Comparison of six decision aid rules for diagnosis of acute myocardial infarction in elderly patients presenting to the emergency department with acute chest pain.

Juraj Hrecko,Jiri Dokoupil,Radek Pudil

doi:10.4149//bll_2022_045

Abstract

This study aimed to evaluate the accuracy and effectiveness of different strategies for the diagnosis of acute myocardial infarction (AMI) in the elderly in real-life clinical practice. Patients older than 70 years presenting to the emergency department with chest pain were included. The performance of six decision aid rules (T-MACS, HEART, EDACS, TIMI, GRACE, and ADAPT) and solo troponin T strategy for diagnosing AMI was evaluated by calculating sensitivity, specificity, odds ratios, negative and positive predictive values. A total of 250 patients, with a mean age of 78.5 years, were enrolled. Forty-eight patients (19.2 %) had an acute myocardial infarction in a 30 day follow-up period. The sensitivity for ruling-out AMI was 100 % for T-MACS, HEART, and ADAPT; 97.9 % for EDACS, 93.8 % for TIMI, and 81.3 % for GRACE and solo TnT strategy. For ruling-in AMI, the specificity was 97.5 % for T-MACS, 95 % for TIMI, 83.2 % for HEART, 81.7 % for GRACE, and 46 % for ADAPT. T-MACS decision aid had the best performance for rule-out and rule-in diagnostics of AMI. Risk stratification of patients with suspected acute coronary syndrome based on decision aid rules can be used in real-life practice, even in the population of the elderly (Tab. 6, Fig. 1, Ref. 17).

Highlights

Chest pain is a common reason for the visit to the emergency department
When looking at the performance in rule-in diagnostics of acute myocardial infarction (AMI) in high-risk patients, the T-MACS score had the best results with the highest specificity (97.5 %) and positive predictive value (64.3 %)
We evaluated decision aid rules for diagnostics of acute myocardial infarction in very old patients in the emergency department with the suspected acute coronary syndrome

Summary

Introduction

Chest pain is a common reason for the visit to the emergency department. A broad spectrum of underlying causes can be masked in this symptom. A spectrum of examination possibilities can be used to reach accurate diagnosis – starting with an evaluation of the patient’s history, rapid assessment of symptoms and physical findings, electrocardiography, cardiac imaging, and biochemical analysis. Typical chest pain with persisting ST-segment elevation on an electrocardiogram is an unquestionable indication for emergent coronary angiography. An approach to the chest pain patient without ST-segment elevation is not so clear. A misdiagnosis of such diseases as acute myocardial infarction (AMI), pulmonary embolism, or acute aortic dissection could lead to severe life harm or even death

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Discussion

Conclusion