Chest Pain In Emergency Department Research Articles

480 Does Sex-Specific High-Sensitivity Troponin T Cut-Off Values Alter Clinical Outcomes in Chest Pain Presentations to the Emergency Department?

Despite gender differences in cardiovascular disease, data is limited on the utility of sex-specific high-sensitivity cardiac troponin (hs-cTn) cut-off values. We aimed to determine the clinical impact of sex-specific hs-cTnT cut-off values (>14ng/L vs >16.8ng/L for males, >9ng/L vs >14ng/L for females) in evaluating patients with chest pain in emergency department. Patients >18 years old with chest pain and hs-cTnT were studied. We excluded patients with ST-segment elevation myocardial infarction, lacked serial hs-cTnT, on dialysis or had trauma-related chest pain. Data were collected retrospectively on baseline characteristics, serial hs-cTnT, discharge diagnosis, coronary anatomy, functional tests and clinical outcome(s) during admission and at one-year follow-up. 1049 patients were included. Regardless of cut-off value, 69/589 males (11.7%) had at least one abnormal troponin with >20% change and were judged to have an ischaemic event. In females, using gender specific cut-off, 13 (2.8%) additional subjects had at least one abnormal troponin with >20% change. 6 were judged to have an ischaemic event and cardiac stress testing (CST) was recommended. 1/2 who did not undergo CST had recurrent admissions for congestive heart failure. 1/4 had positive CST. 7/13 were judged to have a non-ischaemic event and had no further cardiac presentations. Our data showed no change in males, but more false positives in females. However, as only one of the additional 13 females who were identified using the new cut-off had a further cardiac presentation, further investigation is warranted to establish whether sex specific cut-offs improve outcomes for females.

Optimal measuring point for ST deviation in chest pain patients with possible acute coronary syndrome

IntroductionIn the ECG, significant ST elevation or depression according to specific amplitude criteria can be indicative of acute coronary syndrome (ACS). Guidelines state that the ST amplitude should be measured at the J point, but data to support that this is the optimal measuring point for ACS detection is lacking. We evaluated the impact of different measuring points for ST deviation on the diagnostic accuracy for ACS in unselected emergency department (ED) chest pain patients. Material and methodsWe included 14,148 adult patients with acute chest pain and an ECG recorded at a Swedish ED between 2010 and 2014. ST deviation was measured at the J point (STJ) and at 20, 40, 60 and 80 ms after the J point. A discharge diagnosis of ACS or not at the index visit was noted in all patients. ResultsIn total, 1489 (10.5%) patients had ACS. ST amplitude criteria at STJ had a sensitivity of 28% and a specificity of 92% for ACS. With these criteria, the highest positive and negative predictive values for ACS were obtained near the J point, but the optimal point varied with ST deviation, age group and sex. The overall best measuring points were STJ and ST20. ConclusionsThis study indicates that the diagnostic accuracy of the ECG criteria for ACS is very low in ED chest pain patients, and that the optimal measuring point for the ST amplitude in the detection of ACS differs between ST elevation and depression, and between patient subgroups.

Diagnostic accuracy of troponin T measured ≥6h after symptom onset for ruling out myocardial infarction

Objectives: Guidelines recommend a single high-sensitivity cardiac troponin T (hs-cTnT) ≤14 ng/L measured ≥6 h after chest pain onset combined with a GRACE score <140 and the patient being pain-free for ruling out myocardial infarction (MI). There is however little data on the performance of this strategy. We therefore aimed to evaluate the diagnostic accuracy of a hs-cTnT ≤14 ng/L measured ≥6 h after chest pain onset when combined with GRACE score or other clinical risk stratification tools. Design: This was a secondary analysis of a prospective observational study, which enrolled emergency department (ED) chest pain patients. The hs-cTnT strategy was combined with HEART, TIMI, EDACS, GRACE score and ED physician’s overall assessment of patient history and ECG. The primary outcome was MI, and the secondary outcome was 30-day major adverse cardiac events (MACE). Results: All tested diagnostic strategies were shown to have a negative predictive value (NPV) ≥99.5% for ruling out MI. Using HEART, TIMI, EDACS or ECG + patient history also resulted in a NPV ≥98% for ruling out 30-day MACE. An isolated hs-cTnT ≤14 ng/L measured ≥6 h after chest pain onset and the combination with GRACE score both had a NPV <98% for ruling out 30-day MACE. Conclusion: A single hs-cTnT ≤14 ng/L obtained ≥6 h from chest pain onset, with and without GRACE score, reliably ruled out MI but did not perform well for ruling out 30-day MACE. These results question current guideline recommendations, and indicate that HEART, EDACS, TIMI, or ECG + patient history strategies should be the preferred risk stratification tools.

Diagnostic Accuracy of History and Physical Examination for Predicting Major Adverse Cardiac Events Within 30Days in Patients With Acute Chest Pain.

The cornerstones in the assessment of emergency department (ED) patients with suspected acute coronary syndrome (ACS) are patient history and physical examination, electrocardiogram, and cardiac troponins. Although there are several prior studies on this subject, they have in some cases produced inconsistent results. The aim of this study was to evaluate the diagnostic and prognostic accuracy of elements of patient history and the physical examination in ED chest pain patients for predicting major adverse cardiac events (MACE) within 30days. This was a prospective observational study that included 1167 ED patients with nontraumatic chest pain. We collected clinical data during the initial ED assessment of the patients. Our primary outcome was 30-day MACE. Pain radiating to both arms increased the probability of 30-day MACE (positive likelihood ratio [LR+] 2.7), whereas episodic chest pain lasting seconds (LR+ 0.0) and >24h (LR+ 0.1) markedly decreased the risk. In the physical examination, pulmonary rales (LR+ 3.0) increased the risk of 30-day MACE, while pain reproduced by palpation (LR+ 0.3) decreased the risk. Among cardiac risk factors, a history of diabetes (LR+ 3.0) and peripheral arterial disease (LR+ 2.7) were the most predictive factors. No clinical findings reliably ruled in 30-day MACE, whereas episodic chest pain lasting seconds and pain lasting more than 24h markedly decreased the risk of 30-day MACE. Consequently, these two findings can be adjuncts in ruling out 30-day MACE.

Follow-up study of patients admitted to the pediatric emergency department for chest pain.

Chest pain is a relatively common cause of admission to the Emergency Department, being related in most of the cases to benign conditions with only a minority of the cases affected by heart disease. Limited data are available about the follow up of these patients in terms of risk of recurrence of symptoms, Emergency Department re-admissions, level of impairment, and school absenteeism. We identified 761 children who visited our ED with the chief complaint of chest pain, equal to 0.68% of all admissions. Twenty-four patients were excluded for a previous history of cardiac disease. Eight (1%) patients were determined to have chest pain of cardiac origin. Ninety-seven percent of patients were successfully contacted by telephone: 69% agreed to answer the questionnaire. Of these, 33% experienced recurrent chest pain, up to 41% was forced to be absent from school, about 20% was limited in its daily activities, and about 20% repeated a cardiologic evaluation.Conclusion: Chest pain is mainly due to benign causes and is a recurrent symptom in a high percentage of patients, associated with re-admission and school absenteeism.What is Known:• Chest pain is a relatively common cause of admission to the Emergency Department.• It is mainly due to benign causes and is among the most common reasons for referral to the pediatric cardiologist.What is New:• Chest pain is a recurrent symptom associated with re-admission and school absenteeism.• As a family history of cardiac disease or exertional symptoms are a well-known red flag for chest pain of cardiac origin, school absenteeism should be considered a red flag for symptoms related to psychological distress in patients with non-cardiac chest pain.

Implementation of a health-literate patient decision aid for chest pain in the emergency department

ObjectiveThe aim of this study was to investigate the implementation of a new health-literacy-tested patient decision aid for chest pain in Emergency Department (ED) patients. Outcomes included disposition, knowledge, decisional conflict and satisfaction prior to discharge. Patient health literacy was explored as a factor that may explain disparities in sub-group analysis of all outcomes. MethodsA health-literacy adapted tool was deployed using a pre/post intervention design. Patients enrolled during the intervention period were given the adapted chest pain decision aid that was used in conversation with their emergency medicine physician to decide on their course of action prior to being discharged. ResultsA total of 169 participants were surveyed and used in the final analysis. Patients in the usual care group were 2.6 times more likely to be admitted for chest pain than patients in the intervention group. Knowledge scores were higher in the intervention group, while no significant differences were observed in decisional conflict and patient satisfaction, or by patient health literacy level. Conclusion and practice implicationsUsing the adapted chest pain decision tool in emergency medicine may improve knowledge and reduce admissions, while addressing known barriers to understanding related to patient health literacy.

Clinical Effectiveness of Cardiac Noninvasive Diagnostic Testing in Patients Discharged From the Emergency Department for Chest Pain.

BackgroundMore than 4 million cardiac noninvasive diagnostic tests are performed annually in the United States. However, questions remain regarding their effectiveness in improving clinical outcomes. We sought to evaluate whether noninvasive diagnostic tests were associated with lower rates of myocardial infarction or cardiovascular death when compared with no testing.Methods and ResultsWe performed a retrospective, population‐based cohort study of adults evaluated for chest pain and discharged home from an emergency department in Ontario, Canada. Propensity score matching was employed to reduce confounding between the testing and nontesting groups. There were 370 863 patients evaluated in our cohort. Rates of the composite outcome were low for both groups after propensity‐score matching (0.29% and 0.78% for the nontesting group at 90 days and 1 year, respectively, and 0.34% and 0.68% for the noninvasive diagnostic test group at 90 days and 1 year respectively). Over 1 year, patients undergoing noninvasive diagnostic testing had a small but statistically significant lower hazard of developing the composite outcome of myocardial infarction or cardiovascular mortality (hazard ratio, 0.87; 95% CI, 0.78–0.96 [P<0.01]), which appears to be driven by the high‐risk subgroup (hazard ratio, 0.75; 95% CI, 0.61–0.92 [P<0.01]).ConclusionsWe report a lower observed rate of the composite outcome of cardiovascular death or myocardial infarction associated with noninvasive diagnostic testing following evaluation for chest pain in the emergency department. This lower rate was driven by the high‐risk subgroup. These results suggest that risk‐based testing should be considered for patients discharged from the emergency department for chest pain.

EP1.15-01 Spontaneous Mediastinal Hematoma Resembling Mediastinal Tumor in a Haemophiliac Patient

To describe an extremely rare case of spontaneous mediastinal hematoma secondary to a thymic cyst bleeding and its surgical treatment in a patient with haemophilia A. A 22-year-old male was admitted to the Emergency Department for chest pain, fever and haematuria arisen four days before. He was a heavy smoker with a previous diagnosis of haemophilia A (factor VIII deficiency). Vital signs showed tachycardia (110 beats per minute) and fever (37.5°C); physical examination showed a superior vena cava syndrome with oedema of the neck and the left harm. Hematological examination revealed only a prolonged clotting time compatible with his hemophilic disorder. A chest X-ray was performed and a mediastinal widening was revealed. A subsequent chest CT-scan showed a mediastinal mass of 77x35x85mm with compression of the left subclavian vein and superior vena cava (Fig. 1A). A suspect of lymphoma was posed and a surgical biopsy was planned. Through a right uniportal VATS, the anterior mediastinal pleura was incised to reach the mass, and suddenly 400ml of hematinic liquid leaked out and multiple biopsies of the remnant mediastinal tissue were performed. A mediastinal hematoma was then suspected. Post-operative chest X-ray showed a reduction of the mediastinal widening. A chest CT scan performed a few days later revealed an impressive reduction of the mass (Fig. 1B). Histological examination was consistent with a thymic cyst surrounded by a large amount of haemorrhagic and inflammatory tissue. A chest MRI at 3 and 6 month after surgery demonstrated a gradual and complete reduction of the mediastinal mass (Fig. 1C). Spontaneous mediastinal hematoma is a very rare condition that could radiologically be misdiagnosed with a mediastinal tumour. A suspect must be posed in patients with bleeding disorders presenting with a mediastinal widening.

Utilization of stress testing for low-risk patients with chest discomfort in the emergency department

BackgroundThe management of patients presenting to an emergency department with chest discomfort at low-risk for acute coronary syndrome represents a common clinical challenge. Such patients are often triaged to chest pain units for monitoring and cardiac stress testing for further risk stratification. MethodsWe conducted a retrospective study of 292 low-risk patients who presented to an emergency department with chest discomfort. We performed physician-adjudicated chart reviews of all patients with positive stress tests to assess downstream testing, subsequent coronary revascularization, and outcomes. ResultsOf the 292 patients, 33 (11.3%) had stress tests positive for ischemia, and 12 (4.1%) underwent diagnostic cardiac catheterization. Of the 292 patients, 4 (1.4%) underwent coronary revascularization that may have resulted in a mortality benefit. ConclusionThese data suggest a very low yield of detecting clinically significant coronary disease with stress testing low-risk patients with chest discomfort in emergency department chest pain units.

8 Emergency Department Chest Pain Visits and Downstream Cardiac Testing Before and After High-Deductible Health Plan Enrollment

8 Emergency Department Chest Pain Visits and Downstream Cardiac Testing Before and After High-Deductible Health Plan Enrollment

TF1 A Tool for Faculty Preceptors to Guide Emergency Departments Learners in Constructing Focused Assessments of Common Presenting Complaints

Patient management in the emergency department (ED) requires rapid evaluation and stabilization, efficient data collection, and timely risk stratification of life-threatening conditions. Heuristic models for thinking (eg, the ABCDE approach to trauma) are required to efficiently make decisions to resuscitate patients and narrow lists of differential diagnoses. Constructing and practicing such models of thinking is important in the development of the emergency medicine (EM) physician. Instructional modalities that encourage learners to develop systematic approaches to patient presentations, such as simulation, should be used early in their EM education. The goal of this project is to provide faculty preceptors in the ED with a tool to better support students and interns construct focused patient assessments for common presenting complaints. Primary: Provide structured evaluation of ED learners’ assessments of patients with common chief complaints. Secondary: In regards to common ED chief complaints, learners will list critical differential diagnoses, list necessary history and exam items to evaluate such diagnoses, complete a focused history and physical exam, and synthesize history and exam findings to formulate appropriate assessments and plans. “Chest pain” was selected as the chief complaint for an initial tool. A checklist was formed in table format, with rows consisting of history of present illness, review of systems, past and family medical history, and physical exam. Columns consisted of six critical diagnoses for chest pain: myocardial infarction, pulmonary embolism, aortic dissection, pneumothorax, cardiac tamponade, and esophagitis. Cells were populated with relevant history and exam findings, each with empty positive and negative checkboxes. A learner will evaluate an ED patient with chest pain and present to a faculty preceptor. The preceptor will use the checklist to document the learner’s positive and negative history and exam findings. The preceptor will provide feedback regarding the learner’s consideration of the critical differential diagnoses, what history and exam items are still required to complete an evaluation for these diagnoses, and whether the learner’s history and exam findings justify their assessment and plan. Learners are encouraged to re-examine the patient to complete the checklist, and discuss with the preceptor their additional findings and if and how their assessments and plans would change. The primary objective can be measured by asking preceptors if the tool helped them provide more structured feedback to learners and by asking learners to rate the quality of preceptor feedback. Secondary objectives can be measured by tracking learner checklist completion for subsequent assessments of ED chest pain patients or via preceptor evaluations of learners’ assessments over time, particularly whether they consider all critical diagnoses and demonstrate the ability to synthesize history and exam findings into an appropriate assessment and plan. This tool can be an effective adjunct in evaluating new learners' assessments of common ED chief complaints. This method provides more structured feedback from which learners are encouraged to develop their own systematic approaches to common patient presentations.

TCT-203 The Role of CT Angiography in a Management Strategy Based on High-Sensitivity Cardiac Troponin-T for Predicting an Early Prognosis in Patients With Acute Chest Pain Admitted to the Emergency Department

Although algorithms to rule out myocardial infarctions using high sensitivity cardiac troponin (hs-cTn) are recommended for patients with acute chest pain in emergency departments, we assessed the additional usefulness of coronary computed tomography angiography (CTA) performed in the emergency

Point-of-care ultrasound with pocket-size devices in emergency department.

Point-of-care ultrasound is a useful tool for clinicians in the management of patients. Particularly in emergency department, the role of point-of-care ultrasound is strongly increasing due to the need for a rapid assessment of critically ill patients and to speed up the diagnostic process. Hand-carried ultrasound devices are particularly useful in emergency setting and allow rapid assessment of patient even in prehospital setting. This article will review the role of point-of-care ultrasonography, performed with pocket-size devices, in the management of patients presenting with acute onset of undifferentiating dyspnea, chest pain, and shock in emergency department.

360Sex differences in imaging referral patterns and angiographic referral rates among emergency department chest pain unit patients

360Sex differences in imaging referral patterns and angiographic referral rates among emergency department chest pain unit patients

Triage to Observation: A Quality Improvement Initiative for Chest Pain Patients Presenting to the Emergency Department.

The objective of this study was to evaluate the impact of a rapid admission protocol for chest pain patients presenting to the emergency department (ED) on ED length-of-stay (LOS). In this study, ED LOS was defined as the time from triage check-in until the time the patient physically leaves the ED. The purpose of this quality improvement study was to decrease ED crowding. This is a single-center prospective cohort study performed as a quality improvement initiative. This study implemented a rapid admission protocol for patients who were at moderate risk for a major adverse cardiac event based on the HEART score. When a patient presented to the ED through triage with a chief complaint of chest pain, this protocol allowed the provider-in-triage (PIT) to identify eligible patients for potential rapid admission to the hospital's clinical decision unit (CDU). The PIT would complete a rapid medical screening examination, initiate the patient's workup, and call the CDU providers to further evaluate the patient. By identifying these patients early, the lengthy ED chest pain workup contributing to longer ED LOS could then be completed in the CDU. The total number of patients seen in the ED over the study period was 34,251. The total number of patients admitted to the CDU during the study period was 1,442. The PIT identified 13 patients for rapid admission to the CDU during the study period. These patients had a statistically significant reduction in ED LOS (P < 0.001). ED LOS was also adjusted to identify delays in patient movement resulting in a statistically significant difference (P < 0.001). Implementation of a rapid admission protocol for chest pain patients at moderate risk for a major adverse cardiac event resulted in a reduction in ED LOS. Adjusted ED LOS was also significant, highlighting a delay in patient movement from the ED to the CDU indicating continued barriers affecting ED holding times.

SACCULAR CORONARY ANEURYSM PRESENTING AS ACUTE CORONARY SYNDROME WITH ATRIAL FLUTTER AND COMPLETE HEART BLOCK

Coronary artery aneurysm (CAA) are rare clinical entities. The optimal management of CAA remains controversial and largely based on case reports and anecdotal experience. A 78-year-old-man presented to the emergency department for chest pain with lateral ST segment elevation. Coronary angiogram was

ENDOTHELIAL FUNCTION PREDICTS 5-YEAR ADVERSE CLINICAL OUTCOME IN PATIENTS HOSPITALIZED IN THE EMERGENCY DEPARTMENT CHEST PAIN UNIT

Endothelial function is a marker for cardiovascular risk. Thus, abnormal endothelial function may be associated with adverse outcome in patients presenting to the emergency department chest pain unit (CPU). Following endothelial function testing, using EndoPAT 2000 in 300 consecutive subjects with

Effect of a HEART Care Pathway on Chest Pain Management Within an Integrated Health System

We describe the association of implementing a History, ECG, Age, Risk Factors, and Troponin (HEART) care pathway on use of hospital care and noninvasive stress testing, as well as 30-day patient outcomes in community emergency departments (EDs). We performed a prospective interrupted-time-series study of adult encounters for patients evaluated for suspected acute coronary syndrome. The primary outcome was hospitalization or observation, noninvasive stress testing, or both within 30 days. The secondary outcome was 30-day all-cause mortality or acute myocardial infarction. A generalized estimating equation segmented logistic regression model was used to compare the odds of the primary outcome before and after HEART implementation. All models were adjusted for patient and facility characteristics and fit with physicians as a clustering variable. A total of 65,393 ED encounters (before, 30,522; after, 34,871) were included in the study. Overall, 33.5% (before, 35.5%; after, 31.8%) of ED chest pain encounters resulted in hospitalization or observation, noninvasive stress testing, or both. Primary adjusted results found a significant decrease in the primary outcome postimplementation (odds ratio 0.984; 95% confidence interval [CI] 0.974 to 0.995). This resulted in an absolute adjusted month-to-month decrease of 4.39% (95% CI 3.72% to 5.07%) after 12 months' follow-up, with a continued trend downward. There was no difference in 30-day mortality or myocardial infarction (0.6% [before] versus 0.6% [after]; odds ratio 1.02; 95% CI 0.97 to 1.08). Implementation of a HEART pathway in the ED evaluation of patients with chest pain resulted in less inpatient care and noninvasive cardiac testing and was safe. Using HEART to risk stratify chest pain patients can improve the efficiency and quality of care.

ED Chest Pain Rules: Follow Your HEART?

ED Chest Pain Rules: Follow Your HEART?

Value of early rest myocardial perfusion imaging with SPECT in patients with chest pain and non-diagnostic ECG in emergency department.

Evaluation of atypical presentation of angina chest pain in emergency department is difficult. Hospitalization of this patient may impose additional costs and waste the time, early discharge may lead to miss the patients. The aim of this study was to determine volubility of Single Photon Emission Computed Tomography (SPECT) in management of patients admitted to emergency department with atypical manifestations of angina pain, un-diagnostic Electrocardiogram (ECG) and negative enzyme. Half of 100 patients admitted to emergency department with atypical chest pain and un-diagnostic ECG who were candidate for admission, underwent ECG gated resting SPECT. According to the results of SPECT, low risk patient discharged after negative stress SPECT. All discharged patients were followed up for major cardiac events (cardiac death, nonfatal myocardial infarction and repeat admission for congestive heart failure) for 12months. According to rest SPECT Myocardial Perfusion Imaging (MPI), about 70% of patients in case group was low risk and 30% of them had moderate or high risk. Case group represented lower hospitalization rate and lower need for Coronary Artery Angiography (CAG) in comparison with control group. Mean cost in case group was significantly lower than control group (175.15$ vs. 391.33$, P < 0.001). In one year follow- up no cases of mortality or major cardiovascular events as cardiac infraction were found in discharged patients in case group. our study showed that rest SPECT fulfillment in admitted patients in emergency department was validated method for assessing patients' risk which avoids unnecessary hospitalizations and additional costs.