Emergency Department Chest Pain Unit Research Articles

Performance Assessment of an Emergency Department Chest Pain Unit

To determine the prevalence and clinical characteristics of non-traumatic chest pain, to assess the quality of treatment provided by an emergency department chest pain unit (CPU), and to provide a theoretical estimate of the size of future CPUs. This prospective study included 1000 consecutive patients with chest pain seen at a CPU and a second group comprising the remaining patients seen for other complaints. Data on the patients' clinical characteristics, final diagnosis, destination (i.e., admitted or discharged), waiting time, and length of stay were recorded. In the CPU, the door-to-ECG time, and, when referred, the door to needle time and the door-to-balloon time were also recorded. In considering CPU size, the number of chest pain patients and the time to admission or discharge were utilized. Among 22468 visits, the prevalence of chest pain was 4.4%. Compared with other patients, those with chest pain were more frequently male, older, had to wait less time, and were admitted more often. Of the 1000 chest pain patients, 25.9% had acute coronary syndrome (ACS), 64.7% did not, and 9.4% were not diagnosed because exercise testing could not be performed. Patients with ACS were older and had more cardiovascular risk factors, but no gender difference was found. The door-to-ECG time was 10 min, the door to needle time was 26 min, and the door-to-balloon time was 51 min. One CPU stretcher is required for every 13000 emergency department visits per year. The prevalence of chest pain and affected patients' distinct clinical profile support the introduction of emergency department CPUs. Although there were limitations on the use of exercise testing, quality of treatment standards for ACS were achieved.

29.05

29.05

Prospective Multicenter Study of Quantitative Pretest Probability Assessment to Exclude Acute Coronary Syndrome for Patients Evaluated in Emergency Department Chest Pain Units

We compare the diagnostic accuracy of 3 methods--attribute matching, physician's written unstructured estimate, and a logistic regression formula (Acute Coronary Insufficiency-Time Insensitive Predictive Instrument, ACI-TIPI)--of estimating a very low pretest probability (< or = 2%) for acute coronary syndromes in emergency department (ED) patients evaluated in chest pain units. We prospectively studied 1,114 consecutive patients from 3 academic EDs, evaluated for acute coronary syndrome. Physicians collected data required for pretest probability assessment before protocol-driven chest pain unit testing. A pretest probability greater than 2% was considered "test positive." The criterion standard was the outcome of acute coronary syndrome (death, myocardial infarction, revascularization, or > 60% stenosis prompting new treatment) within 45 days, adjudicated by 3 independent reviewers. Fifty-one of 1,114 enrolled patients (4.5%; 95% confidence interval [CI] 3.4% to 6.0%) developed acute coronary syndrome within 45 days, including 4 of 991 (0.4%; 95% CI 0.1% to 1.0%) patients, discharged after a negative chest pain unit evaluation result, who developed acute coronary syndrome. Unstructured estimate identified 293 patients with pretest probability less than or equal to 2%, 2 had acute coronary syndrome, yielding sensitivity of 96.1% (95% CI 86.5% to 99.5%) and specificity of 27.4% (95% CI 24.7% to 30.2%). Attribute matching identified 304 patients with pretest probability less than or equal to 2%; 1 had acute coronary syndrome, yielding a sensitivity of 98.0% (95% CI 89.6% to 99.9%) and a specificity of 26.1% (95% CI 23.6% to 28.7%). ACI-TIPI identified 56 patients; none had acute coronary syndrome, yielding sensitivity of 100% (95% CI 93.0% to 100%) and specificity of 6.1% (95% CI 4.7% to 7.9%). In a low-risk ED population with symptoms suggestive of acute coronary syndrome, patients with a quantitative pretest probability less than or equal to 2%, determined by attribute matching, unstructured estimate, or logistic regression, may not require additional diagnostic testing.

Assessment and Management of Chest Pain in the Septuagenarian Population in the Emergency Department Chest Pain Unit Setting

Objective: The high incidence of cardiovascular events (CVEs) in the elderly argues for an approach that determines which patients presenting with chest pain (CP) can be optimally evaluated and safely discharged from the emergency department chest pain unit setting (CPU) without serious cardiac events. However, the ACC/AHA practice guidelines classify patients over the age of 70 years as intermediate risk and those over 75 years as high risk, making them ineligible for CPU evaluation in most emergency departments. We aimed to investigate the utility and safety of a CPU evaluation in patients age >=70 presenting with CP.

Use of the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument to Predict Outcomes in the Emergency Department Chest Pain Unit

Use of the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument to Predict Outcomes in the Emergency Department Chest Pain Unit

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.

An Assessment of the Prognostic Value of Exercise Treadmill Testing Utilizing the Duke Score in Risk Stratification of Emergency Department Chest Pain Unit Patients

An Assessment of the Prognostic Value of Exercise Treadmill Testing Utilizing the Duke Score in Risk Stratification of Emergency Department Chest Pain Unit Patients

Continuous 12-lead electrocardiographic monitoring in an emergency department chest pain unit: An assessment of potential clinical effect

Study objectives: Continuous 12-lead serial ECG monitoring has been proposed to assist in the evaluation of patients with acute coronary syndrome and nondiagnostic ECG in an emergency department chest pain unit. However, the ability of serial ECG to detect acute coronary syndrome and its benefit in addition to a standard protocol has not been established. We evaluate the ability of continuous 12-lead ECG to detect acute coronary syndrome, assess the incremental benefit of the serial ECG in association with a set protocol in an ED chest pain unit, and evaluate whether serial ECG changes could be considered as prognostic factors. Methods: Patients who met Agency for Health Care Policy and Research guidelines for intermediate risk for short-term cardiovascular event unstable angina were prospectively studied in the chest pain unit. Patients were monitored with the Mortara Instruments ELI 100 STM continuous 12-lead ECG system with ST-segment analysis. ST-segment changes of greater than 100 μV in 2 or more contiguous leads or greater than 200 μV in 1 lead were considered positive. Data were compared with serial serum cardiac markers, cardiac function study results, angiographic results, and 30-day outcome results. Results: One hundred nineteen patients had serial ECG applied. The median duration of monitoring was 4.2 hours. Forty patients were given a diagnosis of acute coronary syndrome. Chest pain unit protocol detected 52 patients, and 23 were given a diagnosis of acute coronary syndrome (sensitivity 58%; specificity 63%). Sixteen patients had ST-segment changes of greater than 100 μV or greater than 200 μV, and 9 were given a diagnosis of acute coronary syndrome. The addition of the serial ECG to the chest pain unit protocol increased the sensitivity to 65% and decreased the specificity to 58%. Two patients with ST-segment changes but none without ST-segment changes had an adverse cardiac event, yielding a sensitivity of 100% and a specificity of 88%. Conclusion: Serial ECG is of limited value in the diagnostic evaluation of intermediate-risk patients managed in the chest pain unit with a standard protocol. However, when ST-segment changes are present, they indicate an increased likelihood for an adverse cardiac event. [Ann Emerg Med. 2003;41:342-351.]

7. Continuous 12-lead electrocardiographic monitoring in an emergency department chest pain unit

7. Continuous 12-lead electrocardiographic monitoring in an emergency department chest pain unit

7. Continuous 12-lead electrocardiographic monitoring in an emergency department chest pain unit

7. Continuous 12-lead electrocardiographic monitoring in an emergency department chest pain unit

Feasability of a Rapid Diagnostic Protocol for an Emergency Department Chest Pain Unit

See related editorial, p 168. Study objective: To evaluate the applicability of a short-stay protocol for exclusion of acute ischemic heart disease without hospital admission and to analyze these results in the context of a conceptual model. Methods: An observational study of patients who presented with chest pain to the emergency department of an 886-bed inner-city municipal hospital and who needed hospital admission to rule out acute myocardial infarction (AMI). Patients were assessed by ED attending physicians to determine eligibility for an alternative, 12- hour protocol in an ED chest pain observation unit (CPOU) followed by immediate exercise testing. Outcome measures were proportion of patients eligible for the short-stay protocol, risk factor profile, and reasons for exclusion. Results: Of 500 patients screened, 446 had sufficient data points to determine protocol eligibility. Of these, 238 (53.3%; 95% confidence interval [CI], 48.7% to 57.9%) were found to have low probability for AMI. After study exclusion criteria were applied to the patient cohort, 63 patients (14.1%; 95% CI, 10.9% to 17.3%) were eligible for the protocol. The most common reasons for exclusion were history of coronary artery disease (46%) and inability to perform an interpretable exercise tolerance test (42%). Conclusion: Although most admitted patients with chest pain (53%) were at low probability for AMI, only a minority (14%) were eligible for a short-stay protocol that required patients to be free of known coronary artery disease and able to perform an exercise tolerance test. Factors affecting the operations and efficiency of a CPOU include clinical characteristics of the target patient population, protocol tests used, and hospital occupancy and reimbursement patterns. [Zalenski RJ, Rydman RJ, McCarren M, Roberts RR, Jovanovic B, Das K, Mensah EK, Kampe LM: Feasibility of a rapid diagnostic protocol for an emergency department chest pain unit. Ann Emerg Med January 1997;29:99-108.]