Independent predictors of repeat emergency room presentations in patients with noncardiac chest pain: insights from a cohort of 1066 consecutive patients with 4770 repeat presentations

Abstract Introduction Repeat attendances with noncardiac chest pain (NCCP) to emergency room (ER) are frequent..Our aim was to analyse predictors of repeat presentations to ER in patients with NCCP. Methods We prospectively enrolled 1066 consecutive presentations with NCCP to a major urban hospital ER. Index of multiple deprivation (IMR) was computed. Charlson comorbidity (CCM) index was determined. Repeat presentation to ER to any national hospital was determined by a national linked database (pop. 53.5m). Results Median age was 43 (IQR 28, 59), 50.8% were male. 63% were current or previous smokers. 1 year incidence of adjudicated MI, coronary revascularisation and all-cause death was 0.6%, 2% and 5.3% respectively. There was a total of 4770 repeat ER presentations. After taking account of death independent predictors for repeat presentation were current smoking (OR 1.844, p=0.001) and CCM score ≥1 (OR 1.58, p=0.014) (table). Conclusions Smoking and patients with multiple comorbidities represent health policy targets for lessening hospital burden of NCCP. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Liverpool University Hospital NHS Trust; North-West Educational Cardiac Group

Download Full-text

313 Prognostic implications of semi-supine exercise stress echocardiography for the evaluation of chest pain in the emergency room

European Journal of Echocardiography ◽

10.1016/s1525-2167(99)80089-4 ◽

1999 ◽

Vol 1 ◽

pp. S26-S26

Author(s):

P LANCELLOTTI ◽

E HOFFER ◽

H APPELTANS ◽

A GHUYSEN ◽

V DORIO ◽

...

Keyword(s):

Chest Pain ◽

Emergency Room ◽

Stress Echocardiography ◽

Exercise Stress ◽

Exercise Stress Echocardiography ◽

Prognostic Implications

Download Full-text

Individuals with familial hypercholesterolemia have increased risk of re-hospitalization after acute myocardial infarction compared with controls

European Heart Journal ◽

10.1093/ehjci/ehaa946.2962 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

K Svendsen ◽

H.W Krogh ◽

J Igland ◽

G.S Tell ◽

L.J Mundal ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Familial Hypercholesterolemia ◽

Cox Regression ◽

Public Institution ◽

University Hospital ◽

Funding Source ◽

Hazard Ratios ◽

Increased Risk ◽

University Of Oslo

Abstract Background and aim We have previously reported that individuals with familial hypercholesterolemia (FH) have a two-fold increased risk of acute myocardial infarction (AMI) compared with the general population. The consequences of having an AMI on re-hospitalization and mortality are however less known. The aim of the present study was to compare the risk of re-hospitalization with AMI and CHD and risk of mortality after incident (first) AMI-hospitalization between persons with and without FH (controls). Methods The original study population comprised 5691 persons diagnosed with FH during 1992–2014 and 119511 age and sex matched controls randomly selected from the general Norwegian population. We identified 221 individuals with FH and 1947 controls with an incident AMI registered in the Norwegian Patient Registry (NPR) or the Cardiovascular Disease in Norway Project during 2001–2017. Persons with incident AMI were followed until December 31st 2017 for re-hospitalization with AMI or coronary heart disease (CHD) registered in the NPR, and for mortality through linkage to the Norwegian Cause of Death Registry. Risk of re-hospitalization was compared with sub-hazard ratios (SHR) from competing risk regression with death as competing event, and mortality was compared using hazard ratios (HR) from Cox regression. All models were adjusted for age. Results Risk of re-hospitalization was 2-fold increased both for AMI [SHR=2.53 (95% CI: 1.88–3.41)] and CHD [SHR=1.82 (95% CI: 1.44–2.28)]. However, persons with FH did not have increased 28-day mortality following an incident AMI (HR=1.05 (95% CI: 0.62–1.78), but the longer-term (>28 days) mortality after first AMI was increased in FH [HR=1.45 (95% CI: 1.07–1.95]. Conclusion This study yields the important finding that persons with FH have increased risk of re-hospitalization of both AMI and CHD after incident AMI. These findings call for more intensive follow-up of individuals with FH after an AMI. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): University of Oslo and Oslo University Hospital

Download Full-text

Adding stress biomarkers to high sensitivity troponin measurements increases precision and efficacy of rapid rule out protocols for NSTEMI

European Heart Journal ◽

10.1093/ehjci/ehaa946.1698 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

I Restan ◽

O.T Steiro ◽

H.L Tjora ◽

J Langoergen ◽

T Omland ◽

...

Keyword(s):

Chest Pain ◽

Acute Chest Pain ◽

High Sensitivity ◽

Final Diagnosis ◽

Public Institution ◽

P Value ◽

Funding Source ◽

University Hospitals ◽

High Sensitivity Troponin ◽

Rule Out

Abstract Background NSTEMI may be ruled out in patients presenting with acute chest pain based on low baseline high sensitivity troponin (cTn) at admission. This procedure is limited by a low expected frequency of ruled out non-cardiac chest pain (NCCP) patients. Purpose To investigate if stress-induced biomarkers (glucose or copeptin) combined with cTn can increase the rate of NCCP ruled out without an unacceptable increase in incorrectly ruled out NSTEMI. Method 971 patients with suspected NSTE-ACS were included. Final diagnosis was adjudicated by two independent cardiologists using clinical data including routine cTnT. Additionally, baseline cTnI, cTnI from Singulex Clarity System (cTnI(sgx)), copeptin and glucose were measured. Diagnostic performance to rule out NSTEMI was compared between the ESC rule out algorithms for cTnT and cTnI(Abbott), a local cTnI(sgx) algorithm and different combinations of cTn with copeptin or glucose Results Median age 61 years, 60% male. 13% had NSTEMI, 12% had UAP and 60% NCCP. Distribution of copeptin and glucose concentrations (NSTEMI and NCCP) is shown in figure 1. Copeptin and cTnT produces an algorithm with lower miss rate for NSTEMI, increased rule out rate for NCCP and significantly higher AUC (DeLong test, p value <0.001) compared to the ESC algorithm (Table 1). cTnI(sgx) and copeptin showed higher rule out for NCCP and higher AUC (p value <0.001), however an increased rule out rate for NSTEMIs. Combining cTnI(Abbott) and glucose gave a similar miss rate for NSTEMI as ESC, but increased rule out rate for NCCP and higher AUC (p value <0.001). Conclusion Combining cTnT or cTnI(sgx) with copeptin; or cTnI with glucose, improves diagnostic precision and efficacy of rule out protocols for NSTEMI in patients presenting with acute chest pain. Figure 1 Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Western Norway Regional Health Authority; Haukeland and Stavanger University Hospitals

Download Full-text

Electrocardiographic markers of atrial cardiomyopathy predict ineffective cardioversion: a FinCV2 cohort study

European Heart Journal ◽

10.1093/ehjci/ehaa946.0408 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Relander ◽

T Hellman ◽

T Vasankari ◽

I Nuotio ◽

K.E.J Airaksinen ◽

...

Keyword(s):

Sinus Rhythm ◽

Independent Predictor ◽

P Wave ◽

University Hospital ◽

Funding Source ◽

Recurrence Rates ◽

Cardiovascular Research ◽

Wave Duration ◽

P Wave Duration ◽

Af Recurrence

Abstract Background Rhythm control using electrical cardioversion (CV) is a common treatment strategy for patients with symptomatic atrial fibrillation (AF). However, little is known about electrocardiographic (ECG) markers predicting CV failure and AF recurrence. Methods This study included 726 patients who underwent a CV for AF lasting >48h in a referral hospital. We analysed markers of atrial cardiomyopathy in post-CV sinus rhythm ECGs and compared them with CV failure and AF recurrence rates within 30 days after CV as well as their combination (ineffective CV). Of those with failed CV the most recent sinus rhythm ECG was used. Results CV was unsuccessful in 66 out of 726 patients (9.09%). Advanced interatrial block (IAB) defined as P-wave duration ≥120ms and biphasic morphology in inferior (II, III and aVF) leads (OR 3.96, 95%-CI 2.09–7.52, p<0.001) was an independent predictor for CV failure. Within 30 days after CV, AF recurred in 214 (32.4%) patients. Advanced IAB (OR 2.10, 95%-CI 1.19–3.72, p=0.011) was an independent predictor for AF recurrence. In total CV was ineffective (CV failure or AF recurrence) 280 of 726 times (38.6%). Advanced IAB (OR 2.72, 95%-CI 1.64–4.51, p<0.001) was an independent predictor for ineffective CV. Partial IAB categorized as P-wave duration ≥120ms with no biphasic morphology did not predict any end points. Conclusions Advanced IAB predicts CV inefficacy. This study identified ECG markers of atrial cardiomyopathy for clinical use in CV patient selection. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): This study research was funded by grants from the Finnish Medical Foundation, the Finnish Foundation for Cardiovascular Research, State Clinical Research Fund of Turku University Hospital, Turku, Finland, Finnish Cardiac Society, the Emil Aaltonen Foundation, and the Maud Kuistila Foundation.

Download Full-text

Real world cost and health outcomes of patients presented with chest pain in England: which is the most cost-effective first-line test?

European Heart Journal ◽

10.1093/ehjci/ehaa946.3547 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Tsiachristas ◽

H West ◽

E.K Oikonomou ◽

B Mihaylova ◽

N Sabharwall ◽

...

Keyword(s):

Chest Pain ◽

Health Outcomes ◽

Diagnostic Tests ◽

Clinical Presentation ◽

Cost Effective ◽

Funding Source ◽

First Line ◽

Nice Guidelines ◽

Exercise Ecg ◽

Stable Chest Pain

Abstract Background The National Institute for Health and Care Excellence (NICE) updated their guidance for the management of patients with stable chest pain and recommended that all patients undergo computed tomography coronary angiography (CTCA). This update has sparked a great deal of debate, and was followed by upgrade of CTCA into a Class I indication in the recent ESC guidelines. The cost-effectiveness of using CTCA as first line investigation is still unclear. Purpose To describe the current clinical pathway of patients with stable chest pain presented to outpatient clinics, assess the compliance with the updated NICE guideline, and explore the costs and health outcomes of different non-invasive diagnostic tests in real-world clinical setting. Methods We used data of 4,297 patients who attended chest pain clinics in Oxford between 1 January 2014 and 31 July 2018. Data included clinical presentation (e.g. age and previous cardiovascular conditions), diagnostic tests, outpatient visits, hospitalization, and hospital mortality and was compared between 6 alternative first-line diagnostic tests. Multinomial regressions were performed to estimate the probability of receiving each alternative and the associated cost after adjusting for clinical presentation. A decision tree was developed to describe the clinical pathway for each alternative first-line diagnostic in terms of subsequent diagnostic tests and treatments and to estimate the associated costs and life days. Results The proportion of patients who received CTCA as first line diagnostic test increased from 1% in 2014 to 17% in 2018, while the publication of the updated NICE guidelines in 2016 led to a threefold increase in this proportion. CTCA is less likely to be provided as a first-line diagnostic to patients who are younger age, males, smokers, and have angina, PVD, or diabetes. The standardised rate of hospital admission was the lowest in the exercise ECG cohort (0.35 admissions per 1,000 life-days) followed by the CTCA cohort (0.40 admissions per 1,000 life-days) while the latter cohort had the lowest standardised rate of cardiovascular treatment (2.74% per 1,000 life days). Stress echocardiography and MPS were associated with higher costs compared with CTCA, other ECG, and exercise ECG after adjusting for clinical presentation and days of follow-up. CTCA is the pathway most likely to be cost-effective, even compared to exercise ECG, while the other diagnostic alternatives are dominated (i.e. they cost more for less life-days). Conclusions Currently, the updated NICE guidelines for stable chest pain are implemented only to a fifth of the cases in England. Our findings support existing evidence that CTCA is the most-cost effective first-line diagnostic test for this population. Hopefully, this will inform the debate around the implementation of the guidelines and help commissioning and clinical decision processes worldwide. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institute of Health Research Oxford Biomedical Research Centre

Download Full-text

Regional disparities in the clinical profiles of patients with peripartum cardiomyopathy in Nigeria: results from the peripartum cardiomyopathy in Nigeria Registry

European Heart Journal ◽

10.1093/ehjci/ehaa946.2068 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

K Karaye ◽

H Sai'du ◽

S.A Balarabe ◽

N.A Ishaq ◽

U.G Adamu ◽

...

Keyword(s):

Systolic Function ◽

Economic Status ◽

Healthcare Providers ◽

Systolic Pressure ◽

Peripartum Cardiomyopathy ◽

Pulmonary Artery Systolic Pressure ◽

Funding Source ◽

Private Company ◽

North West ◽

Clinical Profiles

Abstract Background Peripartum cardiomyopathy (PPCM) seems to have varied epidemiology within and between countries. We recently reported that Kano (North-West Nigeria) has the highest known incidence of PPCM in the world, but the clinical profiles of the patients by regions have not been previously reported. In this study, we aimed to describe the regional differences (if any) in the clinical profiles of patients with PPCM in Nigeria. Methods We consecutively recruited 244 PPCM patients over 9 months from 3 hospitals in Kano (n=199; 81.6%) and from 11 hospitals spread across the North-Central, South-West, South-East and South-South zones (n=45; 18.4%) of Nigeria. Results The baseline characteristics of the patients are summarised in Table 1. 35 (17.6%) patients in Kano and 10 (23.2%) patients in other zones died (p=0.0523) after a median of 17 months. Conclusion PPCM patients in Kano were younger, had lower socio-economic status, presented to hospitals later, were less symptomatic, had larger sizes of cardiac chambers, worse right ventricular systolic function, higher pulmonary artery systolic pressure and were receiving less treatment at enrolment, than those in other zones in Nigeria. This information will be used for advocacy and interactions with healthcare providers. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Dantata Group of Companies (Nigeria). Ammasco International Ltd. (Nigeria). Fortune Oil Mills Nigeria Ltd.

Download Full-text

Impaired Esophageal Mucosal Integrity May Play a Causative Role in Patients With Nongastroesophageal Reflux Disease–Related Noncardiac Chest Pain

Medicine ◽

10.1097/md.0000000000002295 ◽

2015 ◽

Vol 94 (51) ◽

pp. e2295 ◽

Cited By ~ 6

Author(s):

Yang Won Min ◽

Kyu Choi ◽

Jeung Hui Pyo ◽

Hee Jung Son ◽

Poong-Lyul Rhee

Keyword(s):

Chest Pain ◽

Reflux Disease ◽

Noncardiac Chest Pain ◽

Causative Role ◽

Mucosal Integrity

Download Full-text

Triage Ability of Emergency Medical Services Providers and Patient Disposition: A Prospective Study

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00027552 ◽

1999 ◽

Vol 14 (3) ◽

pp. 67-72 ◽

Cited By ~ 17

Author(s):

John R. Richards ◽

Stephen J. Ferrall

Keyword(s):

Chest Pain ◽

Emergency Medical Services ◽

Patient Characteristics ◽

University Hospital ◽

Medical Services ◽

Shortness Of Breath ◽

Study Objective ◽

Patient Disposition ◽

Emergency Medical ◽

Respiratory Complaints

AbstractStudy objective:To determine the ability of emergency medical services (EMS) providers to subjectively triage patients with respect to hospital admission and to determine patient characteristics associated with increased likelihood of admission.Methods:A prospective, cross-sectional study of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban, university hospital, Emergency Department. Emergency medical services providers completed a questionnaire asking them to predict admission to the hospital and requested patient demographic information. Predictions were compared to actual patient disposition.Results:A total of 887 patients were included in the study, and 315 were admitted to the hospital (36%). With respect to admission, emergency medical services providers had an accuracy rate of 79%, with a sensitivity of 72% and specificity of 83% (kappa = 0.56). Blunt traumatic injury and altered mental status were the most common medical reasons for admission. Variables significantly associated with high admission rates were patients with age > 50 years, chest pain or cardiac complaints, shortness of breath or respiratory complaints, Medicare insurance, and Hispanic ethnicity. The emergency medical services providers most accurately predicted admission for patients presenting with labor (kappa = 1.0), shortness of breath / respiratory complaints (kappa = 0.84), and chest pain (kappa = 0.77).Conclusion:Emergency medical services providers can predict final patient disposition with reasonable accuracy, especially for patients presenting with labor, shortness of breath, or chest pain. Certain patient characteristics are associated with a higher rate of actual admission.

Download Full-text