Modification of the Thrombolysis in Myocardial Infarction risk score for patients presenting with chest pain to the emergency department

Objective

To develop a modified Thrombolysis in Myocardial Infarction (TIMI) score to effectively risk stratify patients presenting to the ED with chest pain.

Methods

A prospective observational study was conducted at two metropolitan EDs. Data were obtained during patient interview. The primary outcome was major adverse cardiovascular events (MACE) within 30 days of presentation. Two separate modifications of the TIMI score were developed. These scores were compared to the original TIMI in terms of the area under the receiver operating characteristic curve and diagnostic accuracy statistics (sensitivity, specificity, positive and negative predictive values).

Results

Of 1760 patients, 364 (20.7%) experienced 30 day MACE. The first modified TIMI score was a simplified TIMI (s‐TIMI) including four variables: age ≥65 years, three or more risk factors, high‐sensitivity troponin (hs‐cTnI) and electrocardiogram changes. The second score included the same four variables plus two Global Registry of Acute Coronary Events (GRACE) variables (systolic blood pressure and estimated glomerular filtration rate). This score was termed the GRACE TIMI (g‐TIMI). s‐TIMI had a lower sensitivity compared to the original TIMI score (93.41 and 96.98%), but higher specificity (45.49 and 24.50%). The g‐TIMI had a sensitivity of 98.90% and specificity of 14.90%.

Conclusions

Attempts to modify the TIMI score yielded two scores with added predictive utility in comparison to the original TIMI model. The addition of GRACE variables (g‐TIMI) increased sensitivity for MACE, but decreased the specificity of the model. The s‐TIMI score yielded good specificity but had sensitivity that would not be acceptable by emergency physicians. The s‐TIMI may be useful as part of an accelerated chest pain protocol.     

Application of the TIMI Risk Score for Unstable Angina and Non-ST Elevation Acute Coronary Syndrome to an Unselected Emergency Department Chest Pain Population

Objectives: Patients presenting with chest pain or related symptoms suggestive of myocardial ischemia, without ST‐segment elevation (NSTE) on their presenting electrocardiograms, often present a diagnostic challenge in the emergency department (ED). Prompt and accurate risk stratification to identify those patients with NSTE chest pain who are at highest risk for adverse events is essential, however, to optimal management. Although validated and used frequently in patients already enrolled in acute coronary syndrome trials, the Thrombolysis in Myocardial Infarction (TIMI) risk score never has been examined for its value in risk stratification in an all‐comers, non–trial‐based ED chest pain population. Methods: An analysis of an ED‐based prospective observational cohort study was conducted in 3,929 adult patients presenting with chest pain syndrome and warranting evaluation with an electrocardiogram. These patients had TIMI risk scores determined at ED presentation. The main outcome was the composite of death, acute myocardial infarction (MI), and revascularization within 30 days. Results: The TIMI risk score at ED presentation successfully risk‐stratified this unselected cohort of chest pain patients with respect to 30‐day adverse outcome, with a range from 2.1%, with a score of 0, to 100%, with a score of 7. The highest correlation of an individual TIMI risk indicator to adverse outcome was for elevated cardiac biomarker at admission. Overall, the score had similar performance characteristics to that seen when applied to other databases of patients enrolled in clinical trials and registries using a 14‐day end point. Conclusions: The TIMI risk score may be a useful tool for risk stratification of ED patients with chest pain syndrome.     

Performance of a sensitive troponin assay in the early diagnosis of acute myocardial infarction in the emergency department

Aim: Troponin assays have high diagnostic value for myocardial infarction (MI), but sensitivity has been weak early after chest pain onset. New, so‐called ‘sensitive’ troponin assays have recently been introduced. Two studies report high sensitivity for assays taken at ED presentation, but studied selected populations. Our aim was to evaluate the diagnostic performance for MI of a sensitive troponin assay measured at ED presentation in an unselected chest pain population without ECG evidence of ischaemia. Methods: This is a sub‐study of a prospective cohort study of adult patients with potentially cardiac chest pain who underwent evaluation for acute coronary syndrome. Patients with clear ECG evidence of acute ischaemia or an alternative diagnosis were excluded. Data collected included demographic, clinical, ECG, biomarker and outcome data. A ‘positive’ troponin was defined as >99th percentile of the assay used. MI diagnosis was as judged by the treating cardiologist. The outcomes of interest were sensitivity, specificity and likelihood ratios (LR) for positive troponin assay taken at ED presentation. Data were analysed by clinical performance analysis. Results: Totally 952 were studied. Median age was 61 years; 56.4% were male and median TIMI score was 2. There were 129 MI (13.6, 95% CI 11.5–15.9). Sensitivity of TnI at ED presentation was 76.7% (95% CI 68.5–83.7%), specificity 93.6% (95% CI 91.7–95.1%), with LR positive 11.92 and LR negative 0.25. Conclusion: Sensitive TnI assay at ED presentation has insufficient diagnostic accuracy for detection of MI. Serial biomarker assays in patients with negative initial TnI are required.     

Prognosticating Clinical Prediction Scores Without Clinical Gestalt for Patients With Chest Pain in the Emergency Department

Background

Assessment of patients with chest pain is a regular challenge in the emergency department (ED). Recent guidelines recommended quantitative assessment of ischemic risk by means of risk scores.

Predicting Short‐term Risk of Arrhythmia among Patients With Syncope: The Canadian Syncope Arrhythmia Risk Score

Background

Syncope can be caused by serious occult arrhythmias not evident during initial emergency department (ED) evaluation. We sought to develop a risk tool for predicting 30‐day arrhythmia or death after ED disposition.

Methods

We conducted a multicenter prospective cohort study at six tertiary care EDs and included adults (≥16 years) with syncope. We collected standardized variables from clinical evaluation and investigations including electrocardiogram and troponin at index presentation. Adjudicated outcomes included death or arrhythmias including procedural interventions for arrhythmia within 30 days. We used multivariable logistic regression to derive the prediction model and bootstrapping for interval validation to estimate shrinkage and optimism.

Results

A total of 5,010 patients (mean ± SD age = 53.4 ± 23.0 years, 54.8% females, and 9.5% hospitalized) were enrolled with 106 (2.1%) patients suffering 30‐day arrhythmia/death after ED disposition. We examined 39 variables and eight were included in the final model: lack of vasovagal predisposition, heart disease, any ED systolic blood pressure < 90 or > 180 mm Hg, troponin (>99th percentile), QRS duration > 130 msec, QTc interval > 480 msec, and ED diagnosis of cardiac/vasovagal syncope (optimism corrected C‐statistic 0.90 [95% CI = 0.87–0.93]; Hosmer‐Lemeshow p = 0.08). The Canadian Syncope Arrhythmia Risk Score had a risk ranging from 0.2% to 74.5% for scores of –2 to 8. At a threshold score of ≥0, the sensitivity was 97.1% (95% CI = 91.6%–99.4%) and specificity was 53.4% (95% CI = 52.0%–54.9%).

Conclusions

The Canadian Syncope Arrhythmia Risk Score can improve patient safety by identification of those at risk for arrhythmias and aid in acute management decisions. Once validated, the score can identify low‐risk patients who will require no further investigations.     

Comparison of two clinical scoring systems for emergency department risk stratification of suspected acute coronary syndrome

Objective: To compare two methods of risk stratification for suspected acute coronary syndrome (ACS) in the ED. Methods: A prospective observational multicentre study was undertaken of patients undergoing evaluation in the ED for possible ACS. We compared the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHF/CSANZ) guideline and the Thrombolysis in Myocardial Infarction (TIMI) risk score for differentiating high‐ and low‐risk patients. Composite outcome was all cause death, myocardial infarction or coronary revascularisation within 30 days. Results: Of 1758 enrolments, 223 (13%) reached the study outcome. Area under the receiver operator characteristic (ROC) curve was 0.79 (95% CI 0.76–0.81) for the NHF/CSANZ group and 0.71 (0.68–0.75) for TIMI score based on initial troponin result (P < 0.001), and 0.82 (95% CI 0.80–0.84) and 0.76 (0.73–0.79) respectively when the 8–12 h troponin result is included (P = 0.001). Thirty day event rates were 33% for NHF/CSANZ high‐risk vs 1.5% for combined low/intermediate risk (P < 0.001). For TIMI score, 30 day event rates were 23% for a score ≥2 and 4.8% for TIMI < 2 (P < 0.001). The NHF/CSANZ guideline identified more patients as low risk compared with the TIMI risk score (61% vs 48%, P < 0.001). Conclusions: The NHF/CSANZ guideline is superior to the TIMI risk score for risk stratification of suspected ACS in the ED.     

Prospective evaluation of the use of the thrombolysis in myocardial infarction score as a risk stratification tool for chest pain patients admitted to an ED observation unit

Background

The Thrombolysis in Myocardial Infarction (TIMI) score has shown use in predicting 30-day and 1-year outcomes in emergency department (ED) patients with potential acute coronary syndrome. Few studies have evaluated the TIMI score in risk stratifying patients selected for the ED observation Unit (EDOU). Risk stratification of patients in this group could identify those at risk for significant cardiac events. Our goal was to evaluate TIMI use for risk stratification in this population and compare outcomes among differing scores.

Methods

A prospective observational study with 30-day telephone follow-up for a 12 month period. Baseline data, outcomes related to EDOU stay, admission, and 30-day outcomes were recorded. TIMI scores were calculated for each patient placed in EDOU. TIMI score was not utilized in the decision to place patients in observation.

Results

N = 552. Composite outcomes recorded were myocardial infarction, revascularization, or death either during the EDOU stay, inpatient admission, or the 30-day follow-up. Eighteen composite outcomes were recorded: stent (12 patients), coronary artery bypass graft (3 patients), myocardial infarction and stent (2 patients), and myocardial infarction, and coronary artery bypass graft (1 patient). Distribution by TIMI score was: 0 (102 patients), 1 (196), 2 (142), 3 (72), 4 (27), and 5 (5). Risk of composite outcome increased by score: 0 (1%), 1 (2.6%), 2 (2.1%), 3 (6.9%), 4 (11.1%), and 5 (20%). Those with an intermediate risk score (3-5) were also more likely to require admission (15.4% vs 9.8%, P = .048).

Conclusion

The TIMI risk score may serve as an effective risk stratification tool among chest pain patients selected for EDOU placement. Patients with intermediate-risk by TIMI may be considered for inpatient admission and/or more aggressive evaluation and therapy.     

Risk prediction in patients presenting with suspected cardiac pain: the GRACE and TIMI risk scores versus clinical evaluation

BACKGROUND: Identifying which patients presenting with undifferentiated chest pain are at risk of major cardiac events is a major clinical challenge. Clinical evaluation may lack sufficient precision, leading to unnecessary admission or inappropriate discharge. It is uncertain whether risk scores derived from ACS populations apply to unselected patients with chest pain. AIM: To determine the predictive accuracies of the GRACE risk score, the TIMI risk score and clinical evaluation in unselected patients with suspected cardiac pain. DESIGN: Prospective observational study. METHODS: We recruited 347 sequential patients with suspected cardiac pain presenting to a large teaching hospital. The main outcome measures were death, non-fatal myocardial infarction and emergency revascularization, in hospital and at 3 months. Receiver operating characteristic (ROC) curves were plotted for TIMI and GRACE risk scores and clinical evaluation. RESULTS: Overall 54 patients (15.6%) experienced a major cardiac event (16 deaths, seven myocardial infarctions (MIs), one emergency revascularization) or emergency re-admission (n=30) within 3 months. Both GRACE (p<0.001) and TIMI scores (p<0.001) predicted death/MI/revascularization (and the composite including re-admission), but the GRACE score was superior to the TIMI score for predicting major cardiac events (z=2.05), and both scores were superior to clinical evaluation (ROC areas 0.82, 0.74 and 0.55 respectively). The GRACE score predicted an ACS discharge diagnosis (p<0.001) and duration of hospital stay (p<0.001). DISCUSSION: In unselected patients presenting with suspected cardiac pain, the GRACE risk score is superior to the TIMI risk score in predicting major cardiac events, and both risk scores are superior to using ECG and troponin findings at presentation.     

Prospective validation of Thrombolysis in Myocardial Infarction and front door Thrombolysis in Myocardial Infarction risk scores in Chinese patients presenting to the ED with chest pain

Background

Chest pain is a common complaint among emergency department (ED) patients. The Thrombolysis in Myocardial Infarction (TIMI) and front door TIMI (FDTIMI) scores are used to risk stratify chest pain patients in many Western countries; they have not been validated in patients with undifferentiated chest pain in Asia. Our objective was to establish the relationship between the TIMI and FDTIMI scores and the 30 day rate of major adverse cardiac outcomes (MACE) in Chinese patients presenting to the ED with chest pain.

Methods

Prospective, single-center, observational cohort study of consecutive patients presenting with chest pain from July 2009 until March 2010 to a Hong Kong university hospital ED. Data collected included patient characteristics, TIMI items and past medical and medication history. Primary outcome was MACE within 30 days of presentation. MACE was a composite outcome of any of the following: death (all causes), readmission with myocardial infarction, acute coronary syndrome not diagnosed at initial ED presentation and coronary revascularization.

Results

One thousand patients recruited with complete 30-day follow-up. STEMI patients (n = 75) were excluded. Mean patient age 66.8 ± 13.9 years; 51.7% male. 119 (12.9%) patients had MACE within 30 days of presentation. The incidence of MACE ranged from 0 for TIMI0 to 37.5% for patients with TIMI6/7. Increasing TIMI and FDTIMI scores were associated with a higher incidence of MACE.

Conclusions

This validation suggests that the TIMI/FDTIMI scores can be employed in Hong Kong Chinese; they may be useful for risk stratification of Chinese ED patients with undifferentiated chest pain elsewhere.     

60-day major adverse cardiac events in emergency department patients with non-low modified HEART scores

BackgroundA low (0–3) History, Electrocardiogram, Age, Risk factors and Troponin (HEART) score reliably identifies ED chest pain patients who are low risk for near-term major adverse cardiac events (MACE). To optimize sensitivity, many clinicians employ a modified HEART score by repeating troponin measurements and excluding patients with abnormal troponin values or ischemic electrocardiograms (ECGs). The residual MACE risk among patients with otherwise non-low (≥4) modified HEART scores is thus likely much lower than with non-low original HEART scores.ObjectiveTo explore residual 60-day MACE risks among patients with non-low modified HEART scores.MethodsSecondary analysis of a retrospective cohort of ED patients presenting with chest pain to an integrated healthcare system between 2013 and 2015. Patients with serial troponin measurements within 6 h of ED arrival were considered for inclusion. Exclusions included an ischemic ECG, troponin values above the 99th percentile or a lack of continuous health plan coverage through the 60-day follow-up period. MACE was defined as a composite of myocardial infarction, cardiac arrest, cardiogenic shock or death.ResultsThere were 22,976 study eligible patients encounters, 13,521 (59%) of which had non-low (≥4) modified HEART scores. The observed 60-day MACE risk among non-low HEART score patients was 2.0% (95% CI 1.8–2.3). When including all coronary revascularizations (MACE-R), the risk was 4.4% (95% CI 4.1–4.4).ConclusionRisk of near-term MACE among patients with non-low modified HEART scores (excluding those with abnormal troponin or ischemic ECGs) appears to be much lower than in the original HEART score validation studies.     

Practicality, safety and accuracy of computed tomography coronary angiography in the evaluation of low TIMI-risk score chest pain patients: a pilot study

Objectives: The present pilot study aimed to assess the practicality, safety and accuracy of performing CT coronary angiography (CT‐CA) in the evaluation of acute chest pain of patients with low thrombolysis in myocardial infarction (TIMI) risk scores. Methods: The present prospective observational study was undertaken in a university teaching hospital between November 2004 and December 2005. Participants were a convenience sample of patients admitted to hospital for investigation of chest pain with TIMI risk scores <3. Consenting patients underwent CT‐CA within 48 h of presentation. Outcomes of interest were practicality (proportion of diagnostic quality scans obtained and preparation time for CT‐CA), rate of serious adverse events, and accuracy at the patient level using selective coronary angiography as the reference standard. Results: Thirty‐four patients were recruited. Diagnostic quality scans were obtained in 26/34 or 76% of patients (four failed CT‐CA and four non‐diagnostic scans). The median CT preparation time was 1.9 h (range 0.17–4.0). No serious adverse events were found. Fourteen of those 26 patients with diagnostic CT‐CA subsequently had selective coronary angiography, of which nine were positive. The sensitivity and specificity of CT‐CA in identifying patients with significant coronary artery disease were 9/9 (100%; 95% confidence interval 72–100%) and 4/5 (80%; 95% confidence interval 28–100%), respectively. Conclusions: The majority of acute chest pain patients with low TIMI risk scores were successfully scanned with a 16‐slice CT to produce CT‐CA studies with good diagnostic quality and accuracy. No major adverse events were found. The place of CT‐CA in diagnostic workup for chest pain remains to be defined.     

Cardiac risk factors and risk scores vs cardiac computed tomography angiography: a prospective cohort study for triage of ED patients with acute chest pain

ObjectiveThe objective of the study is to evaluate cardiac risk factors and risk scores for prediction of coronary artery disease (CAD) and adverse outcomes in an emergency department (ED) population judged to be at low to intermediate risk for acute coronary syndrome.MethodsInformed consent was obtained from consecutive ED patients who presented with chest pain and were evaluated with coronary computed tomography angiography (cCTA). Cardiac risk factors, clinical presentation, electrocardiogram, and laboratory studies were recorded; the Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) scores were tabulated. Coronary computed tomography angiography findings were rated on a 6-level plaque burden scale and classified for significant CAD (stenosis ≥ 50%). Adverse cardiovascular outcomes were recorded at 30 days.ResultsAmong 250 patients evaluated by cCTA, 143 (57%) had no CAD, 64 (26%) demonstrated minimal plaque (< 30% stenosis), 26 (10%) demonstrated mild plaque (< 50% stenosis), 9 (4%) demonstrated moderate single vessel disease (50%-70% stenosis), 2 (1%) demonstrated moderate multivessel disease, and 6 (2%) demonstrated severe disease (> 70% stenosis). Six patients developed adverse cardiovascular outcomes. Among traditional cardiac risk factors, only age (older) and sex (male) were significant independent predictors of CAD. Correlation with CAD was poor for the TIMI (r = 0.12) and GRACE (r = 0.09-0.23) scores. The TIMI and GRACE scores were not useful to predict adverse outcomes. Coronary computed tomography angiography identified severe CAD in all subjects with adverse outcomes.ConclusionAmong ED patients who present with chest pain judged to be at low to intermediate risk for acute coronary syndrome, traditional risk factors are not useful to stratify risk for CAD and adverse outcomes. Coronary computed tomography angiography is an excellent predictor of CAD and outcome.     

Performance of HEART and TIMI scores in predicting major adverse cardiovascular events (MACEs) of chest pain patients in the emergency department: A prospective observational study

Objective: To compare the value of HEART and TIMI scores in predicting major adverse cardiovascular events (MACEs) of patients with chest pain in the emergency department at a tertiary care hospital in Ahmedabad, a city in western India. Methods: A prospective study was conducted on chest pain patients from January to December 2019. All adult patients with non-traumatic chest pain presenting to the emergency department were included, and their HEART and TIMI scores were evaluated. The patients were followed up within 4 weeks for monitoring any major adverse cardiac events or death. The receiver-operating characteristics (ROC) curve was used to determine the value of HEART and TIMI scores in predicting MACEs. Besides, the specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) of the two scores were assessed and compared. Results: A total of 350 patients were evaluated [mean age (55.03±16.6) years, 56.6％ of males]. HEART score had the highest predictive value of MACEs with an area under the curve (AUC) of 0.98, followed by the TIMI score with an AUC of 0.92. HEART score had the highest specificity of 98.0％ (95％ CI: 96.4％-99.6％), the sensitivity of 75.0％ (95％ CI: 70.7％-79.3％), and PPV of 97.0％ (95％ CI: 94.1％-99.9％) and NPV of 82.5％ (95％ CI: 74.6％-90.4％) for low-risk patients. TIMI score had a specificity of 95.0％ (95％ CI: 92.4％-97.6％), sensitivity of 75.0％ (95％ CI: 69.4％-80.6％), PPV of 92.3％ (95％ CI: 88.1％-96.5％) and NPV of 82.3％ (95％ CI: 73.8％-90.8％) for low-risk patients. Conclusions: HEART score is an easier and more practical triage instrument to identify chest pain patients with low-risk for MACEs compared to TIMI score. Patients with high HEART scores have a higher risk of MACEs and require early therapeutic intervention and aggressive management.     

The Use of a Brief Depression Screen in Older Emergency Department Patients

Objectives: To determine the sensitivity and specificity of a brief two‐question depression screen for the detection of depression in older emergency department (ED) patients, and to determine the prevalence of depression in this population. Methods: This was a prospective, observational study. Participants included a convenience sampling of ED patients 70 years and older presenting to an urban teaching hospital over a 17‐month period. Exclusions were refusal to participate, inability to communicate, and critical illness. Subjects were screened for depression with the previously validated Short Form Geriatric Depression Scale (SFGDS). Standardized scores on the SFGDS were used to determine the prevalence of depression. Patients were then given a previously published two‐question depression screen, and results were compared with the SFGDS as the criterion standard. Sensitivity, specificity, and prevalence data are reported as proportions with 95% confidence intervals (95% CIs). Results: Two hundred sixty‐seven of 327 eligible patients were enrolled. Forty‐four (17%; 95% CI = 12% to 21%) scored positive for depression on the SFGDS. The sensitivity of the brief two‐question depression screen was 84% (37/44; 95% CI = 70% to 93%), with a specificity of 61% (136/223; 95% CI = 55% to 67%) using a cutoff score of at least one of two positive responses. Conclusions: Depression is fairly prevalent in older ED patients. The brief two‐question depression screen, using a cutoff score of at least one positive response, is promising for ED use. However, given lower specificity, patients scoring positive for depression should be followed up with a more specific tool such as the self‐administered SFGDS prior to referral for further evaluation and treatment.     

Combining Thrombolysis in Myocardial Infarction risk score and clear-cut alternative diagnosis for chest pain risk stratification

Objective

The Thrombolysis in Myocardial Infarction (TIMI) risk score is a validated risk stratification tool useful in patients with definite and potential acute coronary syndromes (ACS) but does not identify patients safe for discharge from the emergency department (ED). Likewise, the use of a clear-cut alternative noncardiac diagnosis risk stratifies patients but does not identify a group safe for discharge. We hypothesized that the presence of an alternative diagnosis in patients with a TIMI risk score less than 2 might identify a cohort of patients safe for ED discharge.

Methods

In prospective cohort study, we enrolled ED patients with potential ACS. Data included demographics, medical history, components of the TIMI risk score, and whether the treating physician ascribed the condition to an alternative noncardiac diagnosis. Investigators followed the patients through the hospital course, and 30-day follow-up was done. The main outcome was 30-day death, myocardial infarction, or revascularization.

Results

A total of 3169 patients were enrolled (mean age, 53.6 ± 14 years; 45% men; 67% black). There were 991 patients (31%) with an alternative diagnosis, 980 patients with a TIMI risk score of 0, and 828 with a TIMI score of 1. At low levels of TIMI risk (<3), adding in a clinical impression of an alternative diagnosis did not reduce risk; at higher levels of TIMI risk, it did. The incidence of 30-day death, myocardial infarction, or revascularization for patients with a clinical impression of an alternative diagnosis and a TIMI score of 0 was 2.9% (95% confidence interval, 1.6%-5.0%).

Conclusions

The TIMI risk score stratifies patients with and without an alternative diagnosis. Unfortunately, patients with both a low TIMI risk score and a clinical impression of an alternative noncardiac diagnosis still have a risk of 30-day adverse events that is not low enough to allow safe discharge from the ED.     

qSOFA Has Poor Sensitivity for Prehospital Identification of Severe Sepsis and Septic Shock

Objectives: Sepsis is a common and deadly disease process for which early recognition and intervention can significantly improve clinical outcomes. Despite this, sepsis remains underrecognized and therefore undertreated in the prehospital setting. Recent recommendations by the Society of Critical Care and European Society of Intensive Care Medicine advocate use of the qSOFA (quick Sequential [Sepsis-related] Organ Failure Assessment) score in non-ICU settings to screen for septic patients at greater risk for poor outcomes. Methods: We retrospectively evaluated the sensitivity and specificity of a prehospital qSOFA score ≥ 2 for prehospital identification of patients with severe sepsis or septic shock. Emergency Department (ED) patients with confirmed or suspected infection were classified as having infection without sepsis (n = 71), sepsis (n = 38), or severe sepsis/septic shock (n = 43), where designation of severe sepsis/septic shock required evidence of end-organ dysfunction, hypoperfusion (lactate > 2), or vasopressor requirement. Results: We found that a prehospital qSOFA score ≥ 2 was 16.3% sensitive (95% CI 6.8–30.7%) and 97.3% specific (95% CI 92.1–99.4%) for patients ultimately confirmed to have severe sepsis/septic shock in the ED. Adding an additional point to the prehospital qSOFA score for a pulse > 100, nursing home residence, age > 50, or reported fever increased the sensitivity to 58.1% (95% CI 42.1–73.0%) and decreased the specificity to 78.0% (95% CI 69.0–85.4%). During their ED stay, approximately two-thirds of patients meeting severe sepsis/septic shock criteria eventually met qSOFA criteria with a sensitivity of 67.4% (95% CI 51.5–80.9) and specificity of 86.2% (95% CI 78.3–92). Failure to meet qSOFA criteria prehospital was predominantly due to a systolic blood pressure and respiratory rate that did not yet meet predetermined thresholds. Conclusions: These findings suggest that the dynamic nature of sepsis can make sensitive detection difficult in the prehospital setting, although combining qSOFA with other clinical information (age, nursing home status, fever, and tachycardia) can identify more patients with sepsis who may benefit from time critical interventions.     

Performance of cardiac troponins within the HEART score in predicting major adverse cardiac events at the emergency department

BackgroundThis study compared the performance of a single blood draw of high-sensitivity troponin T (hsTnT), high-sensitivity troponin I (hsTnI) and conventional troponin I (cTnI) within a modified HEART score for predicting 30-day MACE at Emergency Department (ED) presentation, and established local reference norms for all three assays by determining the cut-off point which yielded the highest sensitivity and negative predictive value for acute myocardial infarction and 30-day MACE.MethodsThis single-center prospective cohort study recruited chest pain patients at the ED, whose hsTnT, hsTnI and cTnI were taken on admission. Subjects were classified into low and non-low risk group according to their modified HEART score, with MACE as the primary endpoint. Receiver-operating characteristic (ROC) curves were generated, area under the curves (AUCs) were calculated; the performance characteristics were determined.ResultsThe performance of modified HEART scores was comparable among the three assays for 30-day MACE (84.9–87.0% sensitivity, 95.6–96.0% NPV, 95%CI) and none of these had very high AUC and specificity (AUC 0.70–0.71, 53.7–56.7% specificity, 95% CI). The modified HEART score using a single blood draw of either hsTnT (3.9 ng/L), hsTnI (0.9 ng/L) or cTnI (0.0 ng/L) at presentation yielded a sensitivity of 100% for 30-day MACE.ConclusionThe modified HEART score using a single blood draw of either hsTnT, hsTnI or cTnI was equally effective in risk-stratifying chest pain patients for safe discharge. The theoretical cut-off points yielding 100% sensitivity are potentially useful (when achieved) for safely discharging low risk patients with undifferentiated chest pain in the ED.     

Accuracy of Multi-organ Point-of-Care Ultrasound for Acute Kidney Injury Etiologies

This study investigated the diagnostic performance of point-of-care ultrasound (POCUS) for acute kidney injury (AKI) etiological subgroups in emergency department (ED) patients. Multi-organ POCUS including kidney, bladder, inferior vena cava (IVC), lung and cardiac examinations were used to identify five AKI subgroups: hypovolemia, reduced cardiac output, systemic vasodilatation and renal vasomodulation, renal and post-renal. One hundred sixty-five AKI patients were included in the study. The most diagnostic parameter in the post-renal group was the presence of any hydronephrosis, with a sensitivity of 93.3% (95% confidence interval [CI]: 68.1–99.8) and specificity of 85.9% (95% CI: 79.3–91.1). For the reduced cardiac output group, the most diagnostic parameter was IVC maximum diameter >17 mm with a sensitivity of 100% (95% CI: 83.2–100) and specificity of 70.2% (95% CI: 61.6–77.7). For the hypovolemia group, the most diagnostic parameter was IVC maximum diameter ≤17.9 mm with a sensitivity of 81.2% (95% CI: 71.2–88.8) and specificity of 56.5% (95% CI: 44–68.4). For the systemic vasodilatation and renal vasomodulation group, the most diagnostic parameter was diffuse ascites with a sensitivity of 56.3% (95% CI: 29.9–80.2) and specificity of 89.9% (95% CI: 83.8–94.2). None of the parameters were significant for the renal group. We concluded that multi-organ POCUS is of diagnostic value for AKI subgroups.     

Application of the TIMI risk score in ED patients with cocaine-associated chest pain

Objective

The TIMI risk score has been validated as a risk stratification tool in emergency department (ED) patients with potential acute coronary syndrome. The goal of this study was to assess its ability to predict adverse cardiovascular outcomes in cocaine-associated chest pain.

Methods

This was a prospective cohort study of ED patients with chest pain with cocaine use. Data included demographics, medical history, and TIMI risk score. The main outcomes were acute myocardial infarction, revascularization, or death within 30 days of ED presentation.

Results

There were 261 patient visits. Patients were 43.2+8 years old, 73% male, 92% black, and 75% smokers. There were 33 patients with the composite outcome. The incidence of 30-day outcomes according to TIMI score is as follows: TIMI 0, 3.7% (95% CI, 0.1-8.3); TIMI 1, 13.2% (5.7-20.7); TIMI 2, 17.1% (4.3-29.8); TIMI 3, 21.4% (4.4-38.4); TIMI 4, 20.0% (0.1-43.6); TIMI 5/6, 50.0% (0.1-100).

Conclusions

The TIMI risk score has no clinically useful predictive value in patients with cocaine-associated chest pain.