scholarly journals Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study

2021 ◽  
Author(s):  
Dustin G. Mark ◽  
Jie Huang ◽  
Dustin W. Ballard ◽  
Mamata V. Kene ◽  
Dana R. Sax ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cohort Study ◽  
Chest Pain ◽  
Risk Stratification ◽  
Resource Utilization ◽  
Coronary Risk ◽  
Index Visit ◽  
Coronary Syndrome ◽  
Estimated Risk ◽  
Cardiac Testing

Background Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA‐ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA‐ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48‐month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7‐day objective cardiac testing). Secondary outcomes were 30‐day objective cardiac testing, 60‐day major adverse cardiac events (MACE), and 60‐day MACE‐CR (MACE excluding coronary revascularization). Difference‐in‐differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30‐day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60‐day MACE risk (−2.5%, 95% CI −3.7 to −1.2%, P <0.001) and increased among patients with non‐low (>2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, P =0.014), without significant overall change (−1.0%, 95% CI −2.1 to 0.1%, P =0.079). There were no statistically significant differences in index visit resource utilization, 60‐day MACE or 60‐day MACE‐CR. Conclusions Implementation of RISTRA‐ACS was associated with better allocation of 30‐day objective cardiac testing and no change in index visit resource utilization or 60‐day MACE. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03286179.

scholarly journals Diagnostic accuracy of the HEART Pathway and EDACS-ADP when combined with a 0-hour/1-hour hs-cTnT protocol for assessment of acute chest pain patients

2021 ◽  
pp. emermed-2020-210833
Author(s):  
Tsvetelina Nilsson ◽  
Erik Johannesson ◽  
Jakob Lundager Forberg ◽  
Arash Mokhtari ◽  
Ulf Ekelund
Keyword(s):  
Chest Pain ◽  
Risk Stratification ◽  
Diagnostic Accuracy ◽  
Troponin T ◽  
Secondary Outcome ◽  
Index Visit ◽  
Heart Score ◽  
Coronary Syndrome ◽  
Pain Patients ◽  
Rule Out

Background/aimIn ED chest pain patients, a 0-hour/1-hour protocol based on high sensitivity cardiac troponin T (hs-cTnT) tests combined with clinical risk stratification in diagnosing acute coronary syndrome is recommended. Two of the most promising risk stratification tools are the History, ECG, Age, Risk Factors and Troponin (HEART) and Emergency Department Assessment of Chest Pain (EDAC) scores. Few studies have assessed the diagnostic accuracy of the 0-hour/1-hour hs-cTnT protocol when combined with HEART score, and none with EDACS. In ED chest pain patients, we aimed to evaluate the diagnostic accuracy of a 0-hour/1-hour hs-cTnT protocol combined the HEART Pathway, or the EDACS accelerated diagnostic pathway (EDACS-ADP).MethodsThis was a secondary analysis of data from a prospective observational study enrolling 1167 ED chest pain patients who visited the ED at Skåne University Hospital in Lund, Sweden in the period between February 2013 and April 2014. HEART and EDAC scores were assessed together with hs-cTnT at 0 and 1 hour and compared with HEART score alone. Sensitivity, specificity, negative predictive value (NPV) and likelihood ratios were evaluated. The primary outcome was major adverse cardiac events (MACE) including unstable angina within 30 days. The secondary outcome was index visit acute myocardial infarction (AMI).ResultsA total of 939 patients were included in the final analysis. When combined with 0-hour/1-hour hs-cTnT testing, the HEART Pathway and EDACS-ADP identified 49.8% and 49.6% of the patients for rule-out, with NPVs for 30-day MACE of 99.8% and 99.1%, compared with the HEART score alone that identified 53.4% of the patients for rule-out with NPV of 99.2%. The NPV for index visit AMI were 100%, 99.8% and 99.2%, respectively.ConclusionThe combination of the HEART Pathway or the EDACS-ADP with a 0-hour/1-hour hs-cTnT protocol allows safe and early rule-out in a large proportion of ED chest pain patients.

scholarly journals Performance Of The Modified Heart Score In An Asian Population

2020 ◽  
Author(s):  
Shanaz Sajeed ◽  
Michael De Dios ◽  
Dan Ong Wei Jun ◽  
Amila Clarence Punyadasa
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Risk Stratification ◽  
Risk Group ◽  
Asian Population ◽  
Low Risk ◽  
Predictive Tool ◽  
Heart Score ◽  
Coronary Syndrome ◽  
Chinese Study

Abstract INTRODUCTION Chest pain is the most common potentially life threatening presentation to the emergency department (ED). Furthermore, the identification of acute coronary syndrome (ACS) including its risk stratification and subsequent disposition can be challenging. The original HEART score was derived as a predictive tool to risk stratify patients presenting with undifferentiated chest pain (CP) and aid physician decision-making. However, it utilized conventional Troponins as its cardiac biomarker component. Our study aims to assess the utility of the modified HEART score with highly sensitive troponins in an Asian setting with mixed ethnicity to determine if it corroborates the findings of the another recent Chinese study by Chun-Peng MA et al[7]. METHODS Clinical data from 413 patients presenting to the ED for evaluation of chest pain were analyzed. The predictive value of the modified HEART score for determining MACE was then evaluated.RESULTS 49 patients (11.9%) had a MACE: 31 patients (7.5%) underwent PCI, and 1 patient (0.2%) underwent CABG. There were 17 (4.1%) deaths.Three risk groups were elucidated based on MACE. In the low risk group (0-2), there were 72 patients (17.4%), with a MACE rate of 1.4%. In the intermediate risk group (3-5), there were 233 patients (56.4%), with a MACE rate of 5.2%. In the high risk group (6-10), there were 108 patients (26.2%), with a MACE rate of 33.3%. CONCLUSION The modified HEART score is an effective risk stratification tool in an ethnically diverse Asian population. Furthermore, it identifies low risk patients who are candidates for early discharge from a local emergency department.

Modified TIMI risk score cannot be used to identify low-risk chest pain in the emergency department: a multicentre validation study

2013 ◽  
Vol 31 (4) ◽  
pp. 281-285 ◽  
Author(s):  
Stephen P J Macdonald ◽  
Yusuf Nagree ◽  
Daniel M Fatovich ◽  
Simon G A Brown
Keyword(s):  
Myocardial Infarction ◽  
Emergency Department ◽  
Chest Pain ◽  
Risk Stratification ◽  
Sensitivity And Specificity ◽  
Risk Score ◽  
Composite Outcome ◽  
Coronary Syndrome ◽  
Timi Score ◽  
Timi Risk Score

AimThe Thrombolysis in Myocardial Infarction (TIMI) risk score (range 0–7), used for emergency department (ED) risk stratification of patients with suspected acute coronary syndrome (ACS), underestimates risk associated with ECG changes or cardiac troponin elevation. A modified TIMI score (mTIMI, range 0–10), which gives increased weighting to these variables, has been proposed. We aimed to evaluate the performance of the mTIMI score in ED patients with suspected ACS.MethodsA multicentre prospective observational study enrolled patients undergoing assessment for possible ACS. TIMI and mTIMI scores were calculated. The study outcome was a composite of all-cause death, myocardial infarction or coronary revascularisation within 30 days.ResultsOf the 1666 patients, 219 (13%) reached the study outcome. Area under the receiver operating characteristic curve for the composite outcome was 0.80 (0.76 to 0.83) for the mTIMI score compared with 0.71 (0.67 to 0.74) for the standard TIMI score, p<0.001, but there was no significant difference for death or revascularisation outcomes. Sensitivity and specificity for the composite outcome were 0.96 (0.92 to 0.98) and 0.23 (0.20 to 0.26), respectively, at score 0 for TIMI and mTIMI. At score <2, sensitivity and specificity were 0.82 (0.77 to 0.87) and 0.53 (0.51 to 0.56) for mTIMI, and 0.74 (0.68 to 0.79) and 0.54 (0.51 to 0.56) for standard TIMI, respectively.ConclusionsmTIMI score performs better than standard TIMI score for ED risk stratification of chest pain, but neither is sufficiently sensitive at scores >0 to allow safe and early discharge without further investigation or follow-up. Observed differences in performance may be due to incorporation bias.

scholarly journals Performance of The Modified Heart Score In An Asian Population

2020 ◽  
Author(s):  
Shanaz Sajeed ◽  
Michael De Dios ◽  
Dan Ong Wei Jun ◽  
Amila Clarence Punyadasa
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Risk Stratification ◽  
Risk Group ◽  
Asian Population ◽  
Low Risk ◽  
Predictive Tool ◽  
Heart Score ◽  
Coronary Syndrome ◽  
Chinese Study

Abstract INTRODUCTION Chest pain is the most common potentially life threatening presentation to the emergency department (ED). Furthermore, the identification of acute coronary syndrome (ACS) including its risk stratification and subsequent disposition can be challenging. The original HEART score was derived as a predictive tool to risk stratify patients presenting with undifferentiated chest pain (CP) and aid physician decision-making. However, it utilized conventional Troponins as its cardiac biomarker component. Our study aims to assess the utility of the modified HEART score with highly sensitive troponins in an Asian setting with mixed ethnicity to determine if it corroborates the findings of the another recent Chinese study by Chun-Peng MA et al[7]. METHODS Clinical data from 413 patients presenting to the ED for evaluation of chest pain were analyzed. The predictive value of the modified HEART score for determining MACE was then evaluated. RESULTS 49 patients (11.9%) had a MACE: 31 patients (7.5%) underwent PCI, and 1 patient (0.2%) underwent CABG. There were 17 (4.1%) deaths. Three risk groups were elucidated based on MACE. In the low risk group (0-2), there were 72 patients (17.4%), with a MACE rate of 1.4%. In the intermediate risk group (3-5), there were 233 patients (56.4%), with a MACE rate of 5.2%. In the high risk group (6-10), there were 108 patients (26.2%), with a MACE rate of 33.3%. CONCLUSION The modified HEART score is an effective risk stratification tool in an ethnically diverse Asian population. Furthermore, it identifies low risk patients who are candidates for early discharge from a local emergency department.

scholarly journals Prospective Validation and Comparative Analysis of Coronary Risk Stratification Strategies Among Emergency Department Patients With Chest Pain

2021 ◽  
Author(s):  
Dustin G. Mark ◽  
Jie Huang ◽  
Mamata V. Kene ◽  
Dana R. Sax ◽  
Dale M. Cotton ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Risk Stratification ◽  
Major Adverse Cardiac Event ◽  
Cardiac Event ◽  
Adverse Cardiac Event ◽  
Coronary Risk ◽  
Net Benefit ◽  
Emergency Department Patients ◽  
Rule Out

Background Coronary risk stratification is recommended for emergency department patients with chest pain. Many protocols are designed as “rule‐out” binary classification strategies, while others use graded‐risk stratification. The comparative performance of competing approaches at varying levels of risk tolerance has not been widely reported. Methods and Results This is a prospective cohort study of adult patients with chest pain presenting between January 2018 and December 2019 to 13 medical center emergency departments within an integrated healthcare delivery system. Using an electronic clinical decision support interface, we externally validated and assessed the net benefit (at varying risk thresholds) of several coronary risk scores (History, ECG, Age, Risk Factors, and Troponin [HEART] score, HEART pathway, Emergency Department Assessment of Chest Pain Score Accelerated Diagnostic Protocol), troponin‐only strategies (fourth‐generation assay), unstructured physician gestalt, and a novel risk algorithm (RISTRA‐ACS). The primary outcome was 60‐day major adverse cardiac event defined as myocardial infarction, cardiac arrest, cardiogenic shock, coronary revascularization, or all‐cause mortality. There were 13 192 patient encounters included with a 60‐day major adverse cardiac event incidence of 3.7%. RISTRA‐ACS and HEART pathway had the lowest negative likelihood ratios (0.06, 95% CI, 0.03–0.10 and 0.07, 95% CI, 0.04–0.11, respectively) and the greatest net benefit across a range of low‐risk thresholds. RISTRA‐ACS demonstrated the highest discrimination for 60‐day major adverse cardiac event (area under the receiver operating characteristic curve 0.92, 95% CI, 0.91–0.94, P <0.0001). Conclusions RISTRA‐ACS and HEART pathway were the optimal rule‐out approaches, while RISTRA‐ACS was the best‐performing graded‐risk approach. RISTRA‐ACS offers promise as a versatile single approach to emergency department coronary risk stratification. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03286179.

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