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Comparative prospective study of the performance of chest pain scores and clinical assessment in an emergency department cohort in Singapore.

ABSTRACT: Objective:Chest pain scores allow emergency department (ED) physicians to identify low-risk patients for whom discharge can be safely expedited. Although these have been extensively validated in Western cohorts, data in patients of Asian heritage are lacking. This study aimed to determine the accuracy of HEART, ED Assessment of Chest Pain Score (EDACS), and Global Registry of Acute Coronary Events (GRACE) in risk-stratifying which chest pain patients are at risk of major adverse cardiovascular events within 30 days (composite of all-cause mortality, acute myocardial infarction and coronary revascularization). Methods:This single-center prospective cohort-study that enrolled 1200 patients was conducted by a large urban tertiary center in Singapore. Chest pain scores were reported before disposition by research assistants blinded to the physician's clinical assessment. Outcomes were assessed independently by a blinded cardiologist and emergency physician, while another cardiologist adjudicated in the case of discrepancies. Results:Of the 1195 patients analyzed, 135 (11.3%) suffered major adverse cardiovascular events within 30 days. HEART, which ruled out major adverse cardiovascular events in 52.8% of patients with 88.1% sensitivity, and EDACS, which ruled out major adverse cardiovascular events in 57.5% of patients with 83.7% sensitivity, proved comparable to clinical judgment that ruled out major adverse cardiovascular events in 73.0% of patients with 85.5% sensitivity. GRACE was weaker-ruling out major adverse cardiovascular events in 79.2% of patients with a dismal sensitivity of 45.0%. The correlation-statistic for HEART (79.4%) was superior to EDACS (69.9%) and GRACE (69.2%). Conclusions:HEART more accurately identified low-risk chest pain patients in an Asian ED, demonstrating comparable performance characteristics to clinical judgment. This has major implications on the use of chest pain scores to safely expedite disposition decisions for low-risk chest pain patients.

SUBMITTER: Ng M

PROVIDER: S-EPMC7593418 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Comparative prospective study of the performance of chest pain scores and clinical assessment in an emergency department cohort in Singapore.

Ng Mingwei M Tan Hong Jie Gabriel HJG Gao Fei F Tan Jack Wei Chieh JWC Lim Swee Han SH Ong Marcus Eng Hock MEH Ponampalam R R

Journal of the American College of Emergency Physicians open 20200905 5

<h4>Objective</h4>Chest pain scores allow emergency department (ED) physicians to identify low-risk patients for whom discharge can be safely expedited. Although these have been extensively validated in Western cohorts, data in patients of Asian heritage are lacking. This study aimed to determine the accuracy of HEART, ED Assessment of Chest Pain Score (EDACS), and Global Registry of Acute Coronary Events (GRACE) in risk-stratifying which chest pain patients are at risk of major adverse cardiova ...[more]

PMID: 33145512

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Project description:Background Coronary risk stratification is recommended for emergency department patients with chest pain. Many protocols are designed as "rule-out" binary classification strategies, while others use graded-risk stratification. The comparative performance of competing approaches at varying levels of risk tolerance has not been widely reported. Methods and Results This is a prospective cohort study of adult patients with chest pain presenting between January 2018 and December 2019 to 13 medical center emergency departments within an integrated healthcare delivery system. Using an electronic clinical decision support interface, we externally validated and assessed the net benefit (at varying risk thresholds) of several coronary risk scores (History, ECG, Age, Risk Factors, and Troponin [HEART] score, HEART pathway, Emergency Department Assessment of Chest Pain Score Accelerated Diagnostic Protocol), troponin-only strategies (fourth-generation assay), unstructured physician gestalt, and a novel risk algorithm (RISTRA-ACS). The primary outcome was 60-day major adverse cardiac event defined as myocardial infarction, cardiac arrest, cardiogenic shock, coronary revascularization, or all-cause mortality. There were 13 192 patient encounters included with a 60-day major adverse cardiac event incidence of 3.7%. RISTRA-ACS and HEART pathway had the lowest negative likelihood ratios (0.06, 95% CI, 0.03-0.10 and 0.07, 95% CI, 0.04-0.11, respectively) and the greatest net benefit across a range of low-risk thresholds. RISTRA-ACS demonstrated the highest discrimination for 60-day major adverse cardiac event (area under the receiver operating characteristic curve 0.92, 95% CI, 0.91-0.94, P<0.0001). Conclusions RISTRA-ACS and HEART pathway were the optimal rule-out approaches, while RISTRA-ACS was the best-performing graded-risk approach. RISTRA-ACS offers promise as a versatile single approach to emergency department coronary risk stratification. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.

Project description:High-sensitivity troponin assay brought new challenges as we detect elevated concentration in many other diseases, and it became difficult to distinguish the real cause of this elevation. In this notion, diagnosis of acute coronary syndrome (ACS) remains a challenge in emergency department (ED). We aim to examine different approaches for rule-in and rule-out of ACS using risk scores, copeptin, and coronary computed tomography angiography (CCTA). A prospective observational study was designed to evaluate chest pain patients. Consecutive adult patients admitted to the ED with a chief complaint of chest pain due to any cause were included. All patients were followed-up for 6 months after discharge for major adverse cardiovascular events and readmissions. Admission data, ED processes, and diagnoses were analyzed. One hundred forty-six patients were included, average age was 63 ± 13.4 years, and 95 (65.1%) were male. Global Registry of Acute Coronary Events (GRACE) and History, ECG, Age, Risk factors, Troponin (HEART) scores showed good prognostic abilities, but HEART combination with copeptin improves diagnoses of myocardial infarction (area under the curve [AUC] 0.764 vs AUC 0.864 P = .0008). Patients with elevated copeptin were older, had higher risk scores, and were more likely to be admitted to hospital and diagnosed with ACS in ED. For copeptin, AUC was 0.715 (95% confidence interval 0.629-0.803), and for combination with troponin, AUC of 0.770 (0.703-0.855) did not improve rule-in of myocardial infarction. High-sensitivity troponin I assay alongside prior stroke, history of carotid stenosis, dyslipidemia, use of diuretics, and electrocardiogram changes (left bundle branch block or ST depression) are good predictors of myocardial infarction (χ² = 52.29, AUC = 0.875 [0.813-0.937], P < .001). The regression analysis showed that combination of copeptin and CCTA without significant stenosis can be used for ACS rule-out (χ² = 26.36, P < .001, AUC = 0.772 [0.681-0.863], negative predictive value of 96.25%). For rule-in of ACS, practitioner should consider not only scores for risk stratification but carefully analyze medical history and nonspecific electrocardiogram changes and even with normal troponin results, we strongly suggest thorough evaluation in chest pain unit. For rule-out of ACS combination of copeptin and CCTA holds great potential.

Project description:BACKGROUND:Guideline-based processes for the assessment of chest pain are lengthy and resource intensive. The IMProved Assessment of Chest Pain Trial (IMPACT) protocol was introduced in one Australian hospital Emergency Department (ED) to more efficiently risk stratify patients. The theoretical domains framework is a useful approach to assist in identifying barriers and facilitators to the implementation of new guidelines in clinical practice. The aim of this study was to understand clinicians' perceptions of facilitators and barriers to the use of the IMPACT protocol. METHODS:Guided by the theoretical domains framework, semi-structured interviews with nine ED clinical staff (medical and nursing) were undertaken in 2016. Content analysis was conducted independently by two researchers to identify those theoretical domains that facilitated or hindered protocol use. RESULTS:Domains most often reported as fundamental to the use of the IMPACT protocol included 'social/professional role and identity', 'environmental context and resources' and 'social influences'. These factors seemingly influenced professional confidence, with participants noting 'goals' that included standardisation of practice, enhanced patient safety, and reduced need for unnecessary testing. The domain 'environmental context and resources' also contained the most noted barrier - the need to inform new members of staff regarding protocol use. Opportunities to overcome this barrier included modelling of protocol use by staff at all levels and education - both formal and informal. CONCLUSIONS:A range of domains were identified by ED staff as influencing their chest pain management behaviour. Fundamental to its use were champions/leaders that were trusted and accessible, as well as social influences (other staff within ED and other specialty areas) that enabled and supported protocol use. Research investigating the implementation and perceived use of the protocol at other sites, of varied geographical locations, is warranted.

Project description:ImportanceNoninvasive testing and coronary angiography are used to evaluate patients who present to the emergency department (ED) with chest pain, but their effects on outcomes are uncertain.ObjectiveTo determine whether cardiovascular testing-noninvasive imaging or coronary angiography-is associated with changes in the rates of coronary revascularization or acute myocardial infarction (AMI) admission in patients who present to the ED with chest pain without initial findings of ischemia.Design, setting, and participantsThis retrospective cohort analysis used weekday (Monday-Thursday) vs weekend (Friday-Sunday) presentation as an instrument to adjust for unobserved case-mix variation (selection bias) between 2011 and 2012. National claims data (Truven MarketScan) was used. The data included a total of 926 633 privately insured patients ages 18 to 64 years who presented to the ED with chest pain without initial diagnosis consistent with acute ischemia.ExposuresNoninvasive testing or coronary angiography within 2 days or 30 days of presentation.Main outcomes and measuresThe primary end points were coronary revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) and AMI admission at 7, 30, 180, and 365 days. The secondary end points were coronary angiography and coronary artery bypass grafting in those who underwent angiography.ResultsThe patients were ages 18 to 64 years with an average age of 44.4 years. A total of 536 197 patients (57.9%) were women. Patients who received testing (224 973) had increased risk at baseline and had greater risk of AMI admission than those who did not receive testing (701 660) (0.35% vs 0.14% at 30 days). Weekday patients (571 988) had similar baseline comorbidities to weekend patients (354 645) but were more likely to receive testing. After risk factor adjustment, testing within 30 days was associated with a significant increase in coronary angiography (36.5 per 1000 patients tested; 95% CI, 21.0-52.0) and revascularization (22.8 per 1000 patients tested; 95% CI, 10.6-35.0) at 1 year but no significant change in AMI admissions (7.8 per 1000 patients tested; 95% CI, -1.4 to 17.0). Testing within 2 days was also associated with a significant increase in coronary revascularization but no difference in AMI admissions.Conclusions and relevanceCardiac testing in patients with chest pain was associated with increased downstream testing and treatment without a reduction in AMI admissions, suggesting that routine testing may not be warranted. Further research into whether specific high-risk subgroups benefit from testing is needed.

Project description:BACKGROUND:The HEART Pathway (history, ECG, age, risk factors, and initial troponin) is an accelerated diagnostic protocol designed to identify low-risk emergency department patients with chest pain for early discharge without stress testing or angiography. The objective of this study was to determine whether implementation of the HEART Pathway is safe (30-day death and myocardial infarction rate <1% in low-risk patients) and effective (reduces 30-day hospitalizations) in emergency department patients with possible acute coronary syndrome. METHODS:A prospective pre-post study was conducted at 3 US sites among 8474 adult emergency department patients with possible acute coronary syndrome. Patients included were ≥21 years old, investigated for possible acute coronary syndrome, and had no evidence of ST-segment-elevation myocardial infarction on ECG. Accrual occurred for 12 months before and after HEART Pathway implementation from November 2013 to January 2016. The HEART Pathway accelerated diagnostic protocol was integrated into the electronic health record at each site as an interactive clinical decision support tool. After accelerated diagnostic protocol integration, ED providers prospectively used the HEART Pathway to identify patients with possible acute coronary syndrome as low risk (appropriate for early discharge without stress testing or angiography) or non-low risk (appropriate for further in-hospital evaluation). The primary safety and effectiveness outcomes, death, and myocardial infarction (MI) and hospitalization rates at 30 days were determined from health records, insurance claims, and death index data. RESULTS:Preimplementation and postimplementation cohorts included 3713 and 4761 patients, respectively. The HEART Pathway identified 30.7% as low risk; 0.4% of these patients experienced death or MI within 30 days. Hospitalization at 30 days was reduced by 6% in the postimplementation versus preimplementation cohort (55.6% versus 61.6%; adjusted odds ratio, 0.79; 95% CI, 0.71-0.87). During the index visit, more MIs were detected in the postimplementation cohort (6.6% versus 5.7%; adjusted odds ratio, 1.36; 95% CI, 1.12-1.65). Rates of death or MI during follow-up were similar (1.1% versus 1.3%; adjusted odds ratio, 0.88; 95% CI, 0.58-1.33). CONCLUSIONS:HEART Pathway implementation was associated with decreased hospitalizations, increased identification of index visit MIs, and a very low death and MI rate among low-risk patients. These findings support use of the HEART Pathway to identify low-risk patients who can be safely discharged without stress testing or angiography. CLINICAL TRIAL REGISTRATION:URL: http://www.clinicaltrials.gov . Unique identifier: NCT02056964.

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Comparative prospective study of the performance of chest pain scores and clinical assessment in an emergency department cohort in Singapore.

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Comparative prospective study of the performance of chest pain scores and clinical assessment in an emergency department cohort in Singapore.

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