Abstract
BackgroundChest pain is the second most common chief complaint in North American emergency departments. Data from the U.S. suggest that 2.1% of patients with acute myocardial infarction and 2.3% of patients with unstable angina are misdiagnosed, with slightly higher rates reported in a recent Canadian study (4.6% and 6.4%, respectively). Information obtained from the history, 12-lead ECG, and a single set of cardiac enzymes is unable to identify patients who are safe for early discharge with sufficient sensitivity. The 2007 ACC/AHA guidelines for UA/NSTEMI do not identify patients at low risk for adverse cardiac events who can be safely discharged without provocative testing. As a result large numbers of low risk patients are triaged to chest pain observation units and undergo provocative testing, at significant cost to the healthcare system. Clinical decision rules use clinical findings (history, physical exam, test results) to suggest a diagnostic or therapeutic course of action. Currently no methodologically robust clinical decision rule identifies patients safe for early discharge.Methods/designThe goal of this study is to derive a clinical decision rule which will allow emergency physicians to accurately identify patients with chest pain who are safe for early discharge. The study will utilize a prospective cohort design. Standardized clinical variables will be collected on all patients at least 25 years of age complaining of chest pain prior to provocative testing. Variables strongly associated with the composite outcome acute myocardial infarction, revascularization, or death will be further analyzed with multivariable analysis to derive the clinical rule. Specific aims are to: i) apply standardized clinical assessments to patients with chest pain, incorporating results of early cardiac testing; ii) determine the inter-observer reliability of the clinical information; iii) determine the statistical association between the clinical findings and the composite outcome; and iv) use multivariable analysis to derive a highly sensitive clinical decision rule to guide triage decisions.DiscussionThe study will derive a highly sensitive clinical decision rule to identify low risk patients safe for early discharge. This will improve patient care, lower healthcare costs, and enhance flow in our busy and overcrowded emergency departments.
Highlights
Chest pain is the second most common chief complaint in North American emergency departments
The goal of this study is to derive a clinical decision rule that predicts adverse cardiac events with a high degree of sensitivity and which will allow emergency physicians to accurately identify patients with chest pain who are safe for early discharge without provocative testing
Statement of the problem in the emergency department Chest pain is a diagnostic dilemma for the emergency physician
Summary
Chest pain is the second most common chief complaint in North American emergency departments. The 2007 ACC/AHA guidelines for UA/NSTEMI do not identify patients at low risk for adverse cardiac events who can be safely discharged without provocative testing. Chest pain can be either cardiac or noncardiac in etiology and represents a continuum of risk from benign self-limiting conditions to lifethreatening illness requiring rapid diagnosis and treatment. It is not well established which patients require extensive diagnostic investigation. The goal of this study is to derive a clinical decision rule that predicts adverse cardiac events with a high degree of sensitivity and which will allow emergency physicians to accurately identify patients with chest pain who are safe for early discharge without provocative testing. On the other hand, indicates myocardial ischemia without biochemical evidence of cardiac myocyte death [2]
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