Current outcomes and outcome measures in acute coronary syndrome

ObjectivesFast diagnostic algorithms using high-sensitivity troponin (hsTn) in suspected acute coronary syndrome (ACS) are regarded as beneficial to expedite diagnosis and safe discharge of patients in crowded emergency departments (ED). This study investigates the effects of crowding on process times related to the diagnostic protocol itself or other time delays, and outcomes.DesignProspective single-centre observational study.SettingED (Germany).ParticipantsFinal study population of 2525 consecutive patients with suspected ACS within 12 months, after exclusion of patients with ST-elevation myocardial infarction, missing blood samples, referral from other hospitals or repeated visits.InterventionsUse of fast algorithms as per 2015 European Society of Cardiology guidelines.Main outcome measuresCrowding was defined as mismatch between patient numbers and monitoring capacities, or mean physician time per case, categorised as normal, high and very high crowding. Outcome measures were length of ED stay, direct discharge from ED, laboratory turn around times (TAT), utilisation of fast algorithms, absolute and relative non-laboratory time, as well as mortality.ResultsCrowding was associated with increased length of ED stay (3.75–4.89 hours, p<0.001). While median TAT of the first hsTnT increased (53–57 min, p<0.001), total TAT of serial hsTnT did not increase significantly with higher crowding (p=0.170). Lower utilisation of fast algorithms (p=0.009) and increase of additional hsTnT measurements after diagnosis (p=0.001) were observed in higher crowding. Most importantly, crowding was significantly associated with prolonged absolute (p<0.001), and particularly relative non-laboratory time (63.3%–71.3%, p<0.001). However, there was no significant effect of crowding on mortality, even after adjustment for relevant clinical variables.ConclusionsProcess times, and particularly non-laboratory times, are prolonged in a crowded ED diminishing some positive effects of fast diagnostic algorithms in suspected ACS. Higher crowding levels were not significantly associated with higher all-cause mortality rates.Trial registration numberNCT03111862.

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LO64: The HEART score in predicting major adverse cardiac events in patients presenting to the emergency department with possible acute coronary syndrome: a systematic review and meta-analysis

CJEM ◽

10.1017/cem.2019.107 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S31

Author(s):

C. Byrne ◽

C. Toarta ◽

B. Backus ◽

T. Holt

Keyword(s):

Acute Coronary Syndrome ◽

Outcome Measures ◽

Meta Analysis ◽

Major Adverse Cardiac Events ◽

Secondary Outcome ◽

Care Providers ◽

Cardiac Events ◽

Heart Score ◽

Coronary Syndrome ◽

Adverse Cardiac Events

Introduction: Acute coronary syndrome (ACS) is a common, sometimes difficult to diagnose spectrum of diseases. Given the diagnostic challenge, it is sensible for emergency physicians to have an approach to prognosticate patients with possible ACS. The objective of this review was to investigate the ability of the HEART score to predict major adverse cardiac events (MACE) in patients presenting to the ED with possible ACS. Methods: Eleven databases and other sources identified 468 potentially relevant studies. Sixty-seven studies underwent full text review with 25 studies meeting eligibility criteria. Main outcome measures were pooled prevalence, risk ratio (RR), and absolute risk reduction (ARR) for MACE within six weeks of ED evaluation, comparing HEART score 0–3 versus 4–10. Model discrimination (sensitivity, specificity, concordance statistic) and calibration (observed to expected events ratio) were also evaluated. Results: Data from 25 studies including 41,397 patients were combined in the meta-analysis. In total, 4815 patients (11.6%) developed MACE. Among 18,866 patients with HEART score 0–3, 396 (2.1%) developed MACE (RR 0.08; ARR 0.20). Outcome measures were consistent across planned subgroup and sensitivity analyses. Among studies with secondary outcome data for patients with HEART score 0–3, 5 of 6461 (0.1%) died and 75 of 7556 (1.0%) had a myocardial infarction. Conclusion: The HEART score provides a reliable quantitative risk assessment of MACE in ED patients with possible ACS. Emergency clinicians should consider using the HEART score to facilitate risk communication and shared decision making with patients and other care providers.

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