Emergency Department Chest Pain Unit Research Articles

Endothelial function predicts 5-year adverse outcome in patients hospitalized in an emergency department chest pain unit.

Although endothelial function is a marker for cardiovascular risk, endothelial dysfunction assessment is not routinely used in daily clinical practice. A growing challenge has emerged in identifying patients prone to cardiovascular events. We aim to investigate whether abnormal endothelial function may be associated with adverse 5-year outcomes in patients presenting to a chest pain unit (CPU). Following endothelial function testing using EndoPAT 2000 in 300 consecutive patients without a history of coronary artery disease, patients underwent coronary computerized tomographic angiography (CCTA) or single-photon emission computed tomography according to availability. Mean 10-year Framingham risk score (FRS) was 6.6 ± 5.9%; mean 10-year atherosclerotic cardiovascular disease (ASCVD) risk was 7.1 ± 7.2%; median reactive hyperemia index (RHI) as a measure of an endothelial function 2.0 and mean was 2.0 ± 0.4. During a 5-year follow-up, the 30 patients who developed major adverse cardiovascular events (MACE), including all-cause mortality, nonfatal myocardial infarction, hospitalization for heart failure or angina pectoris, stroke, coronary artery bypass grafting, and percutaneous coronary interventions, had higher 10-year FRS (9.6 ± 7.8 vs. 6.3 ± 5.6%; P = 0.032), higher 10-year ASCVD risk (10.4 ± 9.2 vs. 6.7 ± 6.9%; P = 0.042), lower baseline RHI (1.6 ± 0.5 vs. 2.1 ± 0.4; P < 0.001) and a greater degree of coronary atherosclerotic lesions (53 vs. 3%, P < 0.001) on CCTA compared with patients without MACE. Multivariate analysis demonstrated that RHI below the median was an independent predictor of 5-year MACE (odds ratio 5.567, 95% confidence interval 1.955-15.853; P = 0.001). Our findings suggest that noninvasive endothelial function testing may contribute to clinical efficacy in triaging patients in the CPU and in predicting 5-year MACE. NCT01618123.

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.

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

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

Endothelial function predicts 1-year adverse clinical outcome in patients hospitalized in the emergency department chest pain unit

BackgroundEndothelial function is a marker for cardiovascular risk. Thus, abnormal endothelial function may be associated with adverse 1-year outcome in patients presenting to the emergency department chest pain unit (CPU). MethodsFollowing endothelial function testing, using EndoPAT 2000 in 300 consecutive subjects with chest pain and no history of coronary artery disease (CAD) presenting to CPU, patients underwent coronary computerized tomographic angiography (CCTA) or single-photon emission computed tomography according to availability. ResultsMean 10-year Framingham risk score (FRS) was 6.6±5.9%, median reactive hyperemia index (RHI) as a measure of endothelial function 2.08 and mean was 2.0±0.4. During a 1-year follow-up, the 20 (6.6%) patients who developed major adverse cardiovascular end-points (MACE), including all-cause mortality, non-fatal myocardial infarction, hospitalization for heart failure or angina pectoris, stroke, coronary artery bypass grafting and percutaneous coronary interventions, had higher 10-year FRS (10.5±8.2% vs 6.3±5.7%; p<0.001), lower baseline RHI (1.43±0.41 vs 2.10±0.44; p<0.001) and a greater extent of coronary atherosclerosis lesions (70% vs 3.9%, p<0.001) in the CPU CCTA, compared to those without MACE. RHI≤the median was associated with higher 1-year MACE (13% vs 0.7%, p<0.001) compared to RHI>the median. Multivariate analysis demonstrated that RHI≤the median is an independent predictor of coronary atherosclerosis lesions in the CPU CCTA (OR 5.98, 95% CI 03.29-10.88; p<0.001) and 1-year MACE (OR 15.207, 95% CI 2.00-115.33; p<0.01). ConclusionsOur findings suggest that non-invasive endothelial function testing may have clinical utility in triaging patients in the CPU and in predicting 1-year MACE.

102 Efficacy and Safety Performance of an Evidence-Based Cardiac Stress Testing Protocol in an Emergency Department Chest Pain Unit

102 Efficacy and Safety Performance of an Evidence-Based Cardiac Stress Testing Protocol in an Emergency Department Chest Pain Unit

Barriers to outpatient stress testing follow-up for low-risk chest pain patients presenting to an ED chest pain unit

IntroductionOutpatient stress testing (OST) after evaluation in the emergency department (ED) is an acceptable evaluation method for patients presenting to the ED with low-risk chest pain (CP). However, not all patients return for OST. Barriers to follow-up evaluation exist and are poorly understood. In this study, we examined the influence of demographic and social characteristics on OST compliance. MethodsData were collected on low-risk CP patients with scheduled OSTs. OST compliance was assessed and then analyzed for correlation with potential barriers including insurance type; age; sex; race; employment status; the distance the patient lived from the hospital; whether or not the patient had a primary care physician; whether or not the patient had a history of hypertension or diabetes; and whether or not the patient had a history of tobacco, alcohol, or illicit drug use. ResultsA total of 275 patients were enrolled over a 5-month period. These patients had an OST follow-up rate of 61.82% within 72hours of discharge from the ED. Patients with Medicaid were statistically less likely (odds ratio [OR], 0.439) to complete OST. Patients with commercial insurance (OR, 1.8225), who were employed (OR, 2.299), or who were retired (OR, 3.44) were more likely to complete OST. All of the other variables analyzed were not statistically significant factors in OST compliance. ConclusionMore than one-third of low-risk CP patients do not follow-up with scheduled OST. Of the variables analyzed, both employment status and insurance type were statistically significant and should be included in risk stratification strategies for OST.

Inter-rater Reliability of the Diamond & Forrester Score in Emergency Department Chest Pain Observation Unit Patients.

Cardiology consensus guidelines recommend use of the Diamond & Forrester (D&F) score in augmenting the decision to pursue stress testing. We have recently shown that it may have value in safely reducing stress utilization in an emergency department chest pain unit (CPU). However, full application necessitates demonstration of a good inter-rater reliability of the D&F score in the CPU setting. We hypothesized that D&F pretest probability would have good inter-rater reliability in CPU patients. This was a chart review of randomly selected patients from a previously collected prospective observational trial of admitted CPU patients in a large-volume academic urban emergency department. Inclusion criteria were: age>18 years, American Heart Association low/intermediate risk, nondynamic electrocardiograms, and normal initial troponin I. Exclusion criteria were: age>75 years with coronary artery disease. A D&F score for likelihood of coronary artery disease was calculated on each patient by 2 trained chart abstractors using a standardized data abstraction instrument. Abstractors were trained to specifically categorize presenting symptoms as fitting 1 of 3 types of chest pain symptoms: nonanginal, atypical, or anginal based on previously published prespecified criteria. Approximately 20% of charts in a CPU registry were abstracted by 2 chart abstractors who were blind to each other's categorization, the patient outcomes, and the study hypothesis. The primary outcome was the kappa statistic for agreement between the 2 raters. The charts of 705 random patients were reviewed. The mean age was 55.1±11.8 years, 52% were female. Forty four percentage of patients received stress testing, and 2.4% of patients had acute coronary syndrome. The mean D&F score was 39±24. There was good inter-rater agreement of chest pain characteristics (κ=0.77, 95% confidence interval, 0.72-0.81; P<0.01). This study supports the use of the D&F score as a reliable indicator of pretest probability in CPU patients by demonstrating that there is good inter-rater reliability. Prospective validation is necessary at the point of patient assessment, in conjunction with application of the D&F score to augment stress utilization decision making.

Discrepancy between clinician and research assistant in TIMI score calculation (TRIAGED CPU).

IntroductionSeveral studies have attempted to demonstrate that the Thrombolysis in Myocardial Infarction (TIMI) risk score has the ability to risk stratify emergency department (ED) patients with potential acute coronary syndromes (ACS). Most of the studies we reviewed relied on trained research investigators to determine TIMI risk scores rather than ED providers functioning in their normal work capacity. We assessed whether TIMI risk scores obtained by ED providers in the setting of a busy ED differed from those obtained by trained research investigators.MethodsThis was an ED-based prospective observational cohort study comparing TIMI scores obtained by 49 ED providers admitting patients to an ED chest pain unit (CPU) to scores generated by a team of trained research investigators. We examined provider type, patient gender, and TIMI elements for their effects on TIMI risk score discrepancy.ResultsOf the 501 adult patients enrolled in the study, 29.3% of TIMI risk scores determined by ED providers and trained research investigators were generated using identical TIMI risk score variables. In our low-risk population the majority of TIMI risk score differences were small; however, 12% of TIMI risk scores differed by two or more points.ConclusionTIMI risk scores determined by ED providers in the setting of a busy ED frequently differ from scores generated by trained research investigators who complete them while not under the same pressure of an ED provider.

Abstract 68: A Cardiologist-Directed, Selective Testing Approach to Emergency Department Chest Pain Patients is Safe and Efficient

Background: A protocol driven, non-selective approach to low to intermediate risk patients with chest pain (CP) in the Emergency Department (ED) usually consists of a period of observation followed by a noninvasive test, with cardiology consultation reserved for those with an abnormal work-up. This approach leads to a high rate of testing utilization in a patient population with a relatively low pretest probability of disease. We sought to assess the safety of a cardiologist-directed approach, whereby all CP patients were quickly evaluated with selective use of testing. Methods: We instituted a CP protocol which entailed early evaluation of low to intermediate risk CP patients by a cardiologist. Entry criteria included age &lt;75, no known history of CAD, negative initial biomarkers, and a non-diagnostic ECG. Patient data was prospectively recorded over 27 months. Utilization of further testing was at the discretion of the cardiologist. Efficacy of care was assessed by telephone follow-up if available, or with the patient’s physician. Results: A total of 686 consecutive patients who met entry criteria were enrolled in the protocol. The mean age was 48.4 years, 47% (326/686) were female, 9% (64/686) were diabetic, 22% (151/686) smoked, 34% (236/686) had hypertension and 24% (168/686) had dyslipidemia. According to the Diamond Forrester criteria, the CP was characterized as non-cardiac in 55% (383/686), atypical in 43% (293/686), and typical in 2% (11/686). Altogether 59.2% (406/686) of patients in the protocol underwent testing. Testing modalities included: Coronary CT angiography in 34% (138/406), exercise ECG in 17% (71/406), exercise echocardiography in 17% (70/406), exercise nuclear in 16% (67/406), transthoracic echocardiography in 8% (32/406), cardiac catheterization in 5% (19/406), and other test in 3% (9/406). Patients who underwent testing spent a mean of 22.4 hours in the ED compared to 13.8 hours if no test was ordered (p&lt;0.001). Of the patients that underwent initial testing, 10% (41/406) of those tests were abnormal. Ultimately, 9.8% of patients (67/686) were admitted and 0.6% (4/686) were diagnosed with myocardial infarction. Follow-up data was available for 61.4% (421/686). Only 1 patient (0.2%, 1/421) was found to have an adverse event. Prior to institution of this cardiologist-driven approach, the rate of testing in our ED for a similar population was 91.9% (137/149). Therefore our approach resulted in a 35% reduction in the rate of testing (p&lt;0.001). Additionally, our results compare favorably with prior studies of ED CP units with protocol driven testing rates which usually approach 100% by design. Conclusion: A cardiologist-directed approach to CP patients in the ED was safe and resulted in lower testing utilization rates than standard protocol-driven management. Replacing a one-size-fits-all approach will likely result in more patient-centered, selective use of testing.

Racial Disparities in Stress Test Utilization in an Emergency Department Chest Pain Unit

Epidemiological studies have demonstrated racial disparities in the workup of emergency department patients with chest pain and the referral of admitted patients for intervention. However, little is known about possible disparities in stress test utilization in low-risk chest pain patients admitted to emergency department chest pain units. A retrospective observational study of consecutive chest pain unit patients was conducted. Eligibility criteria included age >18 years, American Heart Association low-to-intermediate risk, nondynamic electrocardiograms, and normal initial troponin I. Patients aged >75 years with a history of coronary artery heart disease were excluded. On each patient, we calculated a Thrombolysis in Myocardial Infarction (TIMI) risk prediction score and a Diamond and Forrester (D&F) score for likelihood of coronary artery disease. Two separate multivariate analyses were completed, one including the TIMI score and the other including D&F score, using logistic regression to estimate odds ratios (ORs) for receiving testing based on race, controlling for other relevant covariates. Two thousand four hundred fifty-one patients were enrolled over a planned 1.5-year period. In total, 59.7% [95% confidence interval (CI) 57.8-61.7] of patients were white, 11.6% (95% CI 10.4-12.9) African American, and 28.6% (95% CI 26.9-30.4) "other." The overall stress testing rate was 50.3% (95% CI 48.4-52.3). After controlling for insurance and TIMI or D&F scores, African American patients had significantly decreased odds of stress testing (OR(TIMI) 0.68, 95% CI 0.52-0.89; OR(D&F) 0.67, 95% CI 0.51-0.89). Our study confirms racial disparities in the utilization of stress testing in the chest pain unit. Further investigation is needed to identify specific provider or patient-level factors that may contribute to this disparity.

301 The Financial Benefits of Implementing Cardiac Point of Care Testing of Emergency Department Chest Pain Patients

Study Objectives: Glendale Memorial Hospital implemented point of care testing for cardiac biomarkers in their emergency department (ED) in May of 2010 using a rapid disposition protocol. The goal of the hospital was 2fold: 1) to reduce the turnaround time for these markers which would improve workflow for chest pain patients and decrease patient disposition times; and 2) to reduce unnecessary inpatient admissions by admitting more of these patients to an existing ED Chest Pain Unit (EDCPU). The hypothesis was that more appropriate disposition of patients should lead to reduced costs and increased reimbursements. Methods: The implementation included the use of multiple cardiac biomarkers (TnI, CK-MB, myoglobin, and BNP; Alere™ Triage® CardioProfilER) which were evaluated in a rapid (2 hour) serial draw protocol. The analyses performed were comparisons of laboratory versus point of care test turnaround time during the post-implementation period, comparisons of pre-implementation versus post-implementation patient disposition, and the financial impact of the differences in patient disposition. The statistical analysis used was Student's t-test for equality of means for paired data (Excel® 2007) for all of the analyses except turnaround time which used the Mann-Whitney test for equality of means with unequal variance (MedCalc®). The EDCPU began operation in September of 2009 and the POC implementation process was completed in May of 2010. Allowing at least 2 months as a “start-up” period for these 2 events resulted in a pre-implementation period from November 2009 through April 2010 and a post-implementation period of November 2010 through April 2011 (six months in each period). Results: The turnaround time for biomarker results was significantly less for the point of care tests than for those coming from the central laboratory (p<0.0001). For 1736 test results at the point of care the mean time from order to result was about 42 minutes and the median was 37 minutes. 14.2% of the results took longer than an hour. In contrast, for 2208 tests performed in the central laboratory the mean time from order to result was 94 minutes with a median time of 85 minutes. 77.5% of the results took longer than an hour. There were also significant differences in chest pain patient disposition in the pre- versus post-implementation time frames. Whereas there was no significant difference in disposition to telemetry beds, there were highly significant differences in >24 h admissions (26.7 per month versus 14.5 per month; p<0.003) and EDCPU admissions (19.5 per month versus 33.3 per month; p<0.0004) in the pre- versus post-implementation periods. This translated into an approximate $4500 increase in margin per month (p<0.04) which was about $54,000 in increased revenue per year. Conclusion: Institution of a rapid disposition protocol for chest pain patients increased the use of the EDCPU at Glendale Memorial Hospital which resulted in a net financial gain for the hospital.

Predictive value of a 4-hour accelerated diagnostic protocol in patients with suspected ischemic chest pain presenting to an emergency department.

Currently recommended risk stratification protocols for suspected ischemic chest pain in the emergency department (ED) includes point-of-care availability of exercise treadmill/nuclear tests or CT coronary angiograms. These tests are not widely available for most of the ED's. This study aims to prospectively validate the safety of a predefined 4-hour accelerated diagnostic protocol (ADP) using chest pain, ECG, and troponin T among suspected ischemic chest pain patients presenting to an ED of a tertiary care hospital in Oman. One hundred and thirty-two patients aged over 18 years with suspected ischemic chest pain presenting within 12 hours of onset along with normal or non-diagnostic first ECG and negative first troponin T (<0.010 μg/l) were recruited from September 2008 to February 2009. Low-probability acute coronary syndrome (ACS) patients at 4-hours defined as absent chest pain and negative ECG or troponin tests were discharged home and observed for 30-days for major adverse cardiac events (MACE) (Group I: negative ADP). High-probability ACS patients at 4-hours were defined by recurrent or persistent chest pain, positive ECG or troponin tests and were admitted and observed for in-hospital MACE (Group II: positive ADP). One hundred and thirty-two patients were recruited and 110 patients completed the study. The overall 30-day MACE in this cohort was 15% with a mortality of less than 1%. 30-days MACE occurred in 8/95 of group I patients (8.4%) and 9/15 of the in-hospital MACE patients in group II. The ADP had a sensitivity of 52% (95% CI: 0.28-0.76), specificity of 93% (0.85-0.97), a negative predictive value of 91% (0.83-0.96), a positive predictive value of 60% (0.32-0.82), negative likelihood ratio of 0.5 (0.30-0.83) and a positive likelihood ratio of 8.2 (3.3-20) in predicting MACE. A 4-hour ADP using chest pain, ECG, and troponin T had high specificity and negative predictive value in predicting 30-day MACE among low probability ACS patients discharged from ED. However, 30-day MACE in ADP negative patients was relatively high in contrast to guideline recommendations. Hence, there is a need to establish ED chest pain unit and adopt new protocols especially adding a point-of-care exercise treadmill test in the ED.

Physician Discretion Is Safe and May Lower Stress Test Utilization in Emergency Department Chest Pain Unit Patients

Chest pain unit (CPU) observation with defined stress utilization protocols is a common management option for low-risk emergency department patients. We sought to evaluate the safety of a joint emergency medicine and cardiology staffed CPU. Prospective observational trial of consecutive patients admitted to an emergency department CPU was conducted. A standard 6-hour observation protocol was followed by cardiology consultation and stress utilization largely at their discretion. Included patients were at low/intermediate risk by the American Heart Association, had nondiagnostic electrocardiograms, and a normal initial troponin. Excluded patients were those with an acute comorbidity, age >75, and a history of coronary artery disease, or had a coexistent problem restricting 24-hour observation. Primary outcome was 30-day major adverse cardiovascular events-defined as death, nonfatal acute myocardial infarction, revascularization, or out-of-hospital cardiac arrest. A total of 1063 patients were enrolled over 8 months. The mean age of the patients was 52.8 ± 11.8 years, and 51% (95% confidence interval [CI], 48-54) were female. The mean thrombolysis in myocardial infarction and Diamond & Forrester scores were 0.6% (95% CI, 0.51-0.62) and 33% (95% CI, 31-35), respectively. In all, 51% (95% CI, 48-54) received stress testing (52% nuclear stress, 39% stress echocardiogram, 5% exercise, 4% other). In all, 0.9% patients (n = 10, 95% CI, 0.4-1.5) were diagnosed with a non-ST elevation myocardial infarction and 2.2% (n = 23, 95% CI, 1.3-3) with acute coronary syndrome. There was 1 (95% CI, 0%-0.3%) case of a 30-day major adverse cardiovascular events. The 51% stress test utilization rate was less than the range reported in previous CPU studies (P < 0.05). Joint emergency medicine and cardiology management of patients within a CPU protocol is safe, efficacious, and may safely reduce stress testing rates.

Gender and stress test use in an ED chest pain unit

BackgroundWomen with acute coronary syndrome appear to be treated less aggressively than men. However, little is known about potential sex biases in the evaluation of patients with low-risk chest pain admitted to emergency department (ED) chest pain units. MethodsThis was a secondary analysis of prospectively collected data on consecutively admitted chest pain unit patients in a large-volume academic urban ED. Thrombolysis in myocardial infarction (TIMI) risk prediction and Diamond and Forrestor (D&F) scores were calculated for each patient. χ2 And t tests were used for univariate comparisons of demographics, cardiac comorbidities, risk scores, and stress testing between sexes. Multivariable logistic regression was used to estimate odds ratios (ORs) for testing based on sex, controlling for race, insurance status, and either TIMI or D&F score. ResultsEight hundred eleven patients were enrolled (48% male, 52% female) in the study. The mean age for men was 52 ± 12 and 54 ± 12 years for women (P < .01). Men had a higher mean D&F score (42.0 vs 24.4; P < .01), but TIMI risk scores did not differ between sexes. Women received testing more often than men, a difference that was not statistically significant (50% [95% confidence interval {CI}, 45%-55%] vs 43% [95% CI, 39%-48%]; probability ratio of 1.16; P = .19). Women had a higher OR for receiving stress testing (1.61, 95% CI 1.14-2.29 controlling for TIMI score; OR, 1.69, 95% CI 1.12-2.51 controlling for D&F score). ConclusionsThis study demonstrates no association between physician discretionary uses of stress testing based on sex. There is a need for further research on patient- or provider-specific factors that determine stress use and on how differences may affect clinical outcomes.

Stress-Only Tc-99m Myocardial Perfusion Imaging in an Emergency Department Chest Pain Unit

BackgroundStress-only myocardial perfusion imaging (MPI) saves time by eliminating rest imaging, which is important for emergency department (ED) throughput but has not been studied in an ED population. Study ObjectiveTo determine the prognosis of a normal stress-only MPI study compared to a normal rest-stress MPI and establish its effectiveness in an ED setting. MethodsAll patients evaluated in the ED over 6.5 years who underwent a stress-only technetium-99m gated MPI were compared to those who had a rest-stress study. All-cause mortality was determined using the Social Security Death Index. Survival was analyzed in patients with normal and abnormal MPI results. ResultsA total of 4145 studies (2340 stress-only, 1805 rest-stress) were performed. Patients’ average age was 57.9 years, 38.5% were male, and most had an intermediate or low pretest risk of coronary artery disease (87.7%). Average follow-up was 35.9 ± 20.9 months. In patients with normal perfusion, at 1 year of follow-up there were 11 deaths in the stress-only group (0.5% 1-year mortality), and 13 deaths in the rest-stress cohort (1.1% 1-year mortality). At the end of follow-up, the stress-only group had a lower all-cause mortality (p < 0.0001) and similar risk adjusted all-cause mortality (p = 0.10) than the rest-stress cohort. Patients with abnormal perfusion demonstrated the expected differential prognosis based on total perfusion deficits in both groups. ConclusionsA normal stress-only MPI study has a benign 1-year prognosis similar to a rest-stress study when performed in the ED. The ability to triage patients more rapidly and reduce radiation exposure represents an attractive alternative for low-risk patients.

Comparison of Frequency of Inducible Myocardial Ischemia in Patients Presenting to Emergency Department With Typical Versus Atypical or Nonanginal Chest Pain

The present study was designed to assess the value of the presenting symptom of "typical" anginal pain, "atypical/nonanginal" pain, or the lack of chest pain in predicting the presence of inducible myocardial ischemia using cardiac stress testing in emergency department patients being evaluated for possible acute coronary syndrome. We performed a retrospective observational study of adult patients who were evaluated for acute coronary syndrome in an emergency department chest pain unit. The presenting symptoms were obtained from a structured questionnaire administered before stress testing. Patient chest pain was categorized according to the presence of substernal chest pain or discomfort that was provoked by exertion or emotional stress and was relieved by rest and/or nitroglycerin. Chest pain was classified as "typical" angina if all 3 descriptors were present and "atypical" or "nonanginal" if <3 descriptors were present. All patients underwent serial biomarker and cardiac stress testing before discharge. A total of 2,525 patients met the eligibility criteria. Inducible ischemia on stress testing was found in 33 (14%, 95% confidence interval 10% to 19%) of the 231 patients who had typical anginal pain, 238 (11%, 95% confidence interval 10% to 13%) of the 2,140 patients presenting with atypical/nonanginal chest pain, and 25 (16%, 95% confidence interval 11% to 22%) of the 153 patients who had no complaint of chest pain on presentation. Compared to patients with atypical or no chest pain, patients with typical chest pain were not significantly more likely to have inducible ischemia on stress testing (likelihood ratio +1.25, 95% confidence interval 0.89 to 1.78). In conclusion, in our study, the patients who presented with "typical" angina were no more likely to have inducible myocardial ischemia on stress testing than patients with other presenting symptoms.

Risk stratification of patients in an emergency department chest pain unit: prognostic value of exercise treadmill testing using the Duke score

BackgroundExercise treadmill testing (ETT) has been standard for evaluating outpatients at risk for cardiovascular events. Few studies have demonstrated its prognostic usefulness in emergency department chest pain units or have used the Duke score [(exercise duration in minutes) − (5 × ST-segment deviation in millimeters) − (4 × treadmill angina index)] to grade its performance.Aims Our objective was to assess the usefulness of this score in a chest pain unit to predict cardiovascular events.MethodsFrom November 2000 to October 2001, we retrospectively studied consecutive patients in the chest pain unit. Those undergoing ETT were stratified into “low” (Duke score ≥ 5) and “moderate/high” risk groups (< 5). Cardiovascular events defined as death, myocardial infarction > 24 h after presentation, revascularization, acute congestive heart failure, stroke or arrhythmia were identified within 1 year after presentation. Differences in risk of having a cardiovascular event among low-risk and moderate/high-risk groups are presented.ResultsDuring the study period, 1,048 patients entered the chest pain unit; 800 met inclusion criteria. Of these, 599 received ETT and 201 had contraindications or a positive finding in the chest pain unit protocol before ETT. Cardiovascular event rates were 0.7% (3/454), 15.2% (22/145) and 14.9% (30/201) after 1 month of follow-up for low-risk, moderate/high-risk and no-ETT groups, respectively.ConclusionsAccording to the Duke score, the low-risk group developed minimal cardiovascular events compared with the moderate/high-risk group. The Duke score appears effective for risk stratification of chest pain patients in chest pain units.

128: Evaluation of Chest Pain in an Emergency Department Chest Pain Unit: Effect of Age on Outcomes

128: Evaluation of Chest Pain in an Emergency Department Chest Pain Unit: Effect of Age on Outcomes

Triage flowchart to rule out acute coronary syndrome

Aim The aim of the study was to establish a triage flowchart to rule out acute coronary syndrome (ACS) among patients with chest pain (CP) arriving on an Emergency Department (ED). Patients and Method This prospective observational study included 1000 consecutive patients with CP arriving on an ED CP unit. Demographic and clinical characteristics along with vital signs were recorded as independent variables. After CP unit protocol completion and 1-month follow-up, patients were classified as (dependent variable) (1) true non-ACS (all noncoronary patients at the first visit that kept this condition when called 1 month later) or (2) true ACS (all the remaining patients). Relationship among variables was assessed by multiple logistic regression analysis. A triage flowchart was obtained from significant variables and applied to patients with CP who were then grouped in “triage non-ACS” and “triage ACS.” Validity indexes to exclude ACS for triage flowchart were measured. Results Variables significantly associated with non-ACS and included in the triage flowchart were age <40 years (odds ratio 3.61, 95% CI 1.63-7.99), absence of diabetes (2.74, 1.53-4.88), no previously known coronary artery disease (5.46, 3.42-8.71), nonoppressive pain (10.63, 6.04-18.70), and nonretrosternal pain (5.16, 2.82-9.42). For the triage flowchart, both specificity and positive predictive value to rule out ACS were 100%. Conclusions The triage flowchart is able to accurately identify patients with CP not having an ACS. It may help triage nurses make quick decisions on who should be immediately seen and who could safely wait when delays in medical attention are unavoidable. Prospective validation is needed.