Predictive risk stratification using HEART (history, electrocardiogram, age, risk factors, and initial troponin) and TIMI (thrombolysis in myocardial infarction) scores in non-high risk chest pain patients: An African American urban community based hospital study

Validated risk scoring systems in African American (AA) population are under studied. We utilized history, electrocardiogram, age, risk factors, and initial troponin (HEART) and thrombolysis in myocardial infarction (TIMI) scores to predict major adverse cardiovascular events (MACE) in non-high cardiovascular (CV) risk predominantly AA patient population.A retrospective emergency department (ED) charts review of 1266 chest pain patients where HEART and TIMI scores were calculated for each patient. Logistic regression model was computed to predict 6-week and 1-year MACE and 90-day cardiac readmission. Decision curve analysis (DCA) was constructed to differentiate between clinical strategies in non-high CV risk patients.Of the 817 patients included, 500 patients had low HEART score vs. 317 patients who had moderate HEART score. Six hundred sixty-three patients had low TIMI score vs. 154 patients had high TIMI score. The univariate logistic regression model shows odds ratio of predicting 6-week MACE using HEART score was 3.11 (95% confidence interval [CI] 1.43-6.76, P = .004) with increase in risk category from low to moderate vs. 2.07 (95% CI 1.18-3.63, P = .011) using TIMI score with increase in risk category from low to high and c-statistic of 0.86 vs. 0.79, respectively. DCA showed net benefit of using HEART score is equally predictive of 6-week MACE when compared to TIMI.In non-high CV risk AA patients, HEART score is better predictive tool for 6-week MACE when compared to TIMI score. Furthermore, patients presenting to ED with chest pain, the optimal strategy for a 2% to 4% miss rate threshold probability should be to discharge these patients from the ED.

Connecticut Hospital Readmissions Related to Chest Pain and Heart Failure: Differences by Race, Ethnicity, and Payer

BACKGROUND

Racial and ethnic disparities in hospital readmissions for several major illnesses and conditions are well-documented. However, due to the data typically used to assess readmission disparities little is known regarding the interplay between race/ethnicity and payer in fostering readmissions. This study used a statewide database of acute-care hospital admissions to examine 30-day readmission rates following hospitalization for chest pain and heart failure byrace/ethnicity and insurance status.

METHODS

Connecticut hospital discharge data for patients admitted for Chest Pain-DRG 313 (n = 23,450) and Heart Failure and Shock-DRG 291 and 292 (n = 39,985) from 2008 - 2012 were analyzed using marginal logistic models for clustered data with generalized estimating equations.

RESULTS

Results from logistic models indicated that Black patients were significantly more likely to be readmitted within 30 days of discharge following hospitalization for chest pain (OR = 1.19, CI = 1.04, 1.37) than were White patients. Hispanics, but not Blacks, were significantly more likely to be readmitted within 30 days of discharge following hospitalization for heart failure (OR = 1.30, CI = 1.15, 1.47). Rates of 30-day readmission across these conditions were between 50-100% higher among those covered by Medicaid compared to those covered by private payer. Controlling for patient socioeconomic status, patient comorbidities, and payer substantially reduced Black/White differences in the odds of readmission for chest pain but did not reduce Hispanic-White differences for heart failure.

CONCLUSIONS

Racial and ethnic disparities were seen in hospital readmission rates for Chest Pain (DRG 313) and Heart Failure and Shock (DRG 291 and 292) when a statewide database that captures all acute care hospital admissions was analyzed. When controlling for patient socioeconomic status, comorbidities, and payer status, the difference in the odds of readmission for chest pain, but not heart failure, was reduced.

Racial-ethnic biases, time pressure, and medical decisions

This study examined two types of potential sources of racial-ethnic disparities in medical care: implicit biases and time pressure. Eighty-one family physicians and general internists responded to a case vignette describing a patient with chest pain. Time pressure was manipulated experimentally. Under high time pressure, but not under low time pressure, implicit biases regarding blacks and Hispanics led to a less serious diagnosis. In addition, implicit biases regarding blacks led to a lower likelihood of a referral to specialist when physicians were under high time pressure. The results suggest that when physicians face stress, their implicit biases may shape medical decisions in ways that disadvantage minority patients.

Using the Rose Angina Questionnaire cross-culturally: the importance of consulting lay people when translating epidemiological questionnaires

OBJECTIVES

The Rose Angina Questionnaire (RAQ) is an important measure of coronary heart disease prevalence. It has been shown to perform inconsistently across some ethnic groups in Britain. This study investigates whether the best available versions of the RAQ in Punjabi and Cantonese were linguistically equivalent to the English version.

DESIGN

Interviews were carried out with lay people from the Pakistani, Chinese and European-origin communities in Scotland to assess the versions of the RAQ used in the Newcastle Heart Project (the best available versions). For each questionnaire item, participants were asked to elaborate on their understanding of the question and the meaning of keywords or phrases.

RESULTS

Problems were discovered with the Punjabi and Cantonese translations of the RAQ. For example, the translation for 'chest' was interpreted by some Pakistani and Chinese women to mean 'breasts'. 'Walking uphill' was translated in Chinese as 'walking the hill', without stipulation of the direction, so that some Cantonese speakers interpreted the question as pertaining to walking downhill. Many Chinese interpreted RAQ items to be referring to breathlessness rather than chest pain due to ambiguous wording.

CONCLUSION

Existing versions of the RAQ are unlikely to be yielding data that are cross-culturally valid or comparable. For robust health survey research in languages other than that in which the questionnaire was developed, lay assessment of questionnaires prior to and after translation is a necessity rather than a luxury.

Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997-2006

OBJECTIVES

This study assessed whether sociodemographic differences exist in triage assignment and whether these differences affect initial diagnostic testing in the emergency department (ED) for patients presenting with chest pain.

METHODS

A nationally representative ED data sample for all adults (>or=18 years) was obtained from the National Hospital Ambulatory Health Care Survey of EDs for 1997-2006. Weighted logistic regression was used to examine the associations between race and presenting symptom, triage assignment, and test ordering, adjusting for patient and hospital characteristics.

RESULTS

Over 10 years, an estimated 78 million visits to the ED presented with a complaint of chest pain. Of those presenting with chest pain, African Americans (odds ratio [OR] = 0.70; 99% confidence interval [CI] = 0.53 to 0.92), Hispanics (OR = 0.74; 99% CI = 0.51 to 0.99), Medicaid patients (OR = 0.72; 99% CI = 0.54 to 0.94), and uninsured patients (OR = 0.65; 99% CI = 0.51 to 0.84) were less likely to be triaged emergently. African Americans (OR = 0.86; 99% CI = 0.70 to 0.99), Medicaid patients (OR = 0.70; 99% CI = 0.55 to 0.88), and uninsured patients (OR = 0.70; 99% CI = 0.55 to 0.89) were less likely to have an electrocardiogram (ECG) ordered. African Americans (OR = 0.69; 99% CI = 0.49 to 0.97), Medicaid patients (OR = 0.67; 99% CI = 0.47 to 0.95), and uninsured patients (OR = 0.66; 99% CI = 0.44 to 0.96) were less likely to have cardiac enzymes ordered. Similarly, African Americans and Hispanics were less likely to have a cardiac monitor and pulse oximetry ordered, and Medicaid and uninsured patients were less likely to have a cardiac monitor ordered.

CONCLUSIONS

Persistent racial, sex, and insurance differences in triage categorization and basic cardiac testing exist. Eliminating triage disparities may affect "downstream" clinical care and help eliminate observed disparities in cardiac outcomes.

Ethnic differences in healthcare-seeking behaviour and management for acute chest pain: secondary analysis of the MINAP dataset 2002-2003

OBJECTIVE

To examine whether there are ethnic differences in the healthcare-seeking behaviour and management of patients with chest pain.

DESIGN

Prospective cohort of patients attending accident and emergency departments with chest pain.

SETTING

Hospitals in England and Wales from 1 January 2002 to 31 December 2003.

PARTICIPANTS

Patients with chest pain.

MAIN OUTCOME MEASURES

Whether patients arrived by ambulance, whether they received thrombolysis and the time it took from symptom onset to arrive at hospital and receive thrombolysis.

RESULTS

South Asian patients were less likely to arrive by ambulance (age and sex adjusted odds ratio 0.64, 95% CI 0.60 to 0.69, p<0.001) regardless of admission diagnosis. Overall, they were more likely to receive thrombolysis (adjusted multivariable odds ratio 1.19, 95% CI 1.10 to 1.30, p<0.001) and the difference was more marked if they had non-specific ECG changes for heart disease rather than definite evidence of a myocardial infarction. There was no evidence of an important clinical delay in South Asians receiving thrombolysis after arrival at hospital.

CONCLUSIONS

There are ethnic differences in healthcare-seeking behaviour and the way doctors manage South Asians with chest pain. The relative underuse of ambulances by South Asians may either reflect cultural differences or geographical proximity to hospitals. Doctors may have a lower threshold for giving thrombolytic therapy to South Asian men with chest pain possibly because they are aware of the increased risk of coronary heart disease in this population.

Symptom expression in coronary heart disease and revascularization recommendations for black and white patients

OBJECTIVES

We examined whether symptoms of coronary heart disease vary between Black and White patients with coronary heart disease, whether presenting symptoms affect physicians' revascularization recommendations, and whether the effect of symptoms upon recommendations differs in Black and White patients.

METHODS

We interviewed Black and White patients in Pittsburgh in 1997 to 1999 who were undergoing elective coronary catheterization. We interviewed them regarding their symptoms, and we interviewed their cardiologist decision-makers regarding revascularization recommendations. We obtained coronary catheterization results by chart review.

RESULTS

Black and White patients (N=1196; 9.7% Black) expressed similar prevalence of chest pain, angina equivalent, fatigue, and other symptoms, but Black patients had more shortness of breath (87% vs 72%, P=.001). When we considered only those patients with significant stenosis (n=737, 7.1% Black) and controlled for race, age, gender, and number of stenotic vessels, those who expressed shortness of breath were less likely to be recommended for revascularization (odds ratio=0.535; 95% confidence interval=0.375, 0.762; P<.001), but there was no significant interaction with race.

CONCLUSIONS

Black patients reported shortness of breath more frequently than did White subjects. Shortness of breath was a negative predictor for revascularization for all patients with significant stenosis, but there was no difference in the recommendations by symptom by race.

Chest Pain: Physician Perceptions and Decisionmaking in a London Emergency Department

STUDY OBJECTIVE

We describe physician perceptions of decision-making for acute coronary syndromes in the emergency department (ED) and the ways in which patient characteristics influence diagnosis.

METHODS

This is a qualitative analysis of semistructured interview data from physicians practicing at an ethnically diverse and lower-income London ED. All physicians working more than 3 shifts in the department during a 1-month period were approached for interview.

RESULTS

Four themes emerged from the interviews: (1) physicians emphasized the medical history when diagnosing acute coronary syndrome; (2) physicians reported communication barriers as an impediment to diagnosis; (3) physicians cited both epidemiologic data and cultural beliefs when explaining presentation differences between patient groups; (4) physicians interpreted patient complaints by comparing their clinical impressions to a "classic" or "textbook" norm.

CONCLUSION

In most cases, physicians relied on the clinical history when making decisions for patients with suspected acute coronary syndromes. In reaching judgments, physicians elicited features of the presentation they thought were salient, interpreted those features in light of epidemiologic knowledge and cultural beliefs, and compared their overall impression of the patient to a "classic" or "textbook" norm. At each step, physicians' perceptions about patients influenced the data gathered and the interpretation of that data. In addition, the expected features of acute coronary syndrome were thought to differ for some patient groups. These results highlight the need for further research into the role of provider beliefs in medical decision-making.

Physician variability in history taking when evaluating patients presenting with chest pain in the emergency department

OBJECTIVES

The goal of this study was to examine how physicians in the emergency department ask questions of patients presenting with chest pain and whether this varies by patient demographics.

METHODS

This was a cross-sectional study with convenience sampling. A survey was administered to adult emergency department patients presenting with chest pain after emergency physicians obtained the history and performed the physical examination. No identifying data were collected from the patients. In addition to demographics, patients were asked whether or not their physician asked them about factors related to coronary syndrome and myocardial infarction etiology.

RESULTS

A total of 308 of 332 patients (93%) participated. Patients had a mean age of 52 years, 54% were male, and 85% spoke English; classification by race was 31% African American, 28% white, 19% Hispanic, and 13% other. History taking did not differ by gender. Patients who reported being asked about the following were statistically significantly younger than those who reported not being asked: family history, other medical problems, smoking, cocaine use, and alcohol use. Nonwhite patients reported being asked about the following more frequently than white patients: smoking (94% vs. 84%), alcohol use (81% vs. 70%), and cocaine use (64% vs. 42%). In multivariate logistic regression controlling for age, nonwhite patients were more likely than white patients to be asked about smoking (odds ratio [OR], 2.79; 95% confidence interval [CI] = 1.26 to 6.19), cocaine use (OR, 2.49; 95% CI = 1.50 to 4.12), and alcohol use (OR, 1.77; 95% CI = 1.0 to 3.09).

CONCLUSIONS

The variability in questions about behavioral factors associated with chest pain etiology as reported by patients may indicate a possible cultural bias by physicians. Differences in risk identification may lead to differences in treatment decisions.

Culturally Competent Care of Patients with Acute Chest Pain

PURPOSE

To inform nurse practitioners (NPs) about the influence of culture on patients' responses to pain using the example of acute chest pain.

DATA SOURCES

Selected clinical and research articles on pain and culture and the authors' clinical experiences providing care across a variety of cultures.

CONCLUSIONS

There is very little written and even fewer studies on the connection of culture and the response to acute chest pain. This topic needs more attention by nurse researchers. Implications for practice If NPs are not aware that some patients may not demonstrate behavior typically expected in acute myocardial infarction, they may miss the diagnosis and fail to treat or refer these patients for immediate treatment.

Migraine and other headaches: associations with Rose angina and coronary heart disease

OBJECTIVE

To examine the association between a lifetime history of migraines and other headaches with and without aura and Rose angina and coronary heart disease (CHD).

METHODS

Participants were 12,409 African American and white men and women from the Atherosclerosis Risk in Communities Study, categorized by their lifetime history of headaches lasting > or =4 hours (migraine with aura, migraine without aura, other headaches with aura, other headaches without aura, no headaches). Gender-specific associations of headaches with Rose angina and CHD, adjusted for sociodemographic and cardiovascular disease risk factors, were evaluated using Poisson regression.

RESULTS

Participants with a history of migraines and other headaches were more likely to have a history of Rose angina than those without headaches. The associations were stronger for migraine and other headaches with aura (prevalence ratio [PR] = 3.0, 95% CI = 2.4, 3.7 and PR = 2.0, 95% CI = 1.5, 2.7 for women; PR = 2.2, 95% CI = 1.2, 3.9 and PR = 2.4, 95% CI = 1.4, 3.9 for men) than for migraine and other headaches without aura (PR = 1.5, 95% CI = 1.2, 1.9 and PR = 1.3, 95% CI = 1.1, 1.6 for women; PR = 1.9, 95% CI = 1.2, 2.9 and OR = 1.4, 95% CI = 1.0, 1.8 for men). In contrast, migraine and other headaches were not associated with CHD, regardless of the presence of aura.

CONCLUSIONS

The lack of association of migraines with coronary heart disease suggests that the association of migraine with Rose angina is not related to coronary artery disease. Future research assessing other common underlying pathologic mechanisms is warranted.

Racial/ethnic differences in adolescents' physical symptoms

This study was conducted to establish race/ethnic-specific prevalence for 10 physical symptoms in American youths and to examine the extent to which socioeconomic status and depressive symptoms explained racial differences in those symptoms. This descriptive study was based on a cross-sectional analysis of survey data from Wave I of the National Longitudinal Study of Adolescent Health including a school-based sample of over 20,000 adolescents in Grades 7 through 12. Self-reported physical symptoms during the past 12 months were examined. White youths reported the highest frequency of headaches, musculoskeletal pain, and dizziness; feeling hot, chest pain, cold sweats, and urinary symptoms were more common in Black youths. The three symptoms reported by Whites remained significant after controlling for family income and depressive symptoms, whereas racial differences in the four symptoms prominent in Blacks were accounted for by family income and depressive symptoms. Findings highlight racial differences in symptom types and in psychosocial factors contributing to physical symptoms in adolescents and warn against health-care providers' stereotyping associations between physical symptoms and socioeconomic status.

Performance of a population-based cardiac risk stratification tool in Asian patients with chest pain

OBJECTIVES

Most contemporary cardiac risk stratification tools have been derived and validated in mixed-race populations. Their validity in single-race populations has not been tested. The authors sought to compare the performance of a risk stratification tool between a mixed-race U.S. patient population and an Asian patient population.

METHODS

This study is an analysis of data from the Internet Tracking Registry for Acute Coronary Syndromes (i(*)trACS) registry of patients with chest pain presenting to the emergency departments of eight U.S. centers and one site in Singapore. The Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) was computed for included patients, and its performance in predicting acute coronary syndrome (ACS) was compared between patients from the United States and Singapore.

RESULTS

Of the 11,991 included patients, 1,120 experienced ACS. Although the ACI-TIPI demonstrated similar accuracy among groups (area under the curve, 0.729 [U.S.] vs. 0.719 [Singapore]; p = 0.5611), sensitivity and specificity were different when equal ACI-TIPI thresholds were considered. Recreating the logistic regression models used to create the ACI-TIPI showed similar results between the derived parameters and the parameters estimated for the U.S. group. In contrast, age older than 50 years (log-odds ratio [LOR], 0.107; 95% confidence interval [CI] = 0.518 to 0.713), male gender (LOR, 0.487; 95% CI = 0.149 to 1.122), and chest pain as a primary complaint (LOR, 0.237; 95% CI = 0.139 to 0.613) had little predictive power in patients from Singapore.

CONCLUSIONS

Differences exist in presentation and factors associated with ACS among patients from the United States and Singapore that may affect the performance of risk stratification tools. These findings suggest that cardiac clinical decision rules need international validation.

Association of a culturally defined syndrome (nervios) with chest pain and DSM-IV affective disorders in Hispanic patients referred for cardiac stress testing

BACKGROUND

Hispanics have a high prevalence of cardiovascular risk factors, most notably type 2 diabetes. However, in a large public hospital in Houston, Texas, Hispanic patients referred for cardiac stress testing were significantly more likely to have normal test results than were Whites or non-Hispanic Blacks. We undertook an exploratory study to determine if nervios, a culturally based syndrome that shares similarities with both panic disorder and anginal symptoms, is sufficiently prevalent among Hispanics referred for cardiac testing to be considered as a possible explanation for the high probability of a normal test result.

METHODS

Hispanic patients were recruited consecutively when they presented for a cardiac stress test. A bilingual interviewer administered a brief medical history, the Rose Angina Questionnaire (RAQ), a questionnaire to assess a history of nervios and associated symptoms, and the PRIME-MD, a validated brief questionnaire to diagnose DSM-IV defined affective disorders.

RESULTS

The average age of the 114 participants (38 men and 76 women) was 57 years, and the average educational attainment was 7 years. Overall, 50% of participants reported a history of chronic nervios, and 14% reported an acute subtype known as ataque de nervios. Only 2% of patients had DSM-IV defined panic disorder, and 59% of patients had a positive RAQ score (ie, Rose questionnaire angina). The acute subtype, ataque de nervios, but not chronic nervios, was related to an increased probability of having Rose questionnaire angina (P=.006). Adjusted for covariates, a positive history of chronic nervios, but not Rose questionnaire angina, was significantly associated with a normal cardiac test result (OR=2.97, P=.04).

CONCLUSION

Nervios is common among Hispanics with symptoms of cardiac disease. Additional research is needed to understand how nervios symptoms differ from chest pain in Hispanics and the role of nervios in referral for cardiac workup by primary care providers and emergency room personnel.

Bangladeshi patients present with non-classic features of acute myocardial infarction and are treated less aggressively in east London, UK

OBJECTIVE

To analyse differences in the presentation and management of Bangladeshi and white patients with Q wave acute myocardial infarction (AMI).

DESIGN

Prospective observational study.

SETTING

East London teaching hospital.

PARTICIPANTS

263 white and 108 Bangladeshi patients admitted with Q wave AMI.

MAIN OUTCOME MEASURE

Character of presenting symptoms, their interpretation by the patient, and the provision of emergency treatment.

RESULTS

There were no significant differences between Bangladeshi and white patients in the time from pain onset to hospital arrival (arrival time 64.5 (117.5) minutes v 63.0 (140.3) minutes, p = 0.63), but once in hospital it took almost twice as long for Bangladeshi as for white patients to receive thrombolysis (median (interquartile range) door to needle time 42.5 (78.0) minutes v 26.0 (47.7) minutes, p = 0.012). Bangladeshis were significantly less likely than whites to complain of central chest pain (odds ratio (OR) 0.11, 95% confidence interval (CI) 0.03 to 0.38; p = 0.0006) or to offer classic descriptions of the character of the pain (OR 0.25, 95% CI 0.09 to 0.74; p = 0.0118). These differences persisted after adjustment for age, sex, and risk factor profile differences including diabetes. Proportions of Bangladeshi and whites interpreting their symptoms as "heart attack" were similar (45.2% v 46.9%; p = 0.99).

CONCLUSIONS

Bangladeshi patients with AMI often present with atypical symptoms, which may lead to slower triage in the casualty department and delay in essential treatment. This needs recognition by emergency staff if mortality rates in this high risk group are to be reduced.

Perceptions of chest pain differ by race

BACKGROUND

African American patients are less likely to receive thrombolytic therapy and coronary revascularization than are white patients. Delay and clinical presentation may be keys to understanding differences in care.

OBJECTIVE

To determine how symptom recognition and perception influence clinical presentation as a function of race, we characterized symptoms and care-seeking behavior in African American and white patients seen in the ED with chest pain.

METHODS

The prospective study was conducted from April 1999 to September 1999 among patients who were seen in the ED and were admitted or observed in the ED Chest Pain Unit (n = 215). Interviews were conducted within 48 hours with a structured set of questions.

RESULTS

Thirty-one percent of white patients and 8.9% of African American patients were admitted with a diagnosis of acute myocardial infarction (P =.001). African American patients were as likely as white patients to report "typical" objective symptoms but were more likely to attribute their symptoms to a gastrointestinal source rather than a cardiac source (P =.05). Of those patients with the final diagnosis of myocardial infarction (n = 45), 61% of African American patients attributed symptoms to a gastrointestinal source and 11% to a cardiac source, versus 26% and 33%, respectively, for white patients. The median prehospital delay for African American patients was 263 minutes (interquartile range, 120 to 756 minutes), similar to the 247 minutes for white patients (interquartile range, 101 to 825 minutes, P =.72), despite African American patients (80%) being more likely than white patients (66%) to perceive their symptoms as severe/life-threatening at onset (P =.05).

CONCLUSION

Racial differences in symptom perception exist. Although the proportion of objectively defined typical symptoms were similar, self-attribution was more often noncardiac in African American patients than in white patients. Self-attribution, in addition to objective clinical findings, is likely to influence caregiver diagnostic approaches and therefore therapeutic approaches, and merits further study.

Use of emergency medical services for suspected acute cardiac ischemia among demographic and clinical patient subgroups: the REACT trial. Rapid Early Action for Coronary Treatment

OBJECTIVE

Barriers to the use of emergency medical services (EMS) and patient delay in seeking care can limit the receipt or effectiveness of reperfusion therapies and the availability of prehospital emergency cardiac care. The Rapid Early Action for Coronary Treatment (REACT) trial was designed to determine the impact of a community intervention on use of EMS among demographic and clinical subgroups of patients with suspected acute cardiac ischemia.

METHODS

A randomized controlled community trial was conducted in 20 pair-matched communities in the United States. One community from each pair received an 18-month, multicomponent community education program. Data were collected at 44 participating hospitals during a four-month baseline period and throughout the 18-month trial, using medical record abstracts to collect information on mode of transport to the hospital and other sociodemographic and clinical variables. Eligible patients were persons aged > or = 30 years presenting with chest pain or discomfort to emergency departments (EDs) who were admitted and discharged with a cardiac-related diagnoses (ICD 410-414, 427-429, 440, 786.9).

RESULTS

The net change in the odds of EMS use was an increase of 34% in intervention compared with control communities [adjusted odds ratio (OR) 1.34, 95% CI 1.07-1.67]. We observed greater increases in the odds of EMS use among patients who had chronic or other cardiac diagnoses (adjusted OR 1.53, 95% CI 1.18-1.99, and adjusted OR 1.52, 95% CI 1.17-1.97, respectively) than in those diagnosed as having acute ischemia (adjusted OR 1.14, 95% CI 0.91-1.44). We observed greater increases in odds of EMS ulse in those who were retired (adjusted OR 1.62, 95% CI 1.29-2.04) or had systolic blood pressure (SBP) at or below 160 mm Hg upon presentation to the ED (adjusted OR 1.55, 95% CI 1.26-1.91 for SBP 100-160 mm Hg; 1.61, 95% CI 0.88-2.97 for SBP <100 mm Hg).

CONCLUSIONS

The REACT trial demonstrated a significant impact on the use of EMS among patients admitted to the hospital for suspected acute myocardial infarction, with greater increases among patients with chronic or other cardiac ICD-9 discharge diagnoses, those presenting with lower SBP, and retired persons.

Association of atypical chest pain presentations by African Americans and the lack of utilization of reperfusion therapy

OBJECTIVE

One possible factor resulting in delays in using reperfusion therapy in patients with acute myocardial infarction (AMI) is the failure to recognize cardiac symptomatology early in certain subgroups of patients. These patients may undergo extensive evaluation for gastrointestinal or musculoskeletal complaints before it is recognized that they are suffering from an AMI.

METHODS

The records of patients (52% Black and 48% White; 49% male and 51% female) presenting to an urban teaching hospital with enzyme documented myocardial infarctions were retrospectively examined for traditional elements of atypia in their initial chest pain descriptions to the emergency department (ED). The rate of reperfusion therapy utilization was also determined for this group.

RESULTS

Of the patients meeting the study criteria (166 total), 43% were found to have atypical elements in the character of their pain description. This high prevalence of atypia also coincided with a low reperfusion intervention rate of 38%. In examining the subgroups, it appears that African Americans and women had the highest rates of atypical pain (56% and 46%, respectively) while also having the lowest utilization rates for reperfusion therapies (31% and 33%, respectively). This compares to rates of 48% for Whites and 60% for White males who had more typical chest pain.

CONCLUSIONS

While no direct correlation can be drawn from the data, it has been suggested that atypical presentations may result in early failure to recognize myocardial infarction and cause delay in or prevent appropriate therapy. It is thought that chest pain should be de-emphasized as a part of the indication criteria for thrombolytics and emergent angioplasty.

Prevalence of atypical chest pain descriptions in a population from the southern United States

INTRODUCTION

The character of chest pain (CP) is a major factor determining triage and admission for patients presenting to the emergency department (ED). Previous studies have found atypical descriptions in as little as 10-15% of patients with true myocardial ischemic pain. Atypical descriptions may be more prevalent in the Deep South of the United States because of cultural differences in the semantic description of pain.

METHODS

A retrospective study of patients presenting to the ED of a southern U.S. urban hospital with enzyme-documented myocardial infarction was conducted to determine the prevalence of atypical CP descriptions. A multivariate analysis of those patients with atypical pain descriptions was conducted to determine the independent demographic factors associated with these descriptions.

RESULTS

In a total of 77 subjects (56% black; 44% white) meeting the study criteria, 43% were found to have atypical elements in the character of their CP descriptions. Only the black race demographic was found to be significantly correlated with the atypical descriptions. The use of the descriptive term "sharp" accounted for nearly half of the atypical presentations.

CONCLUSION

Regional differences in the description of the character of CP may result in misleading portrayals of ischemic heart disease in southern U.S. populations. These differences are associated with a higher prevalence of atypical CP because of semantic distinctions, such as the use of the term "sharp" as a descriptor of acuity rather than character or quality.

The effect of race and sex on physicians' recommendations for cardiac catheterization

BACKGROUND

Epidemiologic studies have reported differences in the use of cardiovascular procedures according to the race and sex of the patient. Whether the differences stem from differences in the recommendations of physicians remains uncertain.

METHODS

We developed a computerized survey instrument to assess physicians' recommendations for managing chest pain. Actors portrayed patients with particular characteristics in scripted interviews about their symptoms. A total of 720 physicians at two national meetings of organizations of primary care physicians participated in the survey. Each physician viewed a recorded interview and was given other data about a hypothetical patient. He or she then made recommendations about that patient's care. We used multivariate logistic-regression analysis to assess the effects of the race and sex of the patients on treatment recommendations, while controlling for the physicians' assessment of the probability of coronary artery disease as well as for the age of the patient, the level of coronary risk, the type of chest pain, and the results of an exercise stress test.

RESULTS

The physicians' mean (+/-SD) estimates of the probability of coronary artery disease were lower for women (probability, 64.1+/-19.3 percent, vs. 69.2+/-18.2 percent for men; P<0.001), younger patients (63.8+/-19.5 percent for patients who were 55 years old, vs. 69.5+/-17.9 percent for patients who were 70 years old; P<0.001), and patients with nonanginal pain (58.3+/-19.0 percent, vs. 64.4+/-18.3 percent for patients with possible angina and 77.1+/-14.0 percent for those with definite angina; P=0.001). Logistic-regression analysis indicated that women (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) and blacks (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) were less likely to be referred for cardiac catheterization than men and whites, respectively. Analysis of race-sex interactions showed that black women were significantly less likely to be referred for catheterization than white men (odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.7; P=0.004).

CONCLUSIONS

Our findings suggest that the race and sex of a patient independently influence how physicians manage chest pain.

Psychosocial correlates of chest pain among African-American women

While 10-30% of individuals with chest pain who undergo cardiac arteriography are found to have no demonstrable pathology, women are far more likely than men to have normal coronary arteries in the presence of angina. Black women, in particular, frequently seek medical attention for persistent episodes of chest pain. This cross-sectional study was designed to examine the potential role of psychological and social factors in relation to chest pain among black women. Among our population-based sample of 188 women, 48% reported experiencing chest pain. Seventeen of these cases met the Rose criteria for classification as cardiac pain while 74 of them reported pain not consistent with cardiac origin. A statistically significant difference was observed in the stress scores among the women; the highest stress scores occurred among those with Rose angina and the lowest scores were obtained from those women reporting no chest pain experiences (p < 0.001). There was no association detected between the presence and type of chest pain and psychosocial measures of depression and coping abilities. These results confirm the high rates of chest pain experienced among black women, and provide insight into the role of psychological factors that should be considered in the identification of treatment options.

Acute chest pain in African Americans: factors in the delay in seeking emergency care

OBJECTIVES

African Americans have been shown to have longer delay times than the majority population in seeking care for acute cardiac problems. The purpose of this study was to determine whether socioeconomic factors affect delay times.

METHODS

Structured interviews were administered to 254 African Americans admitted to a public hospital and 194 African Americans admitted to a private hospital for suspected acute myocardial infarction.

RESULTS

Patient characteristics found by multiple regression analysis to affect decision-making and travel time for care-seeking were structural access to care, persistence of symptoms, degree of incapacitation, consultation with a layperson, consultation with medical professionals, and mode of transportation.

CONCLUSIONS

Within-group differences were found to be related to socioeconomic status. Strategies to increase knowledge about heart attack symptoms, improve access to care, and improve the socioeconomic status of at-risk African Americans are indicated.

Use of medical care for chest pain: differences between blacks and whites

Data from a 1980, community-based survey of adult residents of Edgecombe County, North Carolina were analyzed to examine differences between Blacks and Whites in the reported use of medical care after experiencing chest pain. Of all adults (N = 302) with chest pain in the year prior to interview, 49 percent of Blacks and 27 percent of Whites did not see a physician following the chest pain (difference = 22%, 95% CI = 12, 33). A multivariable analysis found that although the association between race and utilization was reduced at poverty levels of income, it was not explained by differences in demographic characteristics, health status or other dimensions of access to care.