Acute Coronary Syndrome In Emergency Department Research Articles

Chest pain in the emergency department: From score to core-A prospective clinical study.

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.

Abstract 6984: Cost Effectiveness of a 1-Hour High-Sensitivity Troponin-t Protocol in Suspected Acute Coronary Syndrome: A Trial-Based Analysis of the Rapid-tnt Randomised Trial

Introduction: To better understand the economic impact of an accelerated 0/1-hour high-sensitivity troponin-T (hs-cTnT) protocol compared to conventional 0/3-hour protocol, we conducted a patient-level economic analysis of the RAPID-TnT randomised trial with a 12-month follow-up in patients presenting to emergency department (ED) with suspected acute coronary syndrome (ACS). Methods: An economic evaluation was conducted with 3265 patients randomised to either the 0/1-hour hs-cTnT protocol (n=1634) or the conventional 0/3-hour protocol (n=1631). The primary outcome measure was a composite of all-cause mortality and new/recurrent myocardial infarction (MI). Results: Mean per patients costs were numerically higher in the 0/1-hour arm compared to the conventional 0/3-hour arm (by $1830.56/patient, 95% confidence interval [95%CI]: $-1610.83 - 5271.96, P=0.30) with no statistically significant difference in primary outcome (0/1-hour: 62/1634 [3.8%], 0/3-hour: 82/1631 [5.0%], HR: 1.32 [95%CI: 095-1.83], P=0.1). The mean ED length of stay (LOS) was significantly lower in the 0/1-hour arm (by 0.63 hours/patient, 95%CI: 0.34-0.92, P&lt;0.001), but the cost saving was offset but the higher cumulative emergency-related inpatient costs (by $2247.31/patient, 95%CI: -656.55 - 5151.18, P=0.12). Restricting the analysis to patients with hs-cTnT≤29ng/L, the mean per patients cost remained numerically higher in the 0/1-hour arm (by $1480.24/patient, 95%CI:$-1097.62 - 2058.10, P=0.26), but the reduction in ED LOS was more pronounced (by 0.75 hours/patient, 95%CI: 0.46-1.05, P&lt;0.001). Conclusions: This economic evaluation suggest that there were no differences in costs and outcomes between the 0/1-hour hs-cTnT protocol and the conventional 0/3-hour protocol for the assessment of suspected ACS in ED after 1 year of follow-up from the Australian healthcare system perspective. Our observations suggest that the 0/1-hour hs-cTnT protocol improves initial ED efficiency with more rapid exclusion of ACS and discharge. However, the associated cost savings were offset by the subsequent emergency inpatient costs. Further refinements in cost-effective strategies to improve clinical outcomes whilst efficiently utilising healthcare resources is needed.

Barriers of Nurse Collaboration for the Care of Acute Coronary Syndrome Patients in Emergency Departments: A Pilot Study

Introduction: Acute Coronary Syndrome (ACS) is a cardiovascular disease that is one of the main causes of death worldwide. Nurse collaboration in Indonesia is still very complex and inadequate. Positive collaboration in providing care for patients with ACS is essential in the practice of nursing services. Objective: This study aims to explore the barriers in the implementation of nurses-physicians collaboration for the care of patient with ACS in Emergency Departments (EDs). Method: This research is a qualitative survey using purposive sampling. It was conducted on 16 nurses who worked in emergency departments from four general hospitals in East Java, Indonesia. Research data were collected using open-ended questions in semi-structured interviews. Results: There were three themes obtained from the data analysis, which include the difference of confidence between senior and junior nurses in ACS actions, limitations in performing professional nursing, and unclear job responsibilities. Conclusions: Collaboration of nurses and physicians in emergency departments still faces many problems. It is important to carry out interprofessional education initiations for nursing and medical students, apply peer-mentoring to increase the self-confidence of junior nurse, develop and train the clinical pathway of collaboration between physicians and nurses for the care of ACS patients in EDs.

The Quality of Symptoms in Women and Men Presenting to the Emergency Department With Suspected Acute Coronary Syndrome

IntroductionMore than 5.5 million patients present to emergency departments in the United States annually for potential acute coronary syndrome (ACS); however, diagnosing ACS remains a challenge in emergency departments. Our aim was to describe the quality of symptoms (chest discomfort/description of pain, location/radiation, and overall symptom distress) reported by women and men ruled-in and ruled-out for ACS in emergency departments. MethodsThe sample consisted of 1,064 patients presenting to emergency departments with symptoms that triggered cardiac workups. Trained research staff obtained data using the ACS Patient Information Questionnaire upon patient presentation to emergency departments. ResultsThe sample (n = 1,064) included 474 (44.55%) patients ruled-in and 590 (55.45%) patients ruled-out for ACS. Symptom distress was significantly higher in patients ruled-in versus ruled-out for ACS (7.3 ± 2.6 vs. 6.8 ± 2.5; P = 0.002) and was a significant predictor for an ACS diagnosis in men (odds ratio [OR], 1.10; confidence interval [CI], 1.03-1.17; P = 0.003). Women also reported more chest pressure (51.75% vs. 44.65; P = 0.02) compared with men, and chest pressure was a significant predictor for a diagnosis of ACS (OR, 1.61; CI, 1.03-2.53; P = 0.02). DiscussionHigher levels of symptom distress may help ED personnel in making a decision to evaluate a patient for ACS, and the presence of chest pressure may aid in making a differential diagnosis of ACS.

Cardiac patients\u2019 perceptions of neighboring patients\u2019 risk: influence on psychological stress in the ED and subsequent posttraumatic stress

BackgroundAs many as 12% of acute coronary syndrome (ACS) patients screen positive for post-traumatic stress disorder (PTSD) symptoms due to their cardiac event, and emergency department (ED) factors such as overcrowding have been associated with risk for PTSD. We tested the association of patients’ perceptions of their proximity to a critically ill patient during ED evaluation for ACS with development of posttraumatic stress symptoms (PSS) in the month after hospital discharge.MethodsParticipants were enrolled in the REactions to Acute Care and Hospitalization (REACH) study during evaluation for ACS in an urban ED. Participants reported whether they perceived a patient near them was close to death. They also reported their current fear, concern they may die, perceived control, and feelings of vulnerability on an Emergency Room Perceptions questionnaire. One month later, participants reported on PTSD symptoms specific to the cardiac event and ED hospitalization.ResultsOf 763 participants, 12% reported perceiving a nearby patient was likely to die. In a multivariate linear regression model [F(9757) = 19.69, p < .001, R2 adjusted = .18] with adjustment for age, sex, GRACE cardiac risk score, discharge ACS diagnosis, Charlson comorbidity index, objective ED crowding, and depression symptoms at baseline, perception of a nearby patients’ likely death was associated with a 2.33 point (95% CI, 0.60–4.61) increase in 1 month PTSD score. A post hoc mediation analysis with personal threat perceptions [F(10,756) = 25.28, p < .001, R2 adjusted = .24] showed increased personal threat perceptions during the ED visit, B = 0.71 points on the PCL per point on the personal threat perception questionnaire, β = 0.27, p = .001, fully mediated association of participants’ perceptions of nearby patients’ likely death with 1-month PTSD score (after adjustment for ED threat perceptions,) B = 0.89 (95% CI, −1.33 to 3.12), β = 0.03, p = .43, accounting for 62% of the adjusted effect and causing the main effect to become statistically nonsignificant.ConclusionsWe found patients who perceived a nearby patient was likely to die had significantly greater PTSD symptoms at 1 month. Awareness of this association may be helpful for designing ED patient management procedures to identify and treat patients with an eye to post-ACS psychological care.

Does Uric Acid Level Provide Additional Risk Stratification Information in Emergency Patients With Symptoms of Possible Acute Coronary Syndrome?

Elevated uric acid levels have been associated with the presence and severity of coronary artery disease (CAD). This study aimed to assess the clinical utility of serum uric acid levels to identify patients at high risk of acute coronary syndrome (ACS) in those who presented to the emergency department (ED) with chest pain. This was a prospective observational study of 951 adult patients who were being evaluated for ACS in a single ED. Serum uric acid was taken on presentation. Patients were followed up 30 days and 1 year after initial presentation. The primary outcome was a diagnosis of ACS within 30 days of initial attendance. A logistic regression analysis was performed to identify whether elevated uric acid levels were predictive of ACS. Kaplan-Meier curves were generated to identify 1-year mortality in those who were available for 1-year follow-up and Cox regression was performed to identify whether uric acid levels were an independent predictor of mortality. ACS was diagnosed in 88 patients and 140 patients had elevated uric acid levels. A total of 679 patients agreed to 1-year follow-up. Elevated uric acid levels were not associated with a diagnosis of ACS (p = 0.96). Patients with elevated uric acid had a higher 1-year death rate (8/101; 7.92%) compared with patients with normal uric acid levels (12/596; 2.01%, p < 0.01). Uric acid levels lack diagnostic utility for ACS but may be useful for identifying ED patients with chest pain who are at high risk for 1-year mortality. Elevated uric acid levels correlate with the presence of other risk factors of CAD and are a marker for poor long-term outcome.

Quality of care of patients presenting with acute coronary syndrome in emergency departments in Taiwan

Acute coronary syndrome (ACS) represents one of the most common causes of acute medical admission at Taiwan hospitals. Clinical practice guidelines have been developed to provide physicians with evidence-based approaches to the patient’s daily care. However, data have suggested the presence of a large widespread gap between the medical care provided and the evidence-based recommendations. This report should help us to understand the management of ACS in emergency departments based on quality of care indicators and adherence to recommended practice behaviors and international guidelines in Taiwan. A retrospective patient chart review was undertaken in 14 participating hospitals from July 1, 2006 to June 30, 2007. A random sample of 2388 patients treated at the emergency rooms of these hospitals with the discharge code of ACS was identified. The data captured included final diagnosis, the acute therapies used, the in-hospital revascularization procedures used and the time to initiation of the various procedures. Among the 2388 patients sampled, the mean age was 66.4 years old of which 67.9% were male. Overall, 42.0% of the patients had a history of coronary artery disease (CAD) including 17.0% with a prior myocardial infarction, 23.0% with a prior percutaneous coronary intervention, and 5.5% who had had a prior coronary artery bypass graft. Final diagnoses reported consisted of 29% (n = 701) with ST segment elevation myocardial infarction (STEMI), 30% (n = 718) with unstable angina, 24% (n = 578) with nonSTEMI, 14% (n = 335) with CAD/stable angina and 2.3% (n = 56) with another diagnosis. Out of all STEMI patients, 77.5% (n = 543) received early catheterization and only 4.7% (33/701) were given thrombolytic agent treatment. In addition, among STEMI patients who received an early interventional strategy, only 41.7% received urgent cardiac catheterization within 90 minutes. The average time until a 12-lead electrocardiogram was obtained was 20.6 minutes, and only 52% of the patients had the electrocardiogram completed within 10.0 minutes. Only 42% of patients who underwent an interventional strategy had catheterization intervention within 90 minutes after arriving at the emergency room. There were significant variations in practice between hospital types and across geographic areas. Further stricter implementation of the guidelines is needed to improve the quality of care provided to Taiwanese ACS patients.

Diagnostic accuracy of quantitative heart-fatty acid binding protein assays compared with Cardiodetect ® in the early detection of acute coronary syndrome

Heart-fatty acid binding protein (h-FABP) has been proposed as a cardiac marker for the early detection of acute coronary syndrome (ACS). In a study of 677 patients admitted to the emergency department (ED) for chest pain, we found that a semiquantitative point-of-care test that detects h-FABP (Cardiodetect(®)) had low sensitivity for the prediction of ACS. The aim of this ancillary study was to analyze and compare the performance of h-FABP for early ACS diagnosis in this large cohort of unselected patients, using a quantitative immunoassay and Cardiodetect(®). h-FABP was measured with a ready-to-use, solid-phase, enzyme-linked immunosorbent assay (ELISA) in 677 patients admitted to the ED with chest pain and suspected non-ST-segment elevation ACS. Two physicians, blinded to the results of the marker, categorized patients as having or not having non-ST-segment elevation ACS. Non-ST-segment elevation ACS was diagnosed in 185 patients (27.3%). The median h-FABP level was higher in patients with ACS (1.36μg/L, interquartile range [IQR] 0.59-3.55) than in those without ACS (0.58μg/L, IQR 0.24-1.34; P<0.01). The area under the curve was 0.68 (95% confidence interval [CI] 0.63-0.73). h-FABP did not improve the performance of a model that included the usual diagnostic tools for ACS management (odds ratio 0.92, 95% CI 0.32-2.70). The classification agreement between the ELISA and Cardiodetect(®) was 92.1% (kappa 0.39). In this study, we confirmed that measurement of h-FABP was insufficient to be used as a marker of ACS and NSTEMI in ED, whatever the analytical technique used.

Emergency Physician High Pretest Probability for Acute Coronary Syndrome Correlates with Adverse Cardiovascular Outcomes

The value of unstructured physician estimate of risk for disease processes, other than acute coronary syndrome (ACS), has been demonstrated. The authors sought to evaluate the predictive value of unstructured physician estimate of risk for ACS in emergency department (ED) patients without obvious initial evidence of a cardiac event. This was a post hoc secondary analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospectively collected multicenter data registry of patients over the age of 18 years presenting to the ED with symptoms of ACS between 1999 and 2001. In this registry, following patient history, physical exam, and electrocardiogram (ECG), the unstructured treating physician estimate of risk was recorded. A 30-day follow-up and a medical record review were used to determine rates of adverse cardiac events, death, myocardial infarction (MI), or revascularization procedure. The analysis included all patients with nondiagnostic ECG changes, normal initial biomarkers, and a non-MI initial impression from the registry and excluded those without complete data or who were lost to follow-up. Data were stratified by unstructured physician risk estimate: noncardiac, low risk, high risk, or unstable angina. Of 15,608 unique patients in the registry, 10,145 met inclusion/exclusion criteria. Patients were defined as having unstable angina in 6.0% of cases; high risk, 23.5% of cases; low risk, 44.2%; and noncardiac, 26.3% of cases. Adverse cardiac event rates had an inverse relationship, decreasing from 22.0% (95% confidence interval [CI] = 18.8% to 25.6%) for unstable angina, 10.2% (95% CI = 9.0% to 11.5%) for those stratified as high risk, 2.2% (95% CI = 1.8% to 2.6%) for low risk, and to 1.8% (95% CI = 1.4% to 2.4%) for noncardiac. The relative risk (RR) of an adverse cardiac event for those with an initial label of unstable angina compared to those with a low-risk designation was 10.2 (95% CI = 8.0 to 13.0). The RR of an event for those with a high-risk initial impression compared to those with a low-risk initial impression was 4.7 (95% CI = 3.8 to 5.9). The risk of an event among those with a low-risk initial impression was the same as for those with a noncardiac initial impression (RR = 0.83, 95% CI = 0.6 to 1.2). In ED patients without obvious initial evidence of a cardiac event, unstructured emergency physician (EP) estimate of risk correlates with adverse cardiac outcomes.