Identifying low-risk chest pain in the emergency department: Obstructive coronary artery disease and major adverse cardiac events

BackgroundAccurate risk stratification for obstructive coronary artery disease (CAD) and major cardiac adverse events (MACE) is important in emergency departments. We compared six established chest pain risk scores (the HEART score, CAD basic model, CAD clinical model, TIMI, GRACE, uDF) for prediction of obstructive CAD and MACE.MethodsPatients who presented to the emergency department with chest pain or symptoms of suspected CAD and underwent coronary computed tomographic angiography were analyzed. The primary endpoint was adverse outcomes including the presence of obstructive CAD (≥50% stenosis) and the occurrence of MACE within 6 weeks. We compared the risk scores by the area under the receiver-operating characteristic curve (AUC) and calculated their respective net reclassification index (NRI).ResultsAdverse outcomes occurred in 285 (28.4%) out of the 1002 patients included. For the prediction of adverse outcomes, the AUC of the HEART score (0.792) was superior to those of the CAD clinical model (0.760), CAD basic model (0.749), TIMI (0.749), uDF (0.703), and GRACE (0.653). In terms of the NRI, the HEART score significantly improved the reclassification abilities of the uDF (0.39), GRACE score (0.27), CAD basic model (0.11), TIMI (0.10), and CAD clinical model (0.08) (all P < 0.05). The HEART score also had the highest negative predictive value as well (0.893).ConclusionsThe HEART score was superior to other cardiac risk scores in predicting both obstructive CAD and MACE. However, due to the high false-negative rate (11%) of the HEART score, its use for identifying low-risk patients should be considered with caution.     

The predictive value of the exercise ECG for major adverse cardiac events in patients who presented with chest pain in the emergency department

Background

To improve early diagnostic and therapeutic decision making, we designed the HEART score for chest pain patients in the emergency department (ED). HEART is an acronym of its components: History, ECG, Age, Risk factors and Troponin. Currently, many chest pain patients undergo exercise testing on the consecutive days after presentation. However, it may be questioned how much diagnostic value the exercise ECG adds when the HEART score is already known.

Methods

A subanalysis was performed of a multicenter prospective validation study of the HEART score, consisting of 248 patients who underwent exercise testing within 7 days after presentation in the ED. Outcome is the predictive value of exercise testing in terms of major adverse cardiac events (MACE) within 6 weeks after presentation.

Results

In low-risk patients (HEART score ≤3), 63.1 % were negative tests, 28.6 % non-conclusive and 8.3 % positive; the latter were all false positives. In the intermediate-risk group (HEART score 4–6), 30.9 % were negative tests, 60.3 % non-conclusive and 8.8 % positive, half of these positives were false positives. In the high-risk patients (HEART score ≥7), 14.3 % were negative tests, 57.1 % non-conclusive and 28.6 % positive, of which half were false positives.

Conclusion

In a chest pain population risk stratified with HEART, exercise testing has only a modest contribution to clinical decision making. 50 % of all tests are non-conclusive, with high rates of false positive tests in all three risk groups. In intermediate-risk patients, negative exercise tests may contribute to the exclusion of disease. Clinicians should rather go for sensitive tests, in particular in patients with low HEART scores.     

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.     

Pulmonary embolism in patients attending the accident and emergency department with pleuritic chest pain.

A series of 92 patients presenting to an accident and emergency department with pleuritic chest pain is described. Only one of the patients had a diagnosis of pulmonary embolus. All the patients were followed up over a period of 3 months. During this time none of them suffered from mortality or morbidity which could be related to pulmonary embolism. No evidence was obtained during this study that a more aggressive approach to such patients is required in order to achieve the diagnosis.     

Transcutaneous carbon dioxide monitoring in the emergency department: a pilot study

Study Objective: Pilot study to assess the potential place of transcutaneous carbon dioxide monitoring technology in the emergency department. Design: Prospective Setting: Urban emergency department. Type of participants: 30 patients requiring arterial blood gas analysis as part of their management. Measurement and main results:

• 1 Subjects with capillary return time less than two seconds: Correlation of _PTCCO₂ versus _PACO₂ 0.93, bias 0.2, precision 5.9.
• 2 Subjects with capillary return time of greater than two seconds: Correlation _PTCCO₂ versus _PACO₂ 0.46, bias -6.6, precision 20.

Conclusions:

• 1 Transcutaneous carbon dioxide measurements are unreliable in low flow states as defined by capillary return time of greater than two seconds.
• 2 Measurement of transcutaneous carbon dioxide has the following potential uses in the emergency department: a) Monitoring carbon dioxide in patients with chronic airway limitation receiving oxygen therapy. b) A screening test in respiratory patients with normal peripheral perfusion.

     

The chest pain center in the emergency department

Despite the improvement of medical treatment for acute coronary syndromes throughout the 20th century, the authors believe that many cases of life-threatening coronary events could be avoided through early detection of CAD and the use of preventive strategies. Establishing chest pain units that are linked to the ED is one excellent strategy to risk-stratify patients with symptoms who are at risk for sustaining an AMI or having lethal arrhythmias. There is a need for more research on chest pain units to determine the value for cost and to further optimize strategies for ACI detection and screening. In EDs with high volumes of chest pain patients, or high pressures to avoid hospital admissions, a planned, systematic, and rapid approach to the treatment of AMI and the diagnosis of chest pain is a rewarding necessity.     

Triaging patients with acute chest pain in the emergency department: implications of the CT-STAT trial

Rapid advancements in multidetector-row computed tomography scanner technology over the last decade have significantly improved the diagnostic performance of coronary computed tomography angiography (CTA), enabling it to potentially become the preferred imaging modality used in the rapid assessment of chest pain patients in the emergency department. There is a growing body of evidence suggesting coronary CTA can rule out coronary artery stenosis quickly and accurately, thereby reducing the number of hospitalizations and healthcare costs, without compromising quality of care. CT-STAT is the first multicenter trial to demonstrate the power of coronary CTA to streamline patient care in the acute setting and radically transform current treatment algorithms.     

2-D echocardiography prediction of adverse events in ED patients with chest pain

The objective of this study was to establish the efficacy of two-dimensional (2-D) echocardiography (echo) in predicting adverse cardiac events in patients presenting to the ED with possible acute coronary syndrome (ACS). Patients 25 years of age or older having symptoms consistent with ACS and a non-diagnostic electrocardiogram (ECG) were evaluated with 0-, 3-, 6-, and 9-hour creatine kinase -MB (CK-MB) assays and continuous 12-lead ECG ST-segment monitoring. Patients with normal serial CK-MB assays and no ECG changes after 9 hours had a resting 2-D transthoracic echo performed. A positive 2-D echo was defined as segmental or global wall motion abnormalities. Patients were followed up after 6 months to identify adverse events resulting from ACS. Of the 1112 patients receiving an echo, 18 had positive studies. None had adverse events on follow-up. Of the 1094 patients with a negative 2-D echo, 15 had adverse events (2 acute myocardial infarctions, 2 coronary artery bypass graftings, and 11 percutaneous transluminal coronary angioplasties). Resting 2-D echo did not predict cardiac adverse events in patients with possible ACS and non-diagnostic serial 12-lead ECG and normal serial CK-MB at the end of a 9-hour evaluation.     

急诊胸痛患者心理状态及临床特征研究

目的：评估急诊胸痛患者的心理状态并分析其临床特征。方法：收集2012-06-2013-06我院主诉急性胸痛的患者301人病例,采用汉密顿焦虑量表（Hamilton Anxiety Rating Scale,HAMA）和汉密顿抑郁量表（Hamilton Depression Rating Scale-17,HAMD-17）评估患者心理状态,比较心源性胸痛（cardiac chest pain,CCP）与非心源性胸痛（non cardiac chest pain,NCCP）的临床特点及胸痛病因。结果：301例入选患者中,155例为CCP（51.5%）,146例为NCCP（48.5%）,并普遍表现为焦虑抑郁,其中CCP组中有肯定焦虑（HAMA〉14分）和肯定抑郁症（HAM D-17〉7分）的发生率分别是NCCP组的1.87倍和2.53倍。结论：CCP患者焦虑及抑郁发生率高,应及时给予心理支持,必要时再给予抗焦虑抑郁的药物干预,对降低心血管事件的发病率和病死率或有重要临床意义。     

Safety of immediate treadmill testing in selected emergency department patients with chest pain: A preliminary report

To determine the feasibility and safety of an immediate, symptom-limited, treadmill test on selected emergency department (ED) patients, a convenience sample of 28 patients underwent an exercise treadmill test (ETT) within the first several hours after hospital arrival using the modified Bruce protocol. Patients were included in the study if they presented with otherwise unexplained chest pain consistent with (but not characteristic for) angina pectoris and had a normal electrocardiogram. A negative ETT was seen in 23 of 28 patients, and five of 28 patients had a positive ETT. No patients had serial enzyme or electrocardiogram evolution suggestive of myocardial ischemia, and all patients with a negative ETT were discharged after a full inpatient evaluation designed to rule out unstable coronary disease. At a mean follow-up period of 6.1 months there has been no cardiac morbidity or mortality in the patients with negative ETTs. It was concluded that early ETTS of selected ED patients with chest pain is safe, and an exercise test administered during the ED visit which is negative can preclude unnecessary hospitalization.     

Patient flow in the emergency department: the chest pain patient

Prompt treatment of the chest pain patient in the emergency department (ED) is crucial. To ensure prompt treatment, identification of factors that delay flow of these patients through the department is essential. To identify factors that delay patient flow through the ED, the authors conducted a prospective study of all chest pain patients, using a time-flow analysis. Eighty-eight (36%) of 245 patients required critical unit admissions and had an average department stay of 3 1/2 hours. Flow differences were seen between critical and noncritical care patients. Three primary sources of delay were identified: critical unit bed availability, the registration process, and the role of the unit admitting resident. Additional findings confirmed the efficacy and role of the triage nurse in patient flow. Nursing and medical education and staffing needs were addressed. The use of the community's emergency medical services was examined by analyzing the disposition of patients arriving at the ED by ambulance.     

Clinical utility of CKMB isoform determinations in patients who present to the emergency department with continuous or resolved chest pain

The object of this investigation was to demonstrate that the enhanced sensitivity of the diagnosis of acute myocardial infarction (AMI) using a more-inclusive criterion of CKMB Isoforms may detect earlier stages of AMI (designated Isoform Type 2) than the currently accepted marker for AMI by CKMB Isoform (designated Isoform Type 1) in a busy, urban Emergency Department (ED). Two features characterized the study of CKMB Isoforms in a prospective cohort of 223 ED patients: first, nontraumatic chest pain within 12 h before presentation, thought to be of ischemic etiology; and second, normal or nondiagnostic electrocardiogram (EKG). Patients were further divided into two groups characterized as either recent but resolved chest pain at ED visit, or ongoing or staccato chest pain. Sensitivity (S), specificity (SP), positive (PPV) and negative (NPV) predictive values, and 95% confidence intervals (CI) for AMI diagnosis were determined. Two criteria for AMI diagnosis by CKMB Isoforms were tested. The first and currently recommended criterion was identified as Isoform Type 1. An AMI diagnosis by Type 1 criterion requires both CKMB2> or =2.6 IU/L and CKMB2/CKMB1> or =1.7. The second criterion for AMI diagnosis was identified as Isoform Type 2, which is defined as either CKMB2> or =2.6 IU/L or CKMB2/CKMB1> or =1.7. Both Isoform types are predictive of AMI by the gold standard, and addition of EKG changes results in a small improvement. Type 1 demonstrates SP 0.94 (CI 0.90, 0.97) and NPV 0.90 (CI 0.86, 0.94), and Type 2 demonstrates S 0.90 (CI 0.80, 0.97) and NPV 0.97 (CI 0.93, 0.99) for AMI diagnosis. Type 2 criteria can confidently exclude the immediate risk of AMI in patients with resolved chest pain whereas in patients with continuous chest pain, Type 1 criteria may identify those at high risk for AMI.     

A descriptive study of 100 emergency department patients with abdominal pain

One hundred consecutive patients with abdominal pain attending the Department of Emergency Medicine of the Royal Hobart Hospital were studied. There was a bimodal age distribution, with peaks in the 10–30 and 60–80 year groups. Admitted patients were likely to be older, and were more likely to present in working hours. When compared with later diagnosis, the emergency department diagnosis was “correct” in 75% of cases. No patient admitted with “unspecified abdominal pain” was later diagnosed more definitively. The findings suggest that one may be reasonably confident of a diagnosis made in the emergency department in patients with abdominal pain.     

Psychiatric aspects of chest pain in the emergency department

We estimate that a third of the patients who present to the ED with chest pain have a current psychiatric disorder and that psychiatric disorders among chest pain patients are associated with a high rate of ED utilization for chest pain evaluations. Physicians in the ED recognize only a small fraction of the psychiatric disorders, so appropriate treatment or referral may be infrequent. The proportion of chest pain patients with CAD who also have a psychiatric disorder may be in the range of 20% to 30%, justifying careful assessment of psychiatric disorders in CAD patients. We conclude that the psychiatric aspects of chest pain are sufficiently prevalent, clinically significant, and a contributor to unnecessarily high utilization of medical services. We call for clinical research to address these questions by outlining three areas of study that will advance our knowledge and care of the patient with chest pain.     

Managing recurrent nonischemic chest pain in the emergency department

Many patients who seek emergency evaluation for recurrent chest pain have had negative cardiac evaluations, sometimes including normal coronary angiograms. Despite reassurance, many of these patients return to emergency departments with complaints of chest pain. Studies have shown that one third to one half of these patients suffer from panic disorder characterized by attacks of intense fear accompanied by chest pain or discomfort, nausea, and shortness of breath. If panic disorder is identified, it can be successfully treated. This article explores the causes of recurrent nonischemic chest pain and offers treatment recommendations.