Management strategy of chest pain patients with or without evidence of acute coronary syndrome in the emergency department

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.

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An Italian registry of chest pain patients in the emergency department: clinical predictors of acute coronary syndrome

Minerva Medica ◽

10.23736/s0026-4806.20.06472-1 ◽

2020 ◽

Vol 111 (2) ◽

Cited By ~ 3

Author(s):

Paola Ballarino ◽

Gianfranco Cervellin ◽

Cecilia Trucchi ◽

Fiorella Altomonte ◽

Alessio Bertini ◽

...

Keyword(s):

Emergency Department ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Clinical Predictors ◽

Coronary Syndrome ◽

Pain Patients

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

10.21203/rs.3.rs-51171/v1 ◽

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.

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