The Influence of Race and Gender on Time to Initial Electrocardiogram for Patients with Chest Pain

Objectives: To determine whether race or gender affected time to initial electrocardiogram (ECG) for patients who presented to an emergency department with chest pain.
Methods: This was a prospective cohort study of patients with chest pain. Patients were divided into three groups based on final diagnosis of acute myocardial infarction or unstable angina and all others with noncardiac chest pain. Data were analyzed using ranks in a two-way analysis of covariance adjusted for age.
Results: A total of 4,358 patients were studied; 58.6% were women and 41.4% men, and 70.3% were African American, 26.0% white, and 3.6% other. Overall, nonwhite patients had longer times to initial ECG compared with white patients. These effects were consistent regardless of ultimate diagnosis. Overall, women had longer times to initial ECG than men. However, ECG time differed by final diagnosis. There were no differences in time to ECG for women compared with men with acute myocardial infarction or unstable angina, but women received an ECG significantly slower than men for noncardiac chest pain.
Conclusions: The first screening test for acute coronary syndrome, the ECG, took longer to obtain for nonwhite patients, regardless of final diagnosis. This was unfortunately consistent with the literature that shows racial disparities in all aspects of emergent cardiac care. For women, the overall delay in ECG time can be explained by delays for those women with noncardiac chest pain.     

Radionuclide esophageal transit test: Detection of esophageal dysmotility and reflux in noncardiac chest pain

Thirty-one patients with substernal chest pain but with normal coronary angiographic findings and 25 normal volunteers were included in our study. Esophageal motility—including esophageal mean transit time (MTT), residual fraction (RF), and retrograde index (RI) of the two groups—were evaluated by the radionuclide esophageal transit test. The results showed that among patients with noncardiac chest pain (NCP), 48% have a longer MTT, 39% have a higher RF, and 58% have a higher RI than normal volunteers. We found that esophageal disorders are a common source of noncardiac chest pain, and that radionuclide esophageal transit test is a simple noninvasive screening method to detect esophageal dysmotility or gastroesophageal reflux in such cases.     

Relationship between a Clear-cut Alternative Noncardiac Diagnosis and 30-day Outcome in Emergency Department Patients with Chest Pain

Background: Accurate identification of patients with acute coronary syndromes (ACSs) in the emergency department (ED) remains problematic. Studies have not been able to identify a cohort of patients that are safe for immediate ED discharge; however, prior studies have not examined the utility of a clear‐cut alternative noncardiac diagnosis. Objectives: To compare the 30‐day event rate in ED chest pain patients who were diagnosed with a clear‐cut alternative noncardiac diagnosis with the 30‐day event rate in the cohort of patients in whom a definitive diagnosis could not be made in the ED. Methods: This was a prospective cohort study of consecutive ED patients with potential ACS. Data included demographics, medical and cardiac history, laboratory and electrocardiogram results, and whether or not the treating physician ascribed the condition to a clear‐cut alternative noncardiac diagnosis. The main outcome was death, acute myocardial infarction (AMI), or revascularization within 30 days, as determined by phone follow‐up or medical record review. Results: The investigators enrolled 1,995 patients in the ED who had potential ACSs. Overall, 77 had a final hospital diagnosis of AMI (4%). Within 30 days, 73 patients received revascularization (4%), and 26 died (1%). There were 599 (30%) patients given a clear‐cut alternative noncardiac diagnosis. Comparing the patients with a clear‐cut alternative noncardiac diagnosis with those without an obvious noncardiac diagnosis, the presence of a clear‐cut alternative noncardiac diagnosis was associated with a reduced risk of an in‐hospital triple‐composite endpoint (death, MI, and revascularization), with a risk ratio of 0.32 (95% confidence interval [CI] = 0.19 to 0.55) and 30‐day triple‐composite endpoint with a risk ratio of 0.45 (95% CI = 0.29 to 0.69); however, patients with a clear‐cut alternative noncardiac diagnosis still had a 4% event rate at 30 days (95% CI = 2.4% to 5.6%). Conclusions: In the ED chest pain patient, the presence of a clear‐cut alternative noncardiac diagnosis reduces the likelihood of a composite outcome of death and cardiovascular events within 30 days. However, it does not reduce the event rate to an acceptable level to allow ED discharge of these patients.     

Measuring Quality in the Prehospital Care of Chest Pain Patients

Background. Rates of compliance with evidence-based treatment guidelines are commonly used to evaluate hospital quality of care. This method of quality assessment has not been widely extended to the prehospital environment. Previous studies have shown that the prehospital care of chest pain patients is often incomplete. Objective. To determine how well paramedics in an urban public hospital system deliver high-quality, comprehensive care for patients with nontraumatic chest pain. Methods. Patients with a primary complaint of nontraumatic chest pain for two quarters of 2006 were identified, records were randomly sampled, anda retrospective audit was performed. Seven individual quality indexes were identified by the medical director of the Denver Health Paramedic Division. A composite metric (bundle score) was also created to assess the completeness of care. This bundle score was considered unmet if any single variable was not present. Results. Five hundred eighty-six patient care reports were evaluated. Overall, 92% of the patients received oxygen, 62% received aspirin, 97% had lung sounds assessed, 99% had vital signs assessed, 84% had an intravenous (IV) line established, 92% had an electrocardiogram (ECG) obtained, and73% were assessed for cardiac risk factors. The composite score was met for only 39% of patients. Significant differences across age groups were found in assessing cardiac risk factors, obtaining ECGs, andadministering aspirin, andin the composite measure. In all of these metrics, the prehospital care rendered to the younger patients was associated with a lower rate of provider compliance than that delivered to the older patients. Conclusions. There was generally good compliance with each individual metric, yet compliance with the comprehensive metric was poor. This manner of quality assessment, utilizing a bundle score, can be successfully applied to the prehospital arena, although future work is needed to establish criteria for measuring optimal quality of care     

Influence of Sex on the Out-of-hospital Management of Chest Pain

Background: Sex disparities in the diagnosis and treatment of chest pain or suspected angina have been demonstrated in multiple clinical settings. Out‐of‐hospital (OOH) care for chest pain is protocol‐driven and may be less likely to demonstrate differences between men and women. Objectives: The objectives were to investigate the relationship between sex and the OOH treatment of patients with chest pain. The authors sought to test the hypothesis that OOH care for chest pain patients would differ by sex. Methods: A 1‐year retrospective cohort study of 683 emergency medical services (EMS) patients with a complaint of chest pain was conducted. Included were patients taken to any one of three hospitals (all cardiac referral centers) by a single municipal EMS system. Excluded were patients transported by basic life support (BLS) units, those younger than 30 years, and patients with known contraindications to any of the outcome measures. Multivariable regression was used to adjust for potential confounders. The main outcome was adherence to state EMS protocols for treatment of patients over age 30 years with undifferentiated chest pain. Rates of administration of aspirin, nitroglycerin, and oxygen; establishment of intravenous (IV) access; and cardiac monitoring were measured. Results: A total of 342 women and 341 men were included. Women were less likely than men to receive aspirin (relative risk [RR] = 0.76; 95% confidence interval [CI] = 0.59 to 0.96), nitroglycerin (RR = 0.76; 95% CI = 0.60 to 0.96), or an IV (RR 0.86; 95% CI = 0.77 to 0.96). These differences persisted after adjustment for demographics and emergency department (ED) evaluation for acute coronary syndrome (ACS) as a blunt marker for cardiac risk. Women were also less likely to receive these treatments among the small subgroup of patients who were later diagnosed with acute myocardial infarction (AMI). Conclusions: For OOH patients with chest pain, sex disparities in treatment are significant and do not appear to be explained by differences in patient age, race, or underlying cardiac risk. ACADEMIC EMERGENCY MEDICINE 2010; 17:80–87 © 2010 by the Society for Academic Emergency Medicine     

Evaluation of Acute Chest Pain in the Emergency Department: Utility of Multidetector Computed Tomography

Distinguishing insignificant from life-threatening causes of acute chest pain in patients who present to the emergency department remains a major challenge. Initial evaluation with history, electrocardiography, and biochemical markers is often unrevealing leading to additional workup. Radionuclide perfusion and echocardiography may be diagnostic but provide only indirect assessment of coronary status. The development of multidetector computed tomography (MDCT) and its increasingly frequent placement near the emergency suite has facilitated its use for the evaluation of serious noncardiac diagnoses such as pulmonary embolism and aortic dissection. Recent innovations in MDCT technology have facilitated the depiction of coronary arteries. These advances have led to the possibility of using CT to evaluate cardiac etiologies of chest pain, using either a comprehensive or triple rule out protocol to assess both cardiac and noncardiac causes or a dedicated coronary protocol. This article will review both options and describes our preliminary experience with the first of these protocols. The article also reviews the potential value of an acute chest pain CT protocol and the considerable challenges that remain prior to its implementation for routine clinical use.     

Hypnotherapy for Functional Gastrointestinal Disorders: A Review

Patients with functional gastrointestinal disorders, such as irritable bowel syndrome, functional dyspepsia, and noncardiac chest pain, can suffer from a range of severe symptoms that often substantially erode quality of life. Unfortunately, these conditions are notoriously difficult to treat, with many patients failing to improve despite being prescribed a wide variety of conventional medications. As a consequence, the potential benefits of hypnotherapy have been explored with evidence that this approach not only relieves symptoms but also appears to restore many of the putative psychological and physiological abnormalities associated with these conditions toward normal. These observations suggest that this form of treatment has considerable potential in aiding the management of functional gastrointestinal disorders and should be integrated into the ongoing medical care that these patients are receiving.     

Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain

Background

Chest pain is a frequent chief complaint among the pediatric population. To date, limited data exist on the full spectrum of emergent cardiac disease among such patients; and existing data have been limited to relatively small cohorts.

Objectives

The aims of the study were to investigate the emergent cardiac etiologies of chest pain in a large cohort of patients presenting to a tertiary care pediatric emergency department (PED) and to examine the use of resources (electrocardiogram, chest radiograph, echocardiogram, and laboratories) in those with and without cardiac-related chest pain.

Methods

Patient visits to 2 tertiary care PEDs were evaluated over a 3 and half-year period. Records of patients less than 19 years of age with a chief complaint of chest pain and no history of cardiovascular disease were reviewed. Patients were categorized as having cardiac or noncardiac etiologies or history of cardiovascular disease at the time of discharge, based on PED attending's final diagnoses. Final diagnoses classified as emergent cardiac etiologies were determined a priori.

Results

Four thousand four hundred thirty-six patients reported a chief complaint of chest pain during the study period. Three percent were excluded secondary to a history of heart disease. Only 24 (0.6%) of the remaining 4288 were determined to have chest pain of cardiac origin. Those with cardiac-related chest pain had a rate of admission of 50% compared to those without cardiac disease at 4% (P < .001). Nine patients had an arrhythmia, 6 had pericarditis, 4 had myocarditis, 3 had acute myocardial infarction, and 1 had pulmonary embolism and pneumopericardium. Ninety-two percent of the cardiac-related chest pain cohort received electrocardiograms compared to those without cardiac-related chest pain at 27% (P < .01). Only 1 (4%) of 24 subjects with cardiac-related chest pain had a prior emergency department visit within 72 hours suggesting a high detection rate upon initial presentation. The most common noncardiac etiologies for the chest pain were 56% musculoskeletal disorders; 12% related to wheezing, asthma, and cough; 8% infectious causes; 6% gastrointestinal; and 4% related to sickle cell anemia.

Conclusion

Cardiac-related chest pain in pediatric patients is rare but potentially serious. Arrhythmia was the most common cardiac-related etiology among this cohort. Those with myocarditis and myocardial infarction were the most acutely ill. An electrocardiogram in addition to history and physical examination was most useful in detecting relatively uncommon but significant cardiac-related chest pain. Using a thorough physical examination and potentially an electrocardiogram evaluation by a pediatric emergency care physician has an excellent rate of detection of cardiac-related causes.     

Moving to new settings: pilot study of families' perceptions of professional caregivers' pain management in persons with dementia

Persons with advanced dementia often have pain that is underrecognized and undertreated primarily because they cannot clearly communicate their needs. Consequently, they receive fewer analgesics than cognitively intact persons with the same conditions. Several assessment methods have been developed in the past decade, yet pain assessment and management problems persist in all care settings. These problems are likely to persist when patients move between levels of care. In this study, we determined from family caregivers whether pain was problematic when their family members with dementia moved to different care settings (e.g., admission or transfer). A total of 34 family caregivers responded to an anonymous survey; 50% reported that pain was not discussed at admission or after entry into a new care setting, and 67% were not confident that staff could detect pain. Respondents' recommendations for improving pain management included regular observation and assessment, timely and consistent pain medication administration, communication with family caregivers, and staff education.     

Chest pain in children. Tip-offs to cause

The primary care physician can often delineate the cause of chest pain in a patient under 21 years of age after a thoughtful, careful, and thorough history and physical examination. Occasionally, an ECG and a chest x-ray film may be helpful. Noncardiac causes for the chest pain should be explored, and if found, the child and the parents should be assured that the problem is not serious. Occasionally, psychotherapy may be indicated. A pediatric cardiologist should be consulted when a strong family history of coronary artery disease or a personal history of coronary risk factors is present or a murmur is detected that may not be innocent. The specialist also should evaluate children who have organic cardiac disease. Finally, although the primary care physician may strongly suspect that the chest pain has little or no significance, reassurance by a pediatric cardiologist is frequently helpful to the child and the family.     

Best Clinical Practice: Current Controversies in the Evaluation of Low-Risk Chest Pain with Risk Stratification Aids. Part 2

Background

Chest pain accounts for 10% of emergency department (ED) visits annually, and many of these patients are admitted because of potentially life-threatening conditions. A substantial percentage of patients with chest pain are at low risk for a major cardiac adverse event (MACE).

Follow-up survey of children and adolescents with chest pain

BACKGROUND: The purposes of this study were to identify the outcome of chest pain in children and to identify the incidence of recurrent chest pain and the need for further medical services. METHODS: A telephone survey was conducted of pediatric patients evaluated in the cardiology clinic for chest pain. RESULTS: In the majority of patients (53 of 55), chest pain was thought to be noncardiac in origin. Fifteen patients were offered therapy, and all followed the therapy. Most (10 of 15) thought the therapy was helpful. Forty-one (75%) were satisfied with the explanation given to them. Twenty-six had recurrent chest pain, 12 had pain that was severe, 13 thought the pain interfered with daily activities, and 10 sought further medical care. With the secondary evaluation of chest pain, the diagnosis changed in 9 of 10 cases. CONCLUSION: Chest pain in children is generally benign. However, chest pain can be recurrent and severe, interfering with activities of daily life.     

Optimal healing environments in end-of-life care and beyond

This paper is based on the premise that end-of-life care (EOLC) is the incarnation of an optimal healing environment (OHE). EOLC is characterized by factors that distinguish it from other forms of care or patient populations. These include: (1) formal EOLC did not evolve within the health care "industry," but was a reaction to that industry, created as an OHE; (2) patients nearing the end of life may be cared for in a formal "end-of-life" environment or may be located in other settings or systems; and (3) EOLC has a preordained outcome. Patients die in a variety of settings for medical, cultural, and accessibility reasons, and EOLC principles and practices are only beginning to be integrated into the full range of care settings. This paper proposes and defends the use of a single-question intervention to study the effect of EOLC care on its recipients, and considers the difficulty of establishing meaningful outcome variables. This paper also suggests that the principles of EOLC are well-suited to all phases of health services delivery and recommends the practical application of its elements throughout the medical services arena.     

Factors associated with advanced cardiac care in prehospital chest pain patients

Introduction

Many patients transported by emergency medical services (EMS) may require advanced cardiac care but do not have ST-segment elevation (STEMI) on the initial prehospital EKG. We sought to identify factors associated with the need for advanced cardiac care in undifferentiated EMS patients reporting chest pain in the absence of STEMI on EKG.

Extraesophageal manifestations of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) may manifest as laryngitis, asthma, cough, or noncardiac chest pain. Diagnosing these extraesophageal manifestations may be difficult for primary care physicians because most patients do not have heartburn or regurgitation. Diagnostic tests have low specificity, and a cause-and-effect association between GERD and extraesophageal symptoms is difficult to establish. Response to aggressive acid suppression is often the best indication of GERD etiology in a patient with extraesophageal symptoms.     

GRACE risk score as predictor of in-hospital mortality in patients with chest pain

Introduction  

Chest pain and chest discomfort are common problems in the acute care setting. Life-threatening causes of chest pain must be quickly differentiated from other less serious causes. There is a need to stratify risk rapidly in patients presenting to the emergency department (ED) with chest pain. This study evaluates the relationship between the GRACE risk score (GRS) and in-hospital mortality in patients presenting to the ED with chest pain of all causes.     

Variance Cardiography for Emergency Department Evaluation of Chest Pain Patients

Objective: To determine the test performance of 24–lead variance cardiography (VC), an ECG technique that measures QRS morphologic variability, for ED evaluation of chest pain associated with coronary artery disease (CAD).
Methods: A prospective, single–blind study of VC was performed in a community teaching hospital ED. All chest pain patients (>30 years of age) who, after initial emergency physician evaluation, were believed to have pain of potential cardiac etiology and were admitted to the hospital were eligible. Exclusion criteria included obvious noncardiac etiology for discomfort, bundle–branch block, atrial fibrillation, and incomplete subsequent cardiac evaluation. After initial evaluation and stabilization, VC was obtained. The numerical output of VC was a CAD index (CADI). Serum myoglobin and creatine kinase (CK)–MB levels were obtained at the time of presentation and after one, two, and six hours. Hospital records were reviewed to determine final diagnosis and in–hospital evaluation results.
Results: Fifty–two of 75 eligible patients had complete data. Final diagnoses were as follows: 27/52 (52%), noncardiac; 13/52 (25%), acute myocardial infarction (AMI); and 12/52 (23%), unstable angina due to CAD. Twenty–three percent (12/52) of the patients had CADIs < 75. Eleven of these were found to have noncardiac origins for their chest pain. The twelfth patient had a 12–lead ECG revealing AMI and had been given thrombolytic therapy with subsequent reperfusion prior to VC. Using a CADI < 75 as the cutoff for a negative study, VC alone had a negative predictive value of 92%, a sensitivity of 96%, a positive predictive value of 60%, and a specificity of 41%.
Conclusion: A CADI < 75, in addition to clinical impression and initial ECG, may identify chest pain patients who do not have significant CAD. Further prospective assessment of VC is warranted.     

Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients.

One hundred patients with chest pain and negative coronary arteriography were evaluated for musculoskeletal chest wall findings. Sixty-nine patients had chest wall tenderness. Typical chest pain was evoked by palpation in 16 patients. Tender areas were not found in a control group of patients without chest pain. A diagnosis of fibrositis could be made in five patients, including two in whom chest palpation reproduced typical chest pain. The sternal and xiphoid area, left costosternal junctions, and left anterior chest wall were the areas where tenderness was most common, but no significant differences were found comparing locations of tenderness in those with reproduction of typical pain. There was no significant difference in location, exacerbating factors, or other musculoskeletal symptoms among different groups of patients. Thus, most patients with noncardiac chest pain have chest wall tenderness that is not found in a control group without chest pain. However, reproduction of pain by palpation, a more specific diagnostic finding, is found in a minority of these patients.     

The development of cancer pain management and palliative care over the last 5 years in Japan

After the release of the World Health Organization guidelines in 1986, palliative care units (PCUs) were authorized to offer effective cancer pain management under the Japanese National Health Insurance in 1990. Although the number of PCUs increased to more than 100 during this decade, they could only cover 5% of all terminal-stage cancer patients in Japan. Due to the resistance to opioids together with the delay in establishing oncology practice, palliative care including cancer pain management was offered only to terminal cancer patients in PCUs, and cancer pain management did not improve sufficiently in general practice during the 1990s. To change the situation, the concept of hospital-based palliative care teams (HPCTs) were introduced into general hospitals and covered by the National Health Insurance in 2002. The HPCT mainly acts as a consultation team to help primary physicians or nurses who care for cancer patients in a general hospital. After the initiation of HPCTs, the role of palliative care in Japan is gradually changing because the HPCTs have been required to cover not only the terminal phase, but also overall cancer care. In addition to the spread of HPCTs, the types and formulations of opioids available and education on cancer pain management has also improved during the last 5 years. To further improve cancer pain management and palliative care in Japan, a triangle system should be established to offer seamless care in all healthcare settings based on the coordination among PCUs, general hospitals with HPCTs, and home-based care. This is referred to as a “palliative care program”.     

The prevalence and correlates of psychological outcomes in patients with acute non-cardiac chest pain: a systematic review

Over 40% of patients admitted to emergency departments (ED) with chest pain receive a non-cardiac diagnosis. Patients with non-cardiac chest pain (NCCP) have a good prognosis in terms of cardiac adverse events and mortality; however, they tend to have poor outcomes in terms of psychological morbidity, quality of life (QoL), further chest pain and the use of health services. In recent years there has been an increase in the use of ED-based 'rapid rule-out' protocols and the provision of dedicated chest pain units. This review sought to chart the psychological outcomes of NCCP patients who access ED-based care, and identify the correlates of poorer psychological outcomes. Twelve papers were identified reporting 10 studies. NCCP patients had similar levels of anxiety, depression, and QoL to patients who received a cardiac diagnosis for their pain, but worse levels than healthy controls. Factors associated with poorer psychological outcomes included gender, age, previous psychiatric history and certain symptoms such as fear of dying and light headedness. However, the studies were heterogeneous, with a variety of outcome measures, designs and settings. In summary, the review identifies poor psychological outcomes in NCCP patients accessing ED-based care; however, there is a need for longitudinal studies using reliable and valid measures to define further the predictors of these poor outcomes.