scholarly journals MANAGEMENT OF LOW RISK PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT WITH CHEST PAIN: SELECTED PATIENTS DO NOT REQUIRE PRE-DISCHARGE CARDIAC TESTING TO EXCLUDE ACUTE CORONARY SYNDROME

2014 ◽  
Vol 63 (12) ◽  
pp. A212
Author(s):  
Phong Xuan Ha ◽  
Deborah Diercks ◽  
Douglas Kirk ◽  
Ezra Amsterdam
Keyword(s):  
Emergency Department ◽  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Low Risk ◽  
Coronary Syndrome ◽  
Risk Patients ◽  
Cardiac Testing

scholarly journals LO005: Association between emergency department chest pain volume and outcomes among patients presenting with chest pain

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S31-S32
Author(s):  
N.D. Dattani ◽  
M. Koh ◽  
A. Chong ◽  
A. Czarnecki ◽  
D.T. Ko
Keyword(s):  
Emergency Department ◽  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
High Risk ◽  
High Volume ◽  
Mortality Rates ◽  
Low Risk ◽  
Coronary Syndrome ◽  
All Cause Mortality ◽  
Risk Patients

Introduction: Chest pain is one of the most common reasons for emergency department (ED) visits in developed countries. Patients discharged after ED assessment remain at risk for adverse cardiac events. Although a volume-outcome relationship has been shown for myocardial infarction, it is uncertain whether a similar relationship exists with ED chest pain volume. Accordingly, we aimed to determine whether ED chest pain volume influences outcomes of patients presenting to the ED with chest pain who were discharged home. Methods: This was a retrospective cohort study using population-based data from Ontario, Canada. Patients who were discharged home from an ED in Ontario with a primary diagnosis of chest pain from April 1, 2004 to March 31, 2010 were included. High-risk patients were defined as the presence of diabetes or pre-existing cardiovascular disease, while low-risk patients were defined as the absence of these conditions. ED volume was categorized as low, medium, or high, based on tertiles of annual chest pain patient volume. The primary outcome of this study was all-cause mortality one year after the index ED visit. Mantel-Haenszel Chi-Square was used to compare crude outcome rates. Results: There were 56,767 high-risk patients. The average age was 66 years and 53% were male. All-cause mortality rates were 6.8%, 6.3%, and 6.0% (p=0.028), and rates of hospitalization for acute coronary syndrome were 5.8%, 4.6%, and 4.0% (p<0.001) among low, medium, and high volume EDs respectively. There were 216,527 low-risk patients. The average age was 64 years and 42% were male. All-cause mortality rates were 2.0%, 1.9%, and 1.6% (p<0.001), and rates of hospitalization for acute coronary syndrome were 1.5%, 1.4%, and 1.0% (p<0.001) among low, medium, and high volume EDs respectively. Conclusion: Higher volume EDs were associated with decreased rates of all-cause mortality and admission for acute coronary syndrome among chest pain patients who were discharged home. Future research should study the reasons for this finding and attempt to improve outcomes in lower volume EDs.

scholarly journals External validation of an emergency department triage algorithm for chest pain patients

2020 ◽  
Vol 9 (6) ◽  
pp. 576-585
Author(s):  
Òscar Miró ◽  
Pedro Lopez-Ayala ◽  
Gemma Martínez-Nadal ◽  
Valentina Troester ◽  
Ivo Strebel ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Low Risk ◽  
Single Centre ◽  
Coronary Syndrome ◽  
Emergency Department Triage ◽  
Model C ◽  
Triage Algorithm ◽  
Pain Patients

Background We aimed to externally validate an emergency department triage algorithm including five hierarchical clinical variables developed to identify chest pain patients at low risk of having an acute coronary syndrome justifying delayed rather than immediate evaluation. Methods In a single-centre cohort enrolling 29,269 consecutive patients presenting with chest pain, the performance of the algorithm was compared against the emergency department discharge diagnosis. In an international multicentre study enrolling 4069 patients, central adjudication by two independent cardiologists using all data derived from cardiac work-up including follow-up served as the reference. Triage towards ‘low-risk’ required absence of all five clinical ‘high-risk’ variables: history of coronary artery disease, diabetes, pressure-like chest pain, retrosternal chest pain and age above 40 years. Safety (sensitivity and negative predictive value (NPV)) and efficacy (percentage of patients classified as low risk) was tested in this initial proposal (Model A) and in two additional models: omitting age criteria (Model B) and allowing up to one (any) of the five high-risk variables (Model C). Results The prevalence of acute coronary syndrome was 9.4% in the single-centre and 28.4% in the multicentre study. The triage algorithm had very high sensitivity/NPV in both cohorts (99.4%/99.1% and 99.9%/99.1%, respectively), but very low efficacy (6.2% and 2.7%, respectively). Model B resulted in sensitivity/NPV of 97.5%/98.3% and 96.1%/89.4%, while efficacy increased to 14.2% and 10.4%, respectively. Model C resulted in sensitivity/NPV of 96.7%/98.6% and 95.2%/91.3%, with a further increase in efficacy to 23.1% and 15.5%, respectively. Conclusion A triage algorithm for the identification of low-risk chest pain patients exclusively based on simple clinical variables provided reasonable performance characteristics possibly justifying delayed rather than immediate evaluation in the emergency department.

scholarly journals 0043: Prognosis of patients admitted with chest pain in emergency department and discharged with low risk of acute coronary syndrome

2015 ◽  
Vol 7 (1) ◽  
pp. 109
Author(s):  
Gaëlle Haziza ◽  
Nathalie Cueille ◽  
Julien Magne ◽  
Dominique Cailloce ◽  
Patrice Virot ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Low Risk ◽  
Coronary Syndrome

Comparative Prospective Study of the Performance of Chest Pain Scores and Clinical Assessment in an Emergency Department Cohort in Singapore

2020 ◽  
Author(s):  
Ng Mingwei ◽  
Hong Jie Gabriel Tan ◽  
Fei Gao ◽  
Jack Wei Chieh Tan ◽  
Swee Han Lim ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Clinical Assessment ◽  
Clinical Judgment ◽  
Low Risk ◽  
Major Adverse Cardiovascular Events ◽  
Coronary Syndrome ◽  
Pain Scores ◽  
Pain Patients

Abstract Background Chest pain scores allow emergency physicians to identify low-risk patients for whom discharge can be safely expedited. While their utility have been extensively studied and validated in Western cohorts, data in patients of Asian heritage is lacking. This study aimed to determine the accuracy of HEART, EDACS and GRACE in risk-stratifying which emergency patients with chest pain or angina-equivalent symptoms are at risk of major adverse cardiovascular events (MACE) within 30 days (composite of all-cause mortality, acute myocardial infarction, and coronary revascularization). This single-centre prospective cohort-study enrolling 1200 patients was conducted by a large urban tertiary centre in Singapore. The chest pain scores were reported prior to disposition by research assistants blinded to the physician’s clinical assessment. Outcome adjudication was performed by an independent blinded cardiologist and emergency physician, while a second cardiologist adjudicated in the case of discrepancies. \Results Of 1200 patients enrolled, 5 withdrew consent and were excluded from analyses. 135 patients (11.3%) suffered MACE within 30 days. HEART, which ruled-out acute coronary syndrome in 52.8% of patients with 88.1% sensitivity, and EDACS, which ruled-out acute coronary syndrome in 57.5% of patients with 83.7% sensitivity, proved comparable to clinical judgment which ruled-out acute coronary syndrome in 73.0% of patients with 85.5% sensitivity. GRACE was weaker – ruling-out acute coronary syndrome in 79.2% of patients but with a dismal sensitivity of 45.0%. The correlation-statistic for HEART (79.4%) was also superior to EDACS (69.9%) and GRACE (69.2%). Conclusions HEART more accurately identified low-risk chest pain patients in an Asian emergency department who were suitable for expedited discharge and demonstrated comparable performance characteristics to clinical judgment. This has major implications on the use of chest pain scores to safely expedite disposition decisions for low-risk chest pain patients in the emergency department.

The ethical dilemma of emergency department patients with low-risk chest pain

2021 ◽  
pp. emermed-2020-209900
Author(s):  
Nella W Hendley ◽  
John Moskop ◽  
Nicklaus P Ashburn ◽  
SA Mahler ◽  
Jason P Stopyra
Keyword(s):  
Emergency Department ◽  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Practice Guidelines ◽  
Ethical Dilemma ◽  
Low Risk ◽  
Best Interests ◽  
Ethical Principles ◽  
Coronary Syndrome ◽  
Emergency Department Patients

Millions of patients present to US EDs each year with symptoms concerning for acute coronary syndrome (ACS), but fewer than 10% are ultimately diagnosed with ACS. Well-tested and externally validated accelerated diagnostic protocols were developed to aid providers in risk stratifying patients with possible ACS and have become central components of current ED practice guidelines. Nevertheless, the fear of missing ACS continues to be a strong motivator for ED providers to pursue further testing for their patients. An ethical dilemma arises when the provider must balance the risk of ACS if the patient is discharged compared with the potential harms caused by a cardiac workup. Providers should be familiar with the ethical principles relevant to this dilemma in order to determine what is in the best interests of the patient.

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