Predictive value of electrocardiogram in diagnosing acute coronary artery lesions among patients with out-of-hospital-cardiac-arrest

Aims

Acute coronary lesions are known to be the most common trigger of out of hospital cardiac arrest (OHCA). Aim of the present study was to assess the predictive value of ST-segment changes in diagnosing the presence of acute coronary lesions among OHCA patients

Methods

Findings of coronary angiography (CA) performed in patients resuscitated from OCHA were retrospectively reviewed and related to ST-segment changes on post-ROSC electrocardiogram (ECG)

Results

Ninety-one patients underwent CA after OHCA; 44% of patients had ST-segment elevation and 56% of patients had other ECG patterns on post-ROSC ECG. Significant coronary artery disease (CAD) was found in 86% of patients; CAD was observed in 98% of patients with ST-segment elevation and in 77% of patients with other ECG patterns on post-ROSC ECG (p = 0.004). Acute or presumed recent coronary artery lesions were diagnosed in 56% of patients, respectively in 85% of patients with ST-segment elevation and in 33% of patients with other ECG patterns (p < 0.001). ST-segment analysis on post-ROSC ECG has a good positive predictive value but a low negative predictive value in diagnosing the presence of acute or presumed recent coronary artery lesions (85% and 67%, respectively)

Conclusions

Electrocardiographic findings after OHCA should not be considered as strict selection criteria for performing emergent CA in patients resuscitated from OHCA without obvious extra-cardiac cause; even in the absence of ST-segment elevation on post-ROSC ECG, acute culprit coronary lesions may be present and considered the trigger of cardiac arrest     

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.     

Additional predictive value of serum potassium to Thrombolysis In Myocardial Infarction risk score for early malignant ventricular arrhythmias in patients with acute myocardial infarction

Objective

The aim of this study was to evaluate the additional predictive value of serum potassium (SK) to Thrombolysis In Myocardial Infarction (TIMI) risk score for malignant ventricular arrhythmias (MVA) in patients within 24 hours of acute myocardial infarction (AMI).

Methods

This was a 6-year retrospective study. The receiver operating characteristic curve was used to evaluate the predictive value of SK and TIMI risk score for MVA attack. In addition, SK-modified TIMI risk score was created by incorporating SK information into the usual score; the accuracy of new score was compared with that of the usual TIMI risk score by comparing the area under the receiver operating characteristic curves (AUC).

Results

Among the 468 patients enrolled, the incidence of MVA 24 hours after AMI was 9.4%, and it was higher in the hypokalemia group compared with that of the normokalemic group (27.3% vs 7.5%, P < .001; odds ratio, 4.594; 95% confidence interval [CI], 2.159-9.774). A significant predictive value of SK was indicated by AUC of 0.787 (95% CI, 0.747-0.823, P < .01). Serum potassium remained a predictor of MVA after being adjusted by the variables in TIMI risk score. The AUC of TIMI risk score in relation to MVA was 0.586 (95% CI, 0.54-0.631; P = .0676). The incorporation of SK into TIMI risk score improved its predictive value for MVA attack (AUC = 0.66; 95% CI, 0.568-0.753; P < .001), with significant difference between AUC of the new score and that of the original risk score (Z = 2.474, P = .013).

Conclusions

Serum potassium on admission to the emergency department may be used as a valuable predictor and could add predictive information to some extent to TIMI risk score for MVA attack during 24-hour post-AMI.     

Prognostic value of the Thrombolysis in Myocardial Infarction risk score in a unselected population with chest pain. Construction of a new predictive model

Introduction

The Thrombolysis in Myocardial Infarction (TIMI) risk score (TRS) has proven to be a useful and simple tool for risk stratification of patients with chest pain in intermediate- and high-risk populations. There is little information on its applicability in daily clinical routine with unselected populations.

Aims

The aims of the study were to prospectively analyze the predictive value of the TRS in a heterogeneous population admitted for chest pain and to construct where possible a new modified model with a greater prognostic capacity.

Population and Methods

Seven hundred eleven consecutive patients were admitted over a 1-year period to the cardiology unit for chest pain without ST-segment elevation. Thrombolysis in Myocardial Infarction risk score variables, relevant medical history variables, in-hospital examination results, and therapy information were collected. Cardiac events at 1 and 6 months were recorded.

Results

Seventy-one (9.8%) patients had a compound event (myocardial infarction/revascularization/cardiac death) at 6 months. On multivariate analysis, the variables associated with cardiac events were left ventricular ejection fraction (EF) of <35% (hazard ratio [HR] = 2.9, P = .002), diabetes (HR = 1.8, P = .02), and TRS (HR = 1.3, P = .007). Events at 6 months were 2.3% for a TRS of 0/1, 4.2% for 2, 10.2% for 3, 11.0% for 4, and 18.7% for a score of more than 5. A new modified scale was constructed to include EF and diabetes as independent variables, and this yielded an increase of 44% in the combined event at 6 months per score unit increase (HR = 1.44, P = .001). The modified scale showed a greater predictive capacity than the original model.

Conclusions

The TRS is an important short- and long-term prognostic predictor when applied to an unselected population consulting for chest pain. The inclusion of diabetes and EF as variables in the model increases predictive capacity at no expense to simplicity.     

Characteristics and prognosis in patients with false-positive ST-elevation myocardial infarction in the ED

Background

There are several causes of ST-segment elevation (STE) besides acute myocardial infarction (MI).

Objectives

We design this study to determine the prevalence, etiology, clinical manifestation, electrocardiographic characteristics, and outcome in patients with false-positive STEMI.

Methods

This is a retrospective case-control study design. At our emergency department, 297 patients who underwent emergent coronary angiography for suspected STEMI were enrolled from January 2004 to December 2010.

Results

Of the 297 patients who underwent coronary angiography, 31 patients (10.4%) did not have a clear culprit coronary lesion and were classified as false-positive STEMI. False-positive STEMI patients had a lower incidence of typical chest pain or chest tightness (58.1% vs 87.6%, P < .001). Inferior STE occurred significantly more often in the patients with true-positive STEMI (49.6% vs 25.8%, P = .012), and diffuse STE, more often in the patients with false-positive STEMI (19.4% vs 0.38%, P = .001). Total height of STE was lower in false-positive STEMI patients (7.5 ± 4.9 vs 10.9 ± 7.9 mm, P = .002) if excluding 5 patients of marked STE just after cardiopulmonary resuscitation. Concave STE and no reciprocal ST-segment depression occurred more often in false-positive STEMI patients (51.6% vs 24.1%, P = .001; 64.5% vs 19.2%, P < .001). There was no significant difference of in-hospital major adverse events in the patients with false-positive and true-positive STEMI.

Conclusions

The diagnosis of false-positive STEMI is not uncommon. Detailed clinical evaluation and electrocardiogram interpretation may avoid partly unnecessary catheterization laboratory activation.     

Electrocardiographic abnormalities in patients with acute pulmonary embolism complicated by cardiogenic shock

Background

Cardiogenic shock (CS) is a predictor of poor prognosis in patients with acute pulmonary embolism (APE).

Objectives

The aim of this study was to compare electrocardiography (ECG) parameters in patients with APE presenting with or without CS.

Methods

A 12-lead ECG was recorded on admission at a paper speed of 25 mm/s and 10 mm/mV amplification. All ECGs were examined by a single cardiologist who was blinded to all other clinical data. All ECG measurements were made manually.

Results

Electrocardiographic data from 500 patients with APE were analyzed, including 92 patients with CS. The following ECG parameters were associated with CS: S1Q3T3 sign, (odds ratio [OR]: 2.85, P < .001), qR or QR morphology of QRS in lead V1, (OR: 3.63, P < .001), right bundle branch block (RBBB) (OR: 2.46, P = .004), QRS fragmentation in lead V1 (OR: 2.94, P = .002), low QRS voltage (OR: 3.21, P < .001), negative T waves in leads V2 to V4 (OR: 1.81, P = .011), ST-segment depression in leads V4 to V6 (OR: 3.28, P < .001), ST-segment elevation in lead III (OR: 4.2, P < .001), ST-segment elevation in lead V1 (OR: 6.78, P < .01), and ST-segment elevation in lead aVR (OR: 4.35, P < .01). The multivariate analysis showed that low QRS voltage, RBBB, and ST-segment elevation in lead V1 remained statistically significant predictors of CS.

Conclusions

In patients with APE, low QRS voltage, RBBB, and ST-segment elevation in lead V1 were associated with CS.     

Application of the Sequential Organ Failure Assessment score for predicting mortality in patients with acute myocardial infarction

Background

Thrombolysis in Myocardial Infarction (TIMI) score and Global Registry of Acute Coronary Events (GRACE) score have been validated as predictors of death in patients with acute myocardial infarction (AMI). This study was undertaken to determine whether the Sequential Organ Failure Assessment (SOFA) score had good accuracy for predicting mortality in AMI patients, and to compare the discriminatory performance of the 3 risk scores (RSs).

Methods

This was a retrospective study. We calculated the TIMI RS, GRACE RS, and SOFA score for 726 consecutive AMI patients. The study endpoint was all-cause mortality. All patients were followed up for at least 3 years or until the occurrence of death. The area under the receiver operating characteristic curve (AUC) was used to evaluate the predictive ability of each score at different time points.

Results

For in-hospital death, the AUC were 0.67 for TIMI RS, 0.73 for GRACE RS, and 0.79 for SOFA score (P < 0.001, respectively). However, the SOFA score and GRACE RS were significantly better for predicting the 1-year (P < 0.001, respectively) and 3-year (P < 0.001, respectively) mortality than the TIMI RS was. Multivariate Cox regression analysis revealed that the SOFA score was an independent predictor of long-term mortality in AMI patients [hazard ratio (HR), 1.313; 95% CI, 1.191–1.447].

Conclusions

The SOFA score provides potentially valuable prognostic information on clinical outcome when applied to patients with AMI. Compared with TIMI RS, both SOFA score and GRACE RS provide better discrimination for long-term mortality in patients presenting with AMI.     

Stress echocardiography in the ED: diagnostic performance in high-risk subgroups

Purpose

To assess stress-echo (SE) diagnostic performance in patients presenting to the emergency department (ED) with spontaneous chest pain, especially in subgroups in which exercise ECG diagnostic performance has been questioned (women, elderly, history of coronary artery disease).

Methods

Between June 2008 and May 2011, 474 patients with an episode of spontaneous chest pain, non-diagnostic electrocardiogram and negative cardiac necrosis markers underwent SE. Patients with inducible ischemia (Isch) were asked to undergo coronary angiography. Patients with negative SE were discharged and contacted by telephone at least 6 months after discharge, to ascertain the occurrence of new cardiac events.

Main findings

Exercise stress-echo (ESE) was employed in 270 patients and dobutamine (DSE) in 218 (including 14 with inconclusive ESE); a diagnosis of coronary artery disease (CAD) was confirmed or excluded in 434 (92%) patients. SE was negative for Isch in 318 patients (206 ESE and 112 DSE) and positive in 132. During follow-up, patients with negative SE had 4 cardiac events. SE showed: sensitivity 90%, specificity 92%, positive predictive value 78% and negative predictive value 97%. Sensitivity was comparable between patients aged < or ≥ 70 years (84 vs 94%) and between gender (89 vs 96%), but lower in patients with known CAD (88 vs 94%, P < .05); specificity was comparable regardless of age (94 vs 99%) and presence of CAD (97 vs 91%), but was lower among women (87 vs 96%, P < .05).

Conclusions

SE had a very good diagnostic performance in ED patients with suspected Isch, both overall and in selected high-risk groups.     

Combined copeptin and troponin to rule out myocardial infarction in patients with chest pain and a history of coronary artery disease

Purpose

The main objective of this multicentric study was to evaluate the additional value of copeptin to conventional cardiac troponin (cTn) for a rapid ruling out of acute myocardial infarction (AMI) in patients with acute chest pain and a previous history of coronary artery disease (CAD).

Patients and Method

Patients with a previous history of CAD presenting in the emergency department with acute chest pain lasting for 6 hours or less suggestive of non–ST-segment elevation AMI and negative cTn were selected. Levels of copeptin were blindly measured at presentation. The diagnosis was adjudicated by 2 independent experts using all available data including cTn.

Results

A total of 451 patients were included (mean age, 67 ± 14; 330 [73%] men). The adjudicated final diagnosis was AMI in 36 (8%) patients, unstable angina in 131 (29%), and other diagnosis in 284 (63%). A negative cTn combined with a copeptin value lower than 10.7 pmol/L at presentation was able to rule out AMI, with a negative predictive value of 98% (95% confidence interval, 95%-99%).

Conclusion

In triage patients with acute chest pain lasting for less than 6 hours and a previous history of CAD, the combination of copeptin and cTn allows for the ruling out AMI, with a negative predictive value greater than 95%.     

Pre-hospital body surface potential mapping improves early diagnosis of acute coronary artery occlusion in patients with ventricular fibrillation and cardiac arrest

Aims

To determine whether 80-lead body surface potential mapping (BSPM) improves detection of acute coronary artery occlusion in patients presenting with out-of-hospital cardiac arrest (OHCA) due to ventricular fibrillation (VF) and who survived to reach hospital.

Methods and results

Of 645 consecutive patients with OHCA who were attended by the mobile coronary care unit, VF was the initial rhythm in 168 patients. Eighty patients survived initial resuscitation, 59 of these having had BSPM and 12-lead ECG post-return of spontaneous circulation (ROSC) and in 35 patients (age 69 ± 13 yrs; 60% male) coronary angiography performed within 24 h post-ROSC. Of these, 26 (74%) patients had an acutely occluded coronary artery (TIMI flow grade [TFG] 0/1) at angiography. Twelve-lead ECG criteria showed ST-segment elevation (STE) myocardial infarction (STEMI) using Minnesota 9-2 criteria – sensitivity 19%, specificity 100%; ST-segment depression (STD) ≥0.05 mV in ≥2 contiguous leads – sensitivity 23%, specificity 89%; and, combination of STEMI or STD criteria – sensitivity 46%, specificity 100%. BSPM STE occurred in 23 (66%) patients. For the diagnosis of TFG 0/1 in a main coronary artery, BSPM STE had sensitivity 88% and specificity 100% (c-statistic 0.94), with STE occurring most commonly in either the posterior, right ventricular or high right anterior territories.

Conclusion

Among OHCA patients presenting with VF and who survived resuscitation to reach hospital, post-resuscitation BSPM STE identifies acute coronary occlusion with sensitivity 88% and specificity 100% (c-statistic 0.94).     

Facilitated angioplasty with combo therapy among patients with ST-segment elevation myocardial infarction: a meta-analysis of randomized trials

Introduction

Time to treatment has been shown to be a major determinant of mortality in primary angioplasty. The aim of the current study was to perform a meta-analysis of randomized trials evaluating the benefits from pharmacologic facilitation with adjunctive glycoprotein (Gp) IIb-IIIa inhibitors + reduced lytic therapy vs adjunctive Gp IIb-IIIa inhibitors among patients with ST-segment elevation myocardial infarction (MI).

Methods

We obtained results from all randomized trials comparing facilitated PCI with adjunctive Gp IIb-IIIa inhibitors and reduced lytic therapy vs adjunctive Gp IIb-IIIa inhibitors among patients with ST-segment elevation MI (STEMI). The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL) from January 1990 to December 2007. The following key words were used: randomized trial, MI, reperfusion, primary angioplasty, pharmacologic facilitation, facilitated angioplasty, combo therapy, fibrinolysis, thrombolysis, half-dose lytic therapy, duteplase, reteplase, tenecteplase, alteplase, abciximab, tirofiban, eptifibatide, and Gp IIb-IIIa inhibitors. Angiographic end points were the rate of preprocedural and postprocedural thrombolysis in MI (TIMI) 3 flow. Clinical end points assessed were mortality and reinfarction at 30-day follow-up, whereas major bleeding complications were assessed as safety end point. No language restriction was applied.

Results

We identified 6 randomized trials, including 2684 patients with STEMI. Even though combo therapy was associated with a significant improvement in preprocedural TIMI 3 flow (44.3% vs 15.2%, P < .0001, P_het < .0001), it did not improve the rate of postprocedural TIMI 3 flow (91.5% vs 91.2%, P = .12). No benefits were observed in terms of 30-day mortality (4.2% vs 4.6%, P = .66, P_het = .22) and/or 30-day reinfarction (1.3% vs 1.3%, P = .84). However, combo therapy was associated with higher risk of major bleeding complications (5.8% vs 3.9%, P = .03).

Conclusions

This meta-analysis shows that among patients with STEMI undergoing primary angioplasty, pharmacologic facilitation with combined reduced-dose thrombolytic therapy and Gp IIbIIIa inhibitors is not superior to Gp IIb-IIIa inhibitors alone and, thus, may not be routinely recommended. However, future randomized trials should investigate whether this strategy may further improve outcome when applied within the first hours from symptoms onset, especially in patients undergoing transferring for primary angioplasty.     

Prehospital Electrocardiographic Manifestations of Acute Myocardial Ischemia Independently Predict Adverse Hospital Outcomes

Background

Prehospital electrocardiography (PH ECG) is becoming the standard of care for patients activating Emergency Medical Services for symptoms of acute coronary syndrome (ACS). Little is known about the prognostic value of ischemia found on PH ECG.

Objective

The purpose of this study was to determine whether manifestations of acute myocardial ischemia on PH ECG are predictive of adverse hospital outcomes.

Methods

This study was a retrospective analysis of all PH ECGs recorded in 630 patients who called 911 for symptoms of ACS and were enrolled in a prospective clinical trial. ST-segment monitoring software was added to the PH ECG device with automatic storage and transmission of ECGs to the destination Emergency Department. Patient medical records were reviewed for adverse hospital outcomes.

Results

In 630 patients who called 911 for ACS symptoms, 270 (42.9%) had PH ECG evidence of ischemia. Overall, 37% of patients with PH ECG ischemia had adverse hospital outcomes compared with 27% of patients without PH ECG ischemia (p < 0.05). Those with PH ECG ischemia were 1.55 times more likely to have adverse hospital outcomes than those without PH ECG ischemia (95% CI 1.09–2.21; p < 0.05), after controlling for other predictors of adverse hospital outcomes (i.e., age, sex, and medical history).

Conclusions

Evidence of ischemia on PH ECG is an independent predictor of adverse hospital outcomes. ST-segment monitoring in the prehospital setting can identify high-risk patients with symptoms of ACS and provide important prognostic information at presentation to the Emergency Department.     

Patients with coronary disease fail observation status at higher rates than patients without coronary disease

Background

Few studies have evaluated emergency department (ED) observation unit chest pain protocols for optimal patient characteristics and admission rates. At our 35?000-visits/y ED, we implemented a chest pain protocol for our observation unit that allowed emergency physicians to admit patients with known coronary artery disease (CAD).

Methods

We performed a retrospective chart review of all observation unit patients admitted under the chest pain protocol from April 1, 2006, to May 31, 2007. We compared the outcomes of patients who had a history of CAD with those who did not.

Results

Five hundred thirty-one patients were admitted to the observation unit under the chest pain protocol for the 14-month study period. Of these patients, 125 (23.5%) had a history of CAD. Patients with a history of CAD had a higher inpatient admission rate ( 24% vs 8.6%; P < .001), higher rate of a positive stress test or positive coronary computed tomographic scan (32.3% vs 6.9%; P < .001), a higher rate of cardiac catheterization (12% vs 5.9%; P = .02), and a higher rate of stent placement or coronary artery bypass graft (CABG) (7.2% vs 2.2%; P = .007). In multivariate analysis, patient history of CAD was an independent predictor of hospital admission (P = .005) and stent placement or CABG (P = .030).

Conclusion

Patients with known CAD who were admitted to the ED observation unit failed observation status (ie, required hospitalization) and had higher rates of positive testing than those without CAD.     

Incidence and predictors of new-onset atrial fibrillation in noncardiac intensive care unit patients

Background

Atrial fibrillation (AF) is thought to be a relatively common arrhythmia in the setting of noncardiac intensive care unit (ICU). However, data concerning AF deriving from such populations are scarce. In addition, it is unclear which of the wide spectrum of AF predictors are relevant to the ICU setting.

Objectives

The aim of our study was to evaluate the incidence of new-onset AF and investigate the factors that contribute to its occurrence in ICU patients.

Methods

We prospectively studied all patients admitted to our ICU during a 1-year period. Patients admitted for brief postoperative monitoring and patients with chronic or intermittent AF and AF present upon admission were excluded. A number of conditions incriminated as AF risk factors or “triggers” from demographics, medical history, present disease, and cardiac echocardiography as well as circumstances of AF onset were recorded.

Results

The study population consisted of 133 patients (90 males). Atrial fibrillation was observed in 15% of them. Age older than 65 years (P = .001), arterial hypertension (P = .03), systemic inflammatory response syndrome (P < .001), sepsis (P = .001), left atrial dilatation (P = .01), and diastolic dysfunction (P = .04) were significantly associated with the occurrence of AF. By multivariate analysis, it was demonstrated that only older than 65 years (odds ratio, 7.0; 95% confidence interval, 2.0-24.6; P = .003) and sepsis (odds ratio, 6.5; 95% confidence interval, 2.0-21.1; P = .002) independently predict new-onset AF. Patients manifesting AF were frequently hypovolemic (30%) and had electrolyte disorders (40%) as well as elevated and rising serum C-reactive protein (70%).

Conclusion

A significant fraction of ICU patients manifest AF. The predictors of interest for the ICU patients might be considerably different than those of the general population and other subgroups with systemic inflammation possibly having a pivotal role.     

Clinical characteristics and outcomes of septic patients with new-onset atrial fibrillation

Purpose

No studies have specifically evaluated the incidence or clinical characteristics of atrial fibrillation (AF) in a mixed medical-surgical population of patients with sepsis. We undertook to determine the incidence and clinical course of critically ill septic patients in the intensive care unit (ICU) who developed new-onset AF.

Methods

Retrospective analysis of data collected from the Project IMPACT database on 274 septic patients from July 2003 to December 2004.

Results

Sixteen evaluable septic patients with new-onset AF were identified. Mortality was higher (P = .034) and ICU length of stay (LOS) longer (P = .003) in patients with AF vs those without. Intensive care unit LOS was also longer in the subset of survivors with AF (P = .0001). Hospital LOS was longer among survivors with AF than in survivors without AF (P = .047). Patients with AF had a greater need for mechanical ventilation (P = .0007). Survivors with AF had longer duration of mechanical ventilation than those without AF (P = .006).

Conclusions

Statistically significantly higher mortality was observed in critically ill septic patients with new-onset AF, as were longer duration of mechanical ventilation, ICU, and hospital LOS. Whether the higher incidence of AF in septic patients is a specific risk factor for outcome or an indication of severity of illness remains to be determined.     

Diagnostic yield of coronary angiography in patients with acute chest pain: role of noninvasive test

Objectives

This study investigated the diagnostic yield of invasive coronary angiography (CAG) and the impact of noninvasive test (NIV) in patients presented to emergency department (ED) with acute chest pain.

Methods

Patients 50 years or older who visited ED with acute chest pain and underwent CAG were identified retrospectively. Those with ischemic electrocardiogram, elevated cardiac enzyme, known coronary artery disease (CAD), history of cardiac surgery, renal failure, or allergy to radiocontrast were excluded. Diagnostic yields of CAG to detect significant CAD or differentiate the need for revascularization were analyzed according to whether NIV was performed and its result.

Results

Among the total 375 consecutive patients, significant CAD was observed in 244 (65.1%). Diagnostic yields of CAG were higher in patients who underwent NIV before CAG, but the discriminative effect was modest (59.7% vs 70.7% [P = .026] for detection of CAD; 45.0% vs 50.5% [P = .285] for revascularization). Positive results of NIV were significantly associated with the presence of CAD and the need for revascularization, when compared with patients without NIV or patients with negative results (P < .001, respectively).

Conclusion

The diagnostic yield of CAG was only 65% in low- to intermediate-risk ED patients with acute chest pain. Performing of NIV provided only modest improvement in diagnostic yield of CAG. The unexpectedly low diagnostic yield might be attributable to the underuse of NIV and misinterpretation of physicians. We suggest the use of NIV as a gatekeeper to discriminate patients who require CAG and/or revascularization, and for this, better risk stratification and appropriate application of NIV are required.     

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.     

Can the degree of hydronephrosis on ultrasound predict kidney stone size?

Objective

The aim of the study was to determine if the degree of hydronephrosis on focused emergency renal ultrasound correlates with kidney stone size on computed tomography.

Methods

A retrospective study was performed on all adult patients in the emergency department who had a focused emergency renal ultrasound and ureterolithiasis on noncontrast computed tomography. Severity of hydronephrosis was determined by the performing physician. Ureteral stone size was grouped into 5 mm or less and larger than 5 mm based on likelihood of spontaneous passage.

Results

One hundred seventy-seven ultrasound scans were performed on patients with ureteral calculi. When dichotomized using test characteristic analysis, patients with none or mild hydronephrosis (72.9%) were less likely to have ureteral calculi larger than 5 mm than those with moderate or severe hydronephrosis (12.4% vs 35.4%; P < .001) with a negative predictive value of 0.876 (95% confidence interval, 0.803-0.925).

Conclusion

Patients with less severe hydronephrosis were less likely to have larger ureteral calculi.     

Gender and stress test use in an ED chest pain unit

Background

Women with acute coronary syndrome appear to be treated less aggressively than men. However, little is known about potential sex biases in the evaluation of patients with low-risk chest pain admitted to emergency department (ED) chest pain units.

Methods

This was a secondary analysis of prospectively collected data on consecutively admitted chest pain unit patients in a large-volume academic urban ED. Thrombolysis in myocardial infarction (TIMI) risk prediction and Diamond and Forrestor (D&;F) scores were calculated for each patient. χ² And t tests were used for univariate comparisons of demographics, cardiac comorbidities, risk scores, and stress testing between sexes. Multivariable logistic regression was used to estimate odds ratios (ORs) for testing based on sex, controlling for race, insurance status, and either TIMI or D&;F score.

Results

Eight hundred eleven patients were enrolled (48% male, 52% female) in the study. The mean age for men was 52 ± 12 and 54 ± 12 years for women (P < .01). Men had a higher mean D&;F score (42.0 vs 24.4; P < .01), but TIMI risk scores did not differ between sexes. Women received testing more often than men, a difference that was not statistically significant (50% [95% confidence interval {CI}, 45%-55%] vs 43% [95% CI, 39%-48%]; probability ratio of 1.16; P = .19). Women had a higher OR for receiving stress testing (1.61, 95% CI 1.14-2.29 controlling for TIMI score; OR, 1.69, 95% CI 1.12-2.51 controlling for D&;F score).

Conclusions

This study demonstrates no association between physician discretionary uses of stress testing based on sex. There is a need for further research on patient- or provider-specific factors that determine stress use and on how differences may affect clinical outcomes.     

Emergency endoscopy for upper gastrointestinal bleeding in patients with coronary artery disease

Background

Endoscopy is useful for diagnosis and treatment of upper gastrointestinal bleeding (UGIB). However, both endoscopy and UGIB may compromise the cardiovascular function. The present study is to investigate the cardiovascular responses of emergency endoscopy for patients with UGIB and stable coronary artery disease (CAD).

Methods

Consecutive 50 patients with known CAD and 50 patients without CAD history (non-CAD group) in whom emergency endoscopy was requested for UGIB were prospectively enrolled. All patients received ambulatory electrocardiographic monitoring before, during, and after endoscopies. Cardiac indices including supraventricular and ventricular arrhythmia, ST ischemic change, and autonomic nervous function evaluated by heart rate variability were compared.

Results

All patients in both groups had successful primary hemostasis, and peptic ulcer bleeding was the main etiology (82%). Compared with the non-CAD group, patients with CAD had a significantly higher incidence (42% vs 16%, P = .004) and frequency (1.19 vs 0.12 events per minute, P = .003) of ventricular arrhythmias during endoscopy. Nine patients with CAD and 1 patient without CAD had ischemic ST changes (P = .016). Comorbidity with congestive heart failure was not only associated with a higher frequency (P = .02) but also a more severe fluctuation (P = .002) of ventricular arrhythmia. None in both groups had angina or MI before, during, or after endoscopy. Heart rate variability did not show a difference.

Conclusions

Ventricular arrhythmias and myocardial ischemia, although mostly subclinical, were common in patients with stable CAD undergoing emergent endoscopy for UGIB, especially in those with concomitant congestive heart failure.