Chest Pain Evaluation Unit Research Articles

How Does the Time of Presentation of Chest Pain Affect Patient Length of Stay? An Analysis of a Modern Chest Pain Unit

Background: Coronary artery disease remains a leading cause of morbidity and mortality worldwide. Patient awareness, combined with media campaigns that encourage early recognition and assessment of chest pain, have led to chest pain being the second most common cause of Emergency Department (ED) presentations Australia-wide, contributing to busier EDs and increased costs. To manage this, our chest pain evaluation unit (CPEU) provides streamlined access to specialty assessment of these patients. We sought to assess the effect of the time of patient presentation to ED and the length of time to discharge. Methods: Data were collected prospectively on patients referred to CPEU from May 2013 to June 2016, including ED and CPEU admission and discharge times. Admission times to ED were categorised into working-hours (WH, 0800-1700 hrs), after-hours (AH, 1701-2359 hrs) or after midnight (AM, 0000-0759 hrs). Results: Of the 3586 presentations, 2037 (57%) presented in WH; 939 (26%) in AH and 610 (17%) AM. Patients who presented in WH had the shortest length of stay (7.9h ± 4.9) compared to those AH (10.4h ± 5.9) or AM (8.7h ± 4.5) (p < 0.001). ED length of stay remained relatively constant (2.9h ± 4.7) regardless of time of presentation (p = 0.440). Conclusions: Presentation to ED with chest pain outside of working hours appears to increase the total length of stay in our CPEU, but not within the ED. This result may reflect CPEU staffing or process issues outside of normal working hours. Further evaluation is required to continuously improve the quality of care in CPEU in a cost-effective and patient-centred manner.

Patient Characteristics and Clinical Diagnoses Made in a Modern Chest Pain Evaluation Service

Background: The evaluation of chest pain remains an essential part of cardiology services. Our chest pain evaluation unit (CPEU) assesses patients referred from the Emergency Department and provides early access to rapid coronary intervention when required. We assessed the characteristics and outcomes of these patients. Methods: Data were collected prospectively on patients referred to CPEU from May 2013 to June 2016. Demographic data, TIMI scores, investigation results and clinical diagnoses were analysed. Results: 3586 presentations were analysed. The mean patient age was 57 ± 14 years old, 55% of them male. The majority of patients (83%) had a TIMI score of ≤2. The predominant diagnosis was atypical chest pain (73%). Other causes included acute coronary syndrome (7%), musculoskeletal pain (9%), gastrointestinal (4%), infective (1%) and psychiatric (1%). Higher TIMI scores increased the likelihood of an abnormal first troponin result, increasing to >25% with a score of 5 (graph; OR = 14, 95% CI 7–31). Conclusions: Undifferentiated chest pain remains a common cause for cardiology referral, and a majority remain undifferentiated despite current techniques of evaluation. Higher TIMI scores appear to correlate with an abnormal first troponin result in our referred cohort, reaching over a quarter of patients when the score was 5.

Effectiveness and outcomes of a nurse practitioner-run chest pain evaluation unit.

Every year, more than 5 million patients seek medical care for chest pain. The goal of this study was to evaluate test utilization and outcomes of a nurse practitioner (NP)-based chest pain unit and compare results to data previously reported from our institution. The records from 814 consecutive patients with chest pain admitted to the NP-run unit were compared to the outcomes of 250 patients admitted to a separate hospitalist-run unit at a New York City hospital. Forty-four percent of patients in the NP unit underwent stress myocardial perfusion imaging (MPI) as the primary diagnostic test (compared to 22% in the hospitalist unit, p < .0001). The average length of stay was shorter for patients in the NP unit (2.7 ± 3.6 days compared to 3.9 ± 3.4 days, p < .0001). Additionally, the 90-day readmission rate was less for patients in the NP unit (2.7% vs. 3.9%, p < .0006). An NP-run chest pain unit resulted in decreased length of stay and reduced readmission rates compared to a hospitalist-based unit.

157: Comparison of Two Validated Risk Stratification Scores in Predicting Outcomes of Chest Pain Evaluation Unit Patients

Chest pain evaluation units (CPU) have provided an additional means of evaluating emergency department (ED) patients for acute coronary syndromes (ACS). The Thrombolysis in Myocardial Infarction (TIMI) score is a validated risk stratification tool that correlates with adverse cardiac outcomes in ED patients. A newly developed tool, the Sanchis score, has been shown to be more accurate than the TIMI score in predicting adverse cardiac events. Neither score has been used to predict outcomes of low to moderate risk patients admitted to a CPU. Further risk stratification of CPU patients could limit protocol-driven diagnostic testing to those more likely to represent myocardial ischemia. This study questions if either the TIMI score or the Sanchis score can effectively predict short and long term outcomes in a CPU population.

299: Inclusion of Intermediate Risk Acute Coronary Syndrome Patients in a Midwest Chest Pain Evaluation Unit: It Plays in Peoria!

Chest pain evaluation units (CPU) have become a popular option for emergency physicians to further evaluate patients stratified as low-risk for suspected acute coronary syndromes (ACS). However, restricting such units to only extremely low-risk patients can result in overtesting and limited cost effectiveness. We report our institution's experience utilizing a cardiac observation and testing protocol for patients with both low and moderate risk for short-term cardiac events.

Use of Additional Electrocardiograph Leads in Low-Risk Patients Undergoing Exercise Treadmill Testing

Studies have shown that the addition of right precordial and left posterior leads to the standard 12-lead electrocardiogram (ECG) can significantly improve the sensitivity of exercise treadmill testing (ETT) for the diagnosis of myocardial ischemia. The objective of this study was to determine the value of adding 2 rightsided (RV3, RV4) and 2 left posterior (V8, V9) auxiliary leads to enhance detection of myocardial ischemia in patients with chest pain identified as low risk. The authors conducted a prospective study of all patients undergoing ETT as part of their management in a chest pain evaluation unit (CPEU) at a tertiary medical center from November 1999 to November 2001. Patients were considered low risk for acute coronary syndrome based on the clinical presentation to the CPEU, absence of ischemia on resting ECG, and negative initial cardiac markers. Diagnosis of coronary artery disease (CAD) was based on confirmatory testing, which included coronary angiography, myocardial stress scintigraphy, exercise echocardiography, or 30-day follow-up period. The study cohort comprised 705 patients who underwent 16-lead ETT. Of these, 70 (10%) had positive ETT and CAD was confirmed by further evaluation in 26. ECG changes positive for ischemia were demonstrated on the standard 12-lead exercise ECG in 68 patients. An additional 2 patients had positive ECG alterations only in the 4 auxiliary leads on the 16-lead ECG. There was no significant difference in the sensitivity or positive predictive value between the 12- and 16-lead exercise ECG. Electrocardiographic changes in auxiliary leads did not change the diagnostic use of the ETT and therefore may provide only a minimal contribution to the assessment of the low-risk CPEU population.

Assessing the Need for Functional Diagnostic Testing in Low-Risk Women With Chest Pain

The objective of this study was to assess the need for functional diagnostic testing to identify coronary artery disease (CAD) in women presenting with chest pain and deemed at low risk in a chest pain evaluation unit (CPEU) setting. Low-risk women evaluated in a CPEU were defined as having < or =1 intermediate determinant of CAD (hypertension, tobacco use, or hypercholesterolemia) or < or =2 minor determinants (age, obesity, sedentary lifestyle, or family history of CAD). Patients were followed for 30 days for the occurrence of CAD, defined as a positive stress imaging study, significant CAD on angiography, myocardial revascularization, myocardial infarction (MI), or cardiac death. Of 1355 consecutive women evaluated, 527 (39%) were classified as low risk. The rate of CAD in the low-risk group was 1.3% of which there were no coronary events. Women admitted to a CPEU and identified as low risk are at very low risk for CAD.

Acute coronary syndromes

Jim Christenson and colleagues,[1][1] in their article about emergency department assessment of chest discomfort, state that chest pain evaluation units “are cost-effective relative to admitting all low-risk patients to coronary care units but have never been compared with the unstructured

Diagnostic accuracy of Computer-Assisted Database-Derived pretest probability assessment for acute coronary syndrome

Study objectives: We determine the diagnostic accuracy of a noninvasive clinical screening instrument for the detection of acute coronary syndrome (ACS) in emergency department (ED) patients. The screening instrument is composed of clinical data input into a computer to estimate the probability of ACS. Methods: We aim to enroll 1,000 patients with complete data who were observed in an ED chest pain evaluation unit at Carolinas Medical Center, Duke University, and the University of California–Davis, and prospectively collect data to determine the pretest probability (PTP) of ACS for each patient using 3 methods of PTP assessment: (1) a computer-assisted, database-derived method; (2) the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) method; and (3) physician estimate to the nearest 1%. This information will be used to compare which method of PTP assessment categorizes the highest percentage of patients as being very low risk for ACS (ie, PTP Results: We completed enrollment on August 1, 2004, and follow-up and adjudication of outcomes continues. We enrolled a total of 1,154 patients and expect to obtain valid follow-up in 85% of subjects. Complete pretest probability are data available for 723 patients. Only 12 (1.6%) patients with a positive outcome were identified. The mean (median) pretest probability estimates by the 3 methods were 5.2% (4.0%) for physician estimate, 6.4% (4.3%) for attribute matching, and 13.6% (9.9%) for ACI-TIPI. The percentage of all patients estimated to have a pretest probability of ACS of less than 2% was 19% (95% confidence interval [CI] 16% to 22%) for clinicians, 34% (95% CI 31% to 38%) for attribute-matching, and 9% (95% CI 7% to 12%) for ACI-TIPI. No patient with a pretest probability of less than 2% estimated by any of the 3 methods developed ACS. Conclusion: At interim analysis, the rate of positive outcomes for ACS was unexpectedly low in this sample of patients evaluated in ED chest pain units. Attribute matching categorized significantly more patients as having a very low pretest probability compared with clinician estimate or ACI-TIPI.

Right Precordial and Posterior Electrocardiographic Leads Do Not Increase Detection of Ischemia in Low-Risk Patients Presenting with Chest Pain

Background: A number of innovative approaches have been investigated for their value in the early detection of acute ischemia or infarction in patients presenting to the emergency department (ED) with chest pain suggestive of a cardiac origin. Prior investigations have demonstrated the utility of adding right precordial and posterior chest leads to the standard 12-lead electrocardiogram (ECG) for identifying right ventricular and posterior wall infarctions in the ED. Hypothesis: To assess the utility of additional ECG leads in low-risk patients presenting to the ED with symptoms suggestive of acute coronary syndromes who are managed in a chest pain evaluation unit (CPEU). Methods: We studied low-risk patients who presented to the ED with chest pain compatible with myocardial ischemia. Low-risk patients were identified by a normal 12-lead ECG, no arrhythmias or hemodynamic instability, and one negative serum cardiac troponin I. Patients were admitted to the CPEU where a 16-lead ECG was recorded by the addition of 2 right-sided precordial leads (V4R, V5R) and 2 posterior leads (V8, V9) to the standard 12-lead ECG. Results: The 16-lead ECG system was applied to 316 consecutive patients. The study group was a middle-aged population with equal numbers of men and women and an average of 2 cardiac risk factors per patient. The 16-lead ECG demonstrated evidence of myocardial injury in only 1 patient and no evidence of ischemia in any of the 316 patients. Conclusion: In patients presenting to the ED with chest pain and evidence of low clinical risk by our criteria, the addition of both right-sided precordial and posterior chest leads to the standard 12-lead ECG did not provide additional information for risk stratification.

Bioimpedance-derived differences in cardiac physiology during exercise stress testing in low-risk chest pain patients.

Little has been written about the utility of thoracic electrical bioimpedance (TEB)-derived cardiac physiologic variables in evaluating patients with low-risk chest pain syndromes. Noninvasive bioimpedance can monitor cardiac physiology while a patient is performing an exercise stress test. In addition, the demographics of patients with chest pain, the incidence of coronary artery disease (CAD), and the methods used for evaluation have well-documented sex differences. The objectives are to show that there are different cardiac physiologic responses to exercise stress test in Chest Pain Evaluation Unit patients with and without true CAD that could be used to stratify patients and that there is a sex difference in TEB results. Patients 18 to 65 years of age with low-risk chest pain were eligible. Patients were attached to the TEB throughout the exercise stress test procedure. Heart rate (HR) was monitored. Primary dependent variables were TEB-measured cardiac output (CO, L/min) and stroke volume (SV, ml) at peak exercise. Secondary variables were TEB-measured ejection fraction (%), end-diastolic volume (EDV, ml), ventricular ejection time (ms), and thoracic fluid index (omega) at peak exercise. Outcome variables were either proved CAD or patient sex. CAD was proved by angiography, stress scintigraphy, or stress echocardiogram. Results were compared using a Student's t test assuming equal variances, with significance considered at a P < 0.05, and 95% confidence intervals were calculated for significant results. Nine patients had proved CAD, 82 patients did not. Forty-three women and 48 men were included in the study. At peak exercise, patients with CAD had a significantly smaller increase in EDV than patients without CAD (32.8 +/- 59.5 ml versus 89.3 +/- 101.8 ml) without a significant change in CO, SV, or HR. At peak exercise, women had a significantly smaller increase in CO and SV without a significant change in HR. In addition, women had a significantly smaller increase in EDV. When compared with patients without CAD, patients with CAD have a significantly smaller increase in EDV and a trend toward the same effect in CO and SV. Women have significantly smaller increases CO, SV, and EDV compared with men. Because there were no differences in HR, using HR as the sole end point would miss these differences. TEB is a practical means of measuring these variables.

Patients with Diabetes Can Undergo Immediate Exercise Treadmill Testing in a Chest Pain Evaluation Unit

Patients with Diabetes Can Undergo Immediate Exercise Treadmill Testing in a Chest Pain Evaluation Unit

Multiple clinical risk factors do not preclude immediate exercise testing in a chest pain evaluation unit

Multiple clinical risk factors do not preclude immediate exercise testing in a chest pain evaluation unit

Clinical policy: Critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism

This clinical policy focuses on critical issues in the evaluation and management of patients with signs or symptoms of pulmonary embolism (PE). A MEDLINE search for clinical trials published from January 1995 through April 2001 was performed using the key words “pulmonary embolus” with limits of “clinical investigations” and “clinical policies.” Subcommittee members and expert peer reviewers also supplied articles with direct bearing on the policy. This policy focuses on 2 major areas of current interest and/or controversy: (1) diagnostic: utility of D -dimer, ventilation-perfusion scanning, and spiral computed tomography angiogram in the evaluation of PE; and (2) therapeutic: indications for fibrinolytic therapy. Recommendations for patient management are provided for each 1 of these topics based on strength of evidence (Level A, B, or C). Level A recommendations represent patient management principles that reflect a high degree of clinical certainty; Level B recommendations represent patient management principles that reflect moderate clinical certainty; and Level C recommendations represent other patient management strategies based on preliminary, inconclusive, or conflicting evidence, or based on panel consensus. This guideline is intended for physicians working in emergency departments or chest pain evaluation units. [Ann Emerg Med. 2003;41:257-270.]

Comparison of the Accuracy of Individual Diagnostic Testing Strategies Employed in a Chest Pain Evaluation Unit

Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine: December 2002 - Volume 1 - Issue 4 - p 254-255

Cholesterol Screening in an ED-Based Chest Pain Unit

To evaluate the prevalence of dyslipidemia in patients who are evaluated in a chest pain evaluation unit (CPEU) a prospective study of all patients admitted to our CPEU from January 1 to December 31, 1999 was conducted. Serum total cholesterol (TC) and high density lipoprotein (HDL) levels were obtained unless prior levels were known or at the discretion of the attending physician. Both TC and HDL were tested in 606 (59%) patients. Abnormal lipid levels were reported in 306 (50%) patients. Of these, 86 had both abnormal TC and HDL. Isolated low HDL levels were found in 60 of the patients and TC alone was abnormal in 160. Of the 246 patients with abnormal TC, 169 (69%) had borderline high levels (200-239 mg/dL) and 77 (31%) had high levels (≥240 mg/dL). Our study shows a high prevalence of abnormal lipid levels in patients, as identified by a screening protocol in our CPEU. (Am J Emerg Med 2002;20:510-512. Copyright 2002, Elsevier Science (USA). All rights reserved.)

Immediate exercise testing to evaluate low-risk patients presenting to the emergency department with chest pain.

Our purpose was to determine the safety and accuracy of immediate exercise testing in low-risk patients presenting to the emergency department (ED) with chest pain suggestive of a cardiac etiology. Safe, efficient management of low-risk patients presenting to the ED with chest pain is a continuing challenge. We have employed immediate exercise testing to evaluate a large, heterogeneous group of low-risk patients presenting with chest pain. Patients presenting to the ED with chest pain compatible with a cardiac origin and clinical evidence of low risk on initial assessment underwent immediate exercise treadmill testing in our chest pain evaluation unit. Indicators of low clinical risk included no evidence of hemodynamic instability, arrhythmias or electrocardiographic signs of ischemia. Serial measurements of cardiac injury markers were not obtained. Exercise testing was performed to a sign- or symptom-limited end point in 1,000 patients (520 men, 480 women; age range 31 to 82 years) and was positive for ischemia in 13%, negative in 64% and nondiagnostic in 23% of patients. There were no adverse effects of exercise testing, and all patients with a negative exercise test were discharged directly from the ED. At 30-day follow-up there was no mortality in any of the three groups. Cardiac events in the three groups included: negative group, 1 non-Q-wave myocardial infarction (MI); positive group, 4 non-Q-wave MIs and 12 myocardial revascularizations; nondiagnostic group, 7 myocardial revascularizations. Immediate exercise testing of patients presenting to the ED with chest pain and evidence of low clinical risk is safe and accurate for determining those who require admission and those who can be discharged to further outpatient evaluation.

Comparison of Immediate Exercise Treadmill Testing to Other Methods of Diagnostic Testing in a Chest Pain Evaluation Unit

Comparison of Immediate Exercise Treadmill Testing to Other Methods of Diagnostic Testing in a Chest Pain Evaluation Unit

Chest pain evaluation units

Chest pain is a common cause of emergency department (ED) presentation. In the United States, it accounts for 5% to 6% of new ED attendances.1,2 The principal challenge in these patients is to identify those with an acute coronary syndrome. Early diagnosis allows effective treatment, and premature discharge may have disastrous consequences for patient and doctor: in the United States, between 2% and 5% of patients with acute myocardial infarctions are discharged from the ED, and 20% of malpractice claims against emergency physicians relate to the management of acute coronary syndrome.3 The problem with the emergency assessment of these patients lies in the limitations of diagnostic tests for acute coronary ischemia—electrocardiography (ECG) is diagnostic of acute myocardial infarction in only 40% to 65% of patients and is even less useful in those with unstable angina.4 Despite recent advances, serum markers for myocardial necrosis detect, at best, 66% of patients with acute myocardial infarction on arrival.5 Faced with these diagnostic difficulties and the consequences of misdiagnosis, ED physicians have a low threshold for admitting patients with chest pain in whom the diagnosis is not immediately clear. Some 60% to 65% of these patients have an eventual diagnosis of noncardiac chest pain,3 and although serious disease is diagnosed in a few, this traditional approach to chest pain is both time-consuming and expensive. It is against this background that the concept of ED-based chest pain evaluation units emerged, with the aim to provide medically equivalent care at a lower cost for patients presenting to an ED with chest pain with a probability for acute coronary syndrome that is low, but not sufficiently low to allow discharge. The concept originated in, and has been almost exclusively confined to, the United States. The first chest pain evaluation unit was set up in 1981 and, by 1997, 15% of EDs in the United States had followed suit.6 In this article, I review the literature on chest pain evaluation units to answer the following questions: How are patients managed on chest pain evaluation units? Is there evidence for their clinical effectiveness? Are they cost-effective? Is there evidence of patient satisfaction?

The significance of a raised troponin I in a chest pain evaluation unit

The significance of a raised troponin I in a chest pain evaluation unit