting the ED at the Karolinska University Hospital, Sweden, from 1/1/2010 to 1/1/2015, n = 639,387. All patients were triaged according to the RETTS-A and subsequently separated into three age strata: 18–59, 60–79 and ≥ 80 years. Descriptive analyses and logistic regression was used. The primary outcome measures were 7- and 30-day mortality.

Results

We observed that age was associated with both 7 and 30-day mortality in each triage priority level group. Mortality was higher in older patients across all triage priority levels but the association with age was stronger in the lowest triage group (p-value for interaction = < 0.001). Comparing patients ≥80 years with patients 18–59 years, older patients had a 16 and 7 fold higher risk for 7 day mortality in the lowest and highest triage priority groups, respectively. The corresponding numbers for 30-d mortality were a 21- and 8-foldincreased risk, respectively.

Conclusion

Compared to younger patients, patients above 60 years have an increased short term mortality across the RETTS-A triage priority level groups and this was most pronounced in the lowest triage level. The reason for our findings are unclear and data suggest a validation of RETTS-A in aged patients.

The association between vital signs and mortality in a retrospective cohort study of an unselected emergency department population

Background

Vital signs are widely used in emergency departments. Previous studies on the association between vital signs and mortality in emergency departments have been restricted to selected patient populations. We aimed to study the association of vital signs and age with 1-day mortality in patients visiting the emergency department.

Methods

This retrospective cohort included patients visiting the emergency department for adults at Södersjukhuset, Sweden from 4/1/2012 to 4/30/2013. Exclusion criteria were: age < 18 years, deceased upon arrival, chief complaint circulatory or respiratory arrest, key data missing and patients who were directed to a certain fast track for conditions demanding little resources. Vital sign data was collected through the Rapid Emergency Triage and Treatment System – Adult (RETTS-A). Descriptive analyses and logistic regression models were used. The main outcome measure was 1-day mortality.

Results

The 1-day mortality rate was 0.3 %. 96,512 patients met the study criteria. After adjustments of differences in the other vital signs, comorbidities, gender and age the following vital signs were independently associated with 1-day mortality: oxygen saturation, systolic blood pressure, temperature, level of consciousness, respiratory rate, pulse rate and age. The highest odds ratios was observed when comparing unresponsive to alert patients (OR 31.0, CI 16.9 to 56.8), patients ≥ 80 years to <50 years (OR 35.9, CI 10.7 to 120.2) and patients with respiratory rates <8/min to 8–25/min (OR 18.1, CI 2.1 to 155.5).

Discussion

Most of the vital signs used in the ED are significantly associated with one-day mortality. The more the vital signs deviate from the normal range, the larger are the odds of mortality. We did not find a suitable way to adjust for the inherent influence the triage system and medical treatment has had on mortality.

Conclusions

Most deviations of vital signs are associated with 1-day mortality. The same triage level is not associated with the same odds for death with respect to the individual vital sign. Patients that were unresponsive or had low respiratory rates or old age had the highest odds of 1-day mortality.

Discharge Against Medical Advice From the Emergency Department: Results From a Tertiary Care Hospital in Beirut, Lebanon

Patients who leave the emergency department against medical advice are at high risk for complications. Against medical advice (AMA) discharges are also considered high-risk events potentially leading to malpractice litigation.Our aim was to characterize patients who leave AMA in a payment prior to service emergency department (ED) model and to identify predictors for return visits to ED after leaving AMA.We conducted a retrospective review study of charts of ED patients who were discharged AMA between January 1, 2012 and January 1, 2013 at a tertiary care center in Beirut Lebanon. We carried out a descriptive analysis and a bivariate analysis comparing AMA patients without and with return visit within 72 hours. This was followed by a Logistic regression to identify predictors of return visits after leaving AMA.A total of 1213 ED patients were discharged AMA during the study period. Mean age was 46.9 years (±20.9). There were 654 men (53.9%), 737 married (60.8%). The majority (1059 patients (87.3%)) had an emergency severity index of 3 or less (1 or 2). ED average length of stay was 3.8 hours (±6.8). Self payers accounted for 53.9%. Reasons for leaving AMA were: no reason mentioned (44.1%), incomplete workup (30.5%), refusing admission (12.4%), financial reasons (7.9%), long wait times (2.9%), and others (2.2%). Discharge diagnoses were mainly cardiac (23.4%), gastrointestinal (16.4%), infectious (10.1%), and trauma (9.8%).One hundred nineteen returned to ED within 72 hours (9.8%). Predictors of returning to ED after leaving AMA were: older age (OR 1.02 95% CI (1.01-1.03)), private insurance status (OR 4.64 95% (CI 2.89-7.47) within network insurance status (OR 7.20 95% CI (3.86-13.44), longer ED length of stay during the first visit (OR 1.03 95% CI (1.01-1.05).In our setting, the rate of return visit to ED after leaving AMA was 9.8%. Reasons for leaving AMA, high-risk discharge diagnoses and predictors of return visit were identified. Financial status was a strong predictor of return to ED after leaving AMA.

Impact of prodromal symptoms on prehospital delay in patients with first-time acute myocardial infarction in Korea

BACKGROUND

Information is limited concerning how affected individuals respond to early warning signs before their acute coronary event and how the presence of prodromal symptoms impacts prehospital delay.

OBJECTIVES

This study's aim was to identify the characteristics and interpretation of prodromal symptoms in patients with a first-time acute myocardial infarction (AMI) and to determine whether the presence of prodromal symptoms was predictive of prehospital delay.

SUBJECTS AND METHODS

This was a descriptive study using semistructured interview. A total of 271 hospitalized patients diagnosed as having AMI were interviewed from November 2007 to December 2008 at a university hospital in Korea. Patients were queried regarding whether they noticed a most troubling prodromal symptom prior to their acute cardiac event and how they responded to the symptom.

RESULTS

Men (53.0%) and women (54.2%) experienced prodromal symptoms. Patients who reported prodromal symptoms were more likely to be older and to have no chest pain upon hospitalization than those with no prodromes. Many patients did not generally recognize the importance of their warning symptoms; only about 40% visited a clinic in response to any prodromal symptom. Logistic regression analyses revealed that the presence of prodromal symptoms was an independent predictor affecting prehospital delay of more than 3 hours and more than 12 hours.

CONCLUSIONS

Recognizing prodromal symptoms as needing attention could be a trigger for patients to seek medical help earlier. Educational strategies should focus on improving awareness of prodromal symptoms of AMI, particularly in those with a family history or at high risk for cardiovascular disease.

Emergency department triage scales and their components: a systematic review of the scientific evidence

Emergency department (ED) triage is used to identify patients' level of urgency and treat them based on their triage level. The global advancement of triage scales in the past two decades has generated considerable research on the validity and reliability of these scales. This systematic review aims to investigate the scientific evidence for published ED triage scales. The following questions are addressed: 1. Does assessment of individual vital signs or chief complaints affect mortality during the hospital stay or within 30 days after arrival at the ED?2. What is the level of agreement between clinicians' triage decisions compared to each other or to a gold standard for each scale (reliability)? 3. How valid is each triage scale in predicting hospitalization and hospital mortality? A systematic search of the international literature published from 1966 through March 31, 2009 explored the British Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and PubMed. Inclusion was limited to controlled studies of adult patients (≥ 15 years) visiting EDs for somatic reasons. Outcome variables were death in ED or hospital and need for hospitalization (validity). Methodological quality and clinical relevance of each study were rated as high, medium, or low. The results from the studies that met the inclusion criteria and quality standards were synthesized applying the internationally developed GRADE system. Each conclusion was then assessed as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not available, this was also noted.We found ED triage scales to be supported, at best, by limited and often insufficient evidence.The ability of the individual vital signs included in the different scales to predict outcome is seldom, if at all, studied in the ED setting. The scientific evidence to assess interrater agreement (reliability) was limited for one triage scale and insufficient or lacking for all other scales. Two of the scales yielded limited scientific evidence, and one scale yielded insufficient evidence, on which to assess the risk of early death or hospitalization in patients assigned to the two lowest triage levels on a 5-level scale (validity).

Comparison of factors associated with atypical symptoms in younger and older patients with acute coronary syndromes

Patients with acute coronary syndromes (ACS) who are accompanied by atypical symptoms are frequently misdiagnosed and under-treated. This study was conducted to examine and compare the factors associated with atypical symptoms other than chest pain in younger (<70 yr) and older (> or =70 yr) patients with first-time ACS. Data were obtained from the electronic medical records of the patients (n=931) who were newly diagnosed as ACS and hospitalized from 2005 to 2006. The 7.8% (n=49) of the younger patients and 13.4% (n=41) of the older patients were found to have atypical symptoms. Older patients were more likely to complain of indigestion or abdominal discomfort (P=0.019), nausea and/or vomiting (P=0.040), and dyspnea (P<0.001), and less likely to have chest pain (P=0.007) and pains in the arm and shoulder (P=0.018). A logistic regression analysis showed that after adjustment made for the gender and ACS type, diabetes and hyperlipidemia significantly predicted atypical symptoms in the younger patients. In the older patients, the co-morbid conditions such as stroke or chronic obstructive pulmonary disease were positive predictors. Health care providers need to have an increased awareness of possible presence of ACS in younger persons with diabetes and older persons with chronic concomitant diseases when evaluating patients with no chest pain.