The Impact of an Accelerated Clinical Protocol with Outpatient Stress Testing in Chest Pain Patients at Low Risk of Acute Coronary Syndrome on Admission Rates

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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Predictive Value of a 6-Hour Ecg/Troponin Protocol in Patients with Chest Pain

Hong Kong Journal of Emergency Medicine ◽

10.1177/102490790301000303 ◽

2003 ◽

Vol 10 (3) ◽

pp. 146-152 ◽

Cited By ~ 1

Author(s):

CY Man ◽

PA Cameron ◽

WL Cheung

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Troponin T ◽

Low Risk ◽

Chinese Patients ◽

Initial Assessment ◽

Coronary Syndrome ◽

Pain Patients

Introduction Patients presenting with chest pain and considered to be at low risk of acute coronary syndrome (ACS) may still have coronary heart disease. The potential risk of sudden cardiac death due to arrhythmias or progression to acute myocardial infarction still exists. To minimize this risk, we have designed a 6-hour risk stratification protocol for patients with a low risk of acute myocardial infarction on initial assessment in the Accident and Emergency Department (AED). Materials & Methods This was a retrospective observational study with the aim of determining the risk of adverse cardiovascular events in chest pain patients attending an AED. These patients were subject to an ECG and cardiac troponin T tests (cTnT) at 0 hour and at 6 hours (if the two tests were negative at 0 hour), and were put under observation in the AED observation ward during the same period. The main outcome measures were adverse cardiac events at 30 days. Results A total of 371 Chinese patients considered to have low risk of ACS were recruited into the protocol. Troponin T tested positive in 19 patients (5.1%) at 0 hour and 8 patients (2.2%) at 6 hours. Amongst the 332 patients that were discharged directly from the AED, there were no re-admissions for cardiac-related deaths, acute myocardial infarction, arrhythmia or heart failure. Conclusion The 6-hour ECG and troponin T observation protocol is a useful tool to allow safe discharge of chest pain patients who are at low risk of acute coronary syndrome.

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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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Cost-Effectiveness of a 2 Hour Versus an 8 Hour Assessment Protocol for Chest Pain Patients with Low Risk of Acute Coronary Syndrome

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2005.06.148 ◽

2005 ◽

Vol 46 (3) ◽

pp. 39

Author(s):

S. Upadhye ◽

J. Fan

Keyword(s):

Acute Coronary Syndrome ◽

Cost Effectiveness ◽

Chest Pain ◽

Low Risk ◽

Assessment Protocol ◽

Coronary Syndrome ◽

Pain Patients

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The Impact of B-Type Natriuretic Peptide in Addition to Troponin I, Creatine Kinase-MB, and Myoglobin on the Risk Stratification of Emergency Department Chest Pain Patients With Potential Acute Coronary Syndrome

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2006.08.024 ◽

2007 ◽

Vol 49 (2) ◽

pp. 153-163 ◽

Cited By ~ 16

Author(s):

Aaron M. Brown ◽

Keara L. Sease ◽

Jennifer L. Robey ◽

Frances S. Shofer ◽

Judd E. Hollander

Keyword(s):

Emergency Department ◽

Acute Coronary Syndrome ◽

Creatine Kinase ◽

Chest Pain ◽

Risk Stratification ◽

Troponin I ◽

Coronary Syndrome ◽

Creatine Kinase Mb ◽

The Impact ◽

Pain Patients

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95 Nuclear Stress Testing in Emergency Department Chest Pain Patients With Suspected Acute Coronary Syndrome: Who Should We Stress?

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2011.06.121 ◽

2011 ◽

Vol 58 (4) ◽

pp. S209

Author(s):

R.C. Buchheit ◽

F.M. Fesmire ◽

Y. Cao ◽

H.W. Severance ◽

G.W. Heath

Keyword(s):

Emergency Department ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Stress Testing ◽

Coronary Syndrome ◽

Nuclear Stress Testing ◽

Pain Patients

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Low-risk Chest Pain Patients Younger Than 40 Years Do Not Benefit From Admission and Stress Testing

Critical Pathways in Cardiology ◽

10.1097/hpc.0b013e3182a75e3f ◽

2013 ◽

Vol 12 (4) ◽

pp. 201-203 ◽

Cited By ~ 3

Author(s):

Anthony M. Napoli ◽

Steven Tran ◽

Jing Wang

Keyword(s):

Chest Pain ◽

Stress Testing ◽

Low Risk ◽

Pain Patients

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Reliability of the CARE rule and the HEART score to rule out an acute coronary syndrome in non-traumatic chest pain patients

Internal and Emergency Medicine ◽

10.1007/s11739-018-1803-4 ◽

2018 ◽

Vol 13 (7) ◽

pp. 1111-1119 ◽

Cited By ~ 3

Author(s):

Thomas Moumneh ◽

Vanessa Richard-Jourjon ◽

Emilie Friou ◽

Fabrice Prunier ◽

Caroline Soulie-Chavignon ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Heart Score ◽

Coronary Syndrome ◽

Pain Patients ◽

Rule Out

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PP23 Accuracy of emergency medical services (EMS) telephone triage in identifying acute coronary syndrome (ACS) for chest pain patients. A systematic review abstract

Emergency Medicine Journal ◽

10.1136/emermed-2021-999.23 ◽

2021 ◽

Vol 38 (9) ◽

pp. A10.2-A10

Author(s):

Ahmed Alotaibi ◽

Abdulrhman Alghamdi ◽

Charles Reynard ◽

Richard Body

Keyword(s):

Systematic Review ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Prediction Models ◽

Meta Analysis ◽

Final Diagnosis ◽

Telephone Triage ◽

Coronary Syndrome ◽

Life Threatening ◽

Pain Patients

IntroductionChest pain is one of the most common reasons for ambulance callouts and presentation to Emergency Departments (EDs). Differentiating patients with serious conditions (e.g. acute coronary syndrome [ACS]) from the majority, who have self-limiting, non-cardiac conditions is extremely challenging. This causes over-triage and over-use of healthcare resources. We aimed to systematically review existing evidence on the accuracy of emergency telephone triage to detect ACS or life-threatening conditions associated with chest pain.MethodsWe conducted a systematic review in accordance with PRISMA guidelines. Two independent investigators searched the Embase, Medline, and Cinahl databases for relevant papers. We included retrospective and prospective cohort studies written in English and investigating EMS telephone triage for chest pain patients linked with final diagnosis of ACS. Studies were summarised in a narrative format as the data were not suitable for meta-analysis.ResultIn total, 553 studies were identified from the literature search and cross-referencing. After excluding 550 studies, three were eligible for inclusion. Among those 3 studies, there are different prediction models developed by authors with variation in variables to detect ACS. The result showed that dispatch triage tools have good sensitivity to detect ACS and life-threatening conditions although they are used to triage sign and symptoms rather than diagnosing the patients. On the other hand, prediction models were built to detect ACS and life-threatening conditions and therefore it showed better sensitivity and NPV.ConclusionEMS dispatch systems accuracy for ACS and life-threatening conditions associated with chest pain is good. Since the dispatch tools were built to triage ambulance response priority based on sign and symptoms, this led to over triage among non-life-threatening chest pain patients. Over triage were slightly reduced by deriving prediction models and showed better sensitivity.

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