Potential Acute Coronary Syndrome Research Articles

Emergency Nurses’ Recognition of and Perception of Sex Differences in Acute Coronary Syndrome Symptoms

IntroductionEmergency nurses must quickly identify patients with potential acute coronary syndrome. However, no recent nationwide research has explored nurses’ knowledge of acute coronary syndrome symptoms. The purpose of this study was to explore emergency nurses’ recognition of acute coronary syndrome symptoms, including whether nurses attribute different symptoms to women and men. MethodsWe used a cross-sectional, descriptive design using an online survey. Emergency nurses from across the United States were recruited using postcards and a posting on the Emergency Nurses Association website. Demographic data and participants’ recognition of acute coronary syndrome symptoms, using the Acute Coronary Syndrome Symptom Checklist, were collected. Descriptive statistics and ordinal regression were used to analyze the data. ResultsThe final sample included 448 emergency nurses with a median 7.0 years of emergency nursing experience. Participants were overwhelmingly able to recognize common acute coronary syndrome symptoms, although some symptoms were more often associated with women or with men. Most participants believed that women and men’s symptoms were either “slightly different” (41.1%) or “fairly different” (42.6%). Nurses who completed training for the triage role were significantly less likely to believe that men and women have substantially different symptoms (odds ratio 0.47; 95% CI 0.25-0.87). DiscussionEmergency nurses were able to recognize common acute coronary syndrome symptoms, but some reported believing that the symptom experience of men and women is more divergent than what is reported in the literature.

A Nationwide Study of Emergency Nurses’ Triage Decisions for Potential Acute Coronary Syndrome

IntroductionThis study aimed to identify the symptoms used to assess angina, determine how emergency nurses make triage decisions for potential acute coronary syndrome, and determine emergency nurses’ initial actions. MethodsThis was a cross-sectional, survey-based design. Emergency nurses were recruited through a posting on the Emergency Nurses Association website and through postcards. Measures included demographic data, assessment of angina, and the Nurses’ Cardiac Triage Instrument. Data were analyzed using descriptive statistics and ordinal logistic regression. ResultsA total of 414 registered nurses with a mean age of 41.7 (SD = 12.0) years participated. They were predominantly female (80.7%), had a baccalaureate degree (60.1%), and worked as a registered nurse for a median 10.0 years. Common terms used to assess angina were chest pain (79.5%), chest pressure (77.3%), chest tightness (72.9%), and chest discomfort (72.5%). The severity of chest pressure (median 5.0, interquartile range 1.0) and nature of chest pain (median 5.0, interquartile range 1.0) had the highest overall median scores to support initial cardiac triage decisions. Associated symptoms of diaphoresis, fatigue, and shortness of breath along with health history contributed to decision making. DiscussionEmergency nurses primarily used chest symptoms and health history when deciding to evaluate for acute coronary syndrome in the emergency department. Associated symptoms of diaphoresis, fatigue, and shortness of breath, along with health history, also contributed to decision making. Initial registered nurse actions were to obtain an electrocardiogram, prepare the patient for the cardiac catheterization laboratory, and notify the emergency physician of the patient’s admission.

Effects of the COVID-19 Pandemic on Emergency Department Triage Nurses' Response to Patients With Potential Acute Coronary Syndrome.

The COVID-19 pandemic added challenges to patient assessment and triage in the emergency department (ED). The aim of this study was to describe the effects of the COVID-19 pandemic on ED triage nurse decisions for patients with potential acute coronary syndrome (ACS). This was a secondary analysis of data from a descriptive, electronic, survey-based study. Participants were asked 2 questions: whether the COVID-19 pandemic had affected their triage and/or assessment practices for patients with potential ACS and, if so, how. Descriptive statistics were used to compare the characteristics of participants. A qualitative descriptive approach was used to analyze responses to the open-ended questions about the pandemic's effect on the triage process. Participants from across the United States had a mean age of 41.7 (12.3) years; 358 (80.6%) were women. The participants had a median of 10.0 (interquartile range, 16.0) years of experience as a registered nurse, with a median of 7.0 (interquartile range, 11.0) years of ED experience. A total of 180 of 444 participants (40.5%) indicated that the COVID-19 pandemic affected their triage processes and assessment of potential ACS patients; 156 (86.7%) provided a response to the open-ended question. Responses revealed 4 themes: (1) delays in triage and treatment, (2) ambiguous patient presentation, (3) heightened awareness of COVID-19 complications and sequelae, and (4) process changes. Forty percent of ED triage nurses participating reported that triage processes for patients with potential ACS were affected by the COVID-19 pandemic. Most expressed barriers that resulted in delayed assessment and treatment of patients and often resulted from overlapping cardiac symptoms and COVID-19.

Utility of serial conventional troponin testing for emergency department patients stratified by HEART score and symptom timing

BackgroundThe HEART score for risk stratifying chest pain patients in the emergency department (ED) has been widely adopted in clinical practice, but is often employed with nonconformant serial troponin measurements. ObjectiveThe primary objective of this study was to examine the utility of obtaining a second conventional 3-h troponin I (TnI) level in ED patients presenting with potential acute coronary syndrome (ACS), stratified by HEART score and duration of symptoms. MethodsThis was a retrospective cohort study of consecutive adult ED patients with a complete HEART score. We assessed the utility of repeat TnI measurement by examining the positivity rate of ΔTnI = [Second TnI] – [Initial TnI] stratified by HEART score and time elapsed since onset or resolution of symptoms. Major adverse cardiac events (MACE) within 6 weeks of index visit were assessed. ResultsA total of 944 patients were included with 433 (45.9%) assigned a low risk HEART score 0–3. Of the 268 (61.9%) low risk HEART score patients receiving a second TnI, only 3 (1.1%, [0.2–3.2%]) resulted in a positive ΔTnI, one of which occurred in the setting of an elevated initial TnI. Overall, patients presenting within 3 h of symptoms were more likely to experience positive ΔTnI, index MACE and MACE at 6 weeks compared to patients presenting ≥3 h since symptoms onset/resolution and patients with unknown timing of symptoms (15.9% vs 11.0% vs 10.3%, p < 0.001; 10.0% vs 5.3% vs 4.6%, p = 0.021; 12.7% vs 6.6% vs 6.4%, p = 0.047). ConclusionOur data suggest serial measurement of conventional troponin provides limited added benefit in low risk HEART score patients, regardless of duration and timing of symptoms. Conversely, serial troponin measurement may confer utility in moderate/high risk HEART score patients, particularly those presenting within 3 h of symptoms.

111EMF Exploration of Uncertainty Scale Use in Patients With Potential Acute Coronary Syndrome

Patients seeking care in the emergency department (ED) identify fear related to ongoing symptoms and uncertainty about symptom significance as common drivers of the decision to seek care. These findings resulted in development of the Uncertainty Scale (U-Scale) to quantify patient uncertainty related to symptoms during an acute care encounter. In prior work, psychometric testing of the 30-item U-Scale demonstrated content validity, high internal consistency, reliability, and evidence for concurrent validity.

Single high-sensitivity troponin levels to assess patients with potential acute coronary syndromes

ObjectiveWe tested the hypothesis that patients with a potential acute coronary syndrome (ACS) and very low levels of high-sensitivity cardiac troponin I can be efficiently and safely discharged from the...

Abstract 15529: Multimorbidity Clusters in Patients Presenting to the Emergency Department With Potential Acute Coronary Syndrome

Introduction: The increasing prevalence of multimorbidity (&gt; 2 chronic conditions) is a challenge for healthcare providers and systems. Multimorbidity complicates treatment and increases the risk of adverse outcomes. Objectives: To identify multimorbidity classes (clusters of &gt; 2 specific chronic conditions) in a secondary analysis of a multi-site study about symptoms in patients presenting to the emergency department (ED) for potential acute coronary syndrome (ACS). Hypothesis: Specific multimorbidity classes can predict an ACS diagnosis. Methods: Chronic conditions were measured (Charlson Comorbidity Index and ACS Patient Information Questionnaire) in patients who underwent a cardiac evaluation in the ED. Latent class analysis was used to identify multimorbidity classes, and logistic regression determined whether multimorbidity classes were predictive of being ruled-in versus ruled-out for ACS. Results: The sample ( n = 935) was 38% female, with a mean age of 59 years. Four multimorbidity classes were identified and labeled: High multimorbidity (Class 1, hyperlipidemia, hypertension [HTN], obesity, diabetes, and respiratory disorders); Low multimorbidity (Class 2, obesity); Cardiovascular multimorbidity (Class 3, HTN, hyperlipidemia, and coronary heart disease); and Cardio-oncology multimorbidity (Class 4, HTN, hyperlipidemia, and cancer). Patients in Classes 3 and 4 had a 2.8-fold and 1.7-fold increased risk of ruling-in for ACS compared to those in Class 2 who were half as likely to rule-in for ACS (OR 0.45 95% CI 0.33 to 0.61 p=0.001). Class membership differed by sex, age, and family history. Females were more likely to be in Class 1 (44.2%), younger patients in Class 2 (mean age 43.4 ± 9.8 years), older patients in class 4 (mean age 80.0 ± 6.3 years), and those with a family history of sudden cardiac death (&lt; age 55) in Class 3 (58.3%). Conclusion: Multimorbidity classes differed according to demographic and clinical variables. Membership in Classes 3 and 4 were predictive of an ACS diagnosis. Clustering patients by multimorbidity class may inform risk-stratification during evaluation for ACS.

Exploring the complex interactions of baseline patient factors to improve nursing triage of acute coronary syndrome.

Emergency department (ED) nurses need to identify patients with potential acute coronary syndrome (ACS) rapidly because treatment delay could impact patient outcomes. Aims of this secondary analysis were to identify key patient factors that could be available at initial ED nurse triage that predict ACS. Consecutive patients with chest pain who called 9-1-1, received a 12-lead electrocardiogram in the prehospital setting, and were transported via emergency medical service were included in the study. A total of 750 patients were recruited. The sample had an average age of 59 years old, was 57% male, and 40% Black. One hundred and fifteen patients were diagnosed with ACS. Older age, non-Caucasian race, and faster respiratory rate were independent predictors of ACS. There was an interaction between heart rate by Type II diabetes receiving insulin in the context of ACS. Type II diabetics requiring insulin for better glycemic control manifested a faster heart rate. By identifying patient factors at ED nurse triage that could be predictive of ACS, accuracy rates of triage may improve, thus impacting patient outcomes.

Protein Cytokines, Cytokine Gene Polymorphisms, and Potential Acute Coronary Syndrome Symptoms.

The purpose of this study was to determine whether relationships exist among protein cytokines, cytokine gene polymorphisms, and symptoms of potential acute coronary syndrome (ACS). Participants included 438 patients presenting to the emergency department (ED) whose symptoms triggered a cardiac evaluation (206 ruled in and 232 ruled out for ACS). Presence or absence of 13 symptoms was recorded upon arrival. Levels of tumor necrosis factor α (TNF-α), interleukin (IL)-6, and IL-18 were measured for all patients. A pilot analysis of 85 patients (ACS = 49; non-ACS = 36) genotyped eight single-nucleotide polymorphisms (SNPs; four TNF and four IL6 SNPs). Logistic regression models were tested to determine whether cytokines or SNPs predicted symptoms. Increased levels of TNF-α and IL-6 were associated with a decreased likelihood of chest discomfort for all patients. Increased levels of IL-6 were associated with a lower likelihood of chest discomfort and chest pressure for ACS patients, and an increased likelihood of shoulder and upper back pain for non-ACS patients. Elevated IL-18 was associated with an increased likelihood of sweating in patients with ACS. Of the four TNF SNPs, three were associated with shortness of breath, lightheadedness, unusual fatigue, and arm pain. In all, protein cytokines and TNF polymorphisms were associated with 11 of 13 symptoms assessed. Future studies are needed to determine the predictive ability of cytokines and related SNPs for a diagnosis of ACS or to determine whether biomarkers can identify patients with specific symptom clusters.

Gender Variation of In-Hospital Outcome In Patients With Unstable Angina by Timi Risk Score

Background: The TIMI (Thrombolysis in Myocardial Infarction) risk score is a seven item risk stratification tool derived from trials of patients with Unstable Angina (UA) that has been validated in Emergency Department (ED) patients with potential Acute Coronary Syndromes (ACS). To evaluate frequency, outcome and correlation of the gender variation of in-hospital outcome in patients of unstable angina by TIMI risk score. Materials and methods: This was an observational study of Cardiac Care Unit (CCU) patients with unstable angina. Data included demographics, medical and cardiac history, and components of the TIMI risk score. Investigators followed the hospital course daily. The outcomes were death, Acute Myocardial Infarction (AMI) heart failure and arrhythmia during hospital stay as stratified by TIMI risk score and compared between genders using 2 tests. Data were analyzed by SPSS version-19. Results: In this study 62% patients were male and 38% patients were female. 55.20% female had low TIMI score whereas 16.10% male and 18.40% female had very high TIMI scores. The mortality rate was 0% in low TIMI score but the rate was increased in high TIMI score e.g. 3.30% in male patients and 2.60% in female patients with unstable angina. The rate of occuring MI, Cardiogenic shock, Heart failure is increased respectively from low to high TIMI score. In case of Arrhythmia, 17.70% male and 15.70% female had low TIMI score whereas 25.80% male and 26.30% female had high TIMI score. Conclusion: The TIMI risk score successfully stratifies risk in both males and females with UA at the time of CCU presentation; however, males have worse outcome at low TIMI scores than female.&#x0D; JCMCTA 2018 ; 29 (2) : 35-40

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

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

105 Unexpected Cardiac Magnetic Resonance Imaging Findings in Patients Presenting to the Emergency Department for Potential Acute Coronary Syndrome

105 Unexpected Cardiac Magnetic Resonance Imaging Findings in Patients Presenting to the Emergency Department for Potential Acute Coronary Syndrome

Panic Disorder in Patients Presenting to the Emergency Department With Chest Pain: Prevalence and Presenting Symptoms

Patients with panic disorder experience symptoms such as palpitations, chest pain, dizziness, and breathlessness. Consequently, they may attend the Emergency Department (ED) to be assessed for possible emergency medical conditions. Recognition of panic disorder within the ED is low. We sought to establish the prevalence of panic disorder in patients presenting for ED investigation of potential acute coronary syndrome. We also sought to characterise the cohort of patients with panic disorder in terms of presenting symptoms, risk factors, medical history and major adverse cardiac events (MACE). This was an observational study of 338 adult patients presenting to the Emergency Department of a tertiary hospital in Australia. Research nurses collected clinical data using a customised case report form. The outcome was panic disorder, assessed using the Mini International Neuropsychiatric Interview. The average age of participants was 50.2 years and 37.9% were female. Thirty-day MACE occurred in 7.7% of the cohort. The clinical diagnosis of panic disorder was made in 5.6% (95% CI: 3.4-8.6%) of patients. Compared to patients without panic disorder, patients with panic disorder were slightly more likely to report that their pain felt heavy (48.9% and 73.7% respectively, p=0.04). All other reported symptoms were similar in the two groups. The prevalence of panic disorder was low in patients presenting to an Australian ED with chest pain. Clinical signs or symptoms that are routinely collected as part of the chest pain workup cannot be used to distinguish patients with and without panic disorder.

Factors influencing choice of pre-hospital transportation of patients with potential acute coronary syndrome: An observational study.

To determine factors associated with ambulance use in patients with confirmed and potential acute coronary syndrome presenting to the ED. A convenience sample of patients (n = 247) presenting to the ED from April 2014 to January 2015 with suspected acute coronary syndrome were included in the study. Data on mode of transport and patient demographics were collected from the Emergency Department Information System database. Clinical data were collected from chart records and information systems. A questionnaire assessed reasons for using a chosen method of transport, symptom timing and characteristics, acute coronary syndrome knowledge, and awareness of the National Heart Foundation Early Warning Symptoms campaign. Approximately half the patients (49.4%) assessed with symptoms of potential acute coronary syndrome used ambulance transport to the ED. Patients who arrived by ambulance were older than those not arriving by ambulance (mean 56.7 years vs 51.7 years, P = 0.01). Risk factors were not associated with ambulance use. Dizziness (P < 0.01), sweating (P = 0.03), nausea (P = 0.03) and vomiting (P = 0.04) were associated with increased ambulance use. Mean systolic blood pressure was lower in the ambulance group (136 mmHg, standard deviation [SD] = 19.8) than in the non-ambulance group (143 mmHg, SD = 25.9). Awareness of the National Heart Foundation Heart Attack Warning Signs campaign was not associated with ambulance use. Patients with possible ischaemic symptoms who are at a high risk of cardiac disease do not utilise ambulance services more than low risk patients. In general, transport to hospital using ambulance services by patients with symptoms of possible acute coronary syndrome is low despite community campaigns.

Predictors of Multivessel Disease in Patients Undergoing In-Patient Coronary Angiography for Potential Acute Coronary Syndromes

Background: Predicting whether a patient has multivessel coronary disease prior to invasive coronary angiography has potential clinical importance as it may help guide treatment decisions. We performed a prospective analysis of patients presenting to the catheter laboratory as an inpatient for possible acute coronary syndrome (ACS) to determine predictors of MVD. Methods: 2 independent observers who were blinded to the final diagnosis prospectively reviewed all in-patient angiograms undertaken for possible ACS. The number of diseased vessels (≥ 50% stenosis) were recorded. The definition of MVD in our study was a ≥ 2 vessels with > 50% stenosis. Patient history, demographics and clinical characteristics were collected Results: 303 patients were studied, 141 had MVD. Age was significantly higher in the MVD group (65 ± 11.3 vs. 60.7 ± 12.1). A history of recent chest pain (30% vs. 7%) and previous MI (24% vs. 4%) were also higher in the MVD group. Grace score was higher in the MVD group (98 vs. 83) as was the proportion of patients with NIDDM (19% vs. 4%). Logistic regression analysis was performed to examine predictors of MVD. Pre-treatment with aspirin (OR 4.7), a final diagnosis of ACS (OR 3.3) and the presence of NIDDM (OR 8.9) were independent predictors of multi-vessel coronary disease. Conclusion: In patients presenting to the cath lab, pre-treatment with aspirin, the presence of diabetes and a final diagnosis of ACS are independently predictive of MVD.

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes.

It is well established that clinicians cannot use clinical judgment alone to determine whether an individual patient who presents to the emergency department has an acute coronary syndrome. The history and physical examination do not distinguish sufficiently between the many conditions that can cause acute chest pain syndromes. Cardiac risk factors do not have sufficient discriminatory ability in symptomatic patients presenting to the emergency department. Most patients with non-ST-segment-elevation myocardial infarction do not present with electrocardiographic evidence of active ischemia. The improvement in cardiac troponin assays, especially in conjunction with well-validated clinical decision algorithms, now enables the clinician to rapidly exclude myocardial infarction. In patients in whom unstable angina remains a concern or there is a desire to evaluate for underlying coronary artery disease, coronary computed tomography angiography can be used in the emergency department. Once a process that took ≥24 hours, computed tomography angiography now can rapidly exclude myocardial infarction and coronary artery disease in patients in the emergency department.

Symptom Trajectories After an Emergency Department Visit for Potential Acute Coronary Syndrome.

Many patients evaluated for acute coronary syndrome (ACS) in emergency departments (EDs) continue to experience troubling symptoms after discharge-regardless of their ultimate medical diagnosis. However, comprehensive understanding of common post-ED symptom trajectories is lacking. The aim of this study was to identify common trajectories of symptom severity in the 6 months after an ED visit for potential ACS. This was a secondary analysis of data from a larger observational, prospective study conducted in five U.S. EDs. Patients (N = 1005) who had electrocardiogram and biomarker testing ordered, and were identified by the triage nurse as potentially having ACS, were enrolled. Symptom severity was assessed in the hospital after initial stabilization and by telephone at 30 days and 6 months using the validated 13-item ACS Symptom Checklist. Growth mixture modeling was used for the secondary analysis. The eight most commonly reported symptoms (chest discomfort, chest pain, chest pressure, light-headedness, shortness of breath, shoulder pain, unusual fatigue, and upper back pain) were modeled across the three study time points. Models with increasing numbers of classes were compared, and final model selection was based on a combination of interpretability, theoretical justification, and statistical fit indices. The sample was 62.6% male with a mean age of 60.2 years (SD = 14.17 years), and 57.1% ruled out for ACS. Between two and four distinct trajectory classes were identified for each symptom. The seven different types of trajectories identified across the eight symptoms were labeled "tapering off," "mild/persistent," "moderate/persistent," "moderate/worsening," "moderate/improving," "late onset, "and "severe/improving." Trajectories differed on age, gender, and diagnosis. Research on the individual nature of symptom trajectories can contribute to patient-centered, rather than disease-centered, care. Further research is needed to verify the existence of multiple symptoms trajectories in diverse populations and to assess the antecedents and consequences of individual symptom trajectories.

Troponin assay use in the emergency department for management of patients with potential acute coronary syndrome: current use and future directions

Troponins are proteins commonly found in cardiac tissue that are released during myocardial ischemia or necrosis. These troponins can be detected by assays that can then be used to guide clinical decision-making and disposition, especially if the suspected insult is related to acute coronary syndrome. Timing of troponin measurement can be important as elevations may not be detectible immediately after an insult. New assays have been designed to detect troponin con-centrations previously too low to be detected by conventional assays. These tests are known as high-sensitivity cardiac troponin assays. Current research is aimed at evaluating the clinical sig-nificance of troponin elevations detected by these new assays especially in management of pa-tients with suspected acute coronary syndrome. A number of risk-stratification scores exist to assist physicians with evaluating chest pain in the emergency department in the context of de-tection (or absence) of troponins in systemic circulation. Additionally, investigators are working to integrate data generated by hs-cTn measurements into existing and new risk-stratification scores.

Diagnostic values of chest pain history, ECG, troponin and clinical gestalt in patients with chest pain and potential acute coronary syndrome assessed in the emergency department.

In the assessment of chest pain patients with suspected acute coronary syndrome (ACS) in the emergency department (ED), physicians rely on global diagnostic impressions (‘gestalt’). The aim of this study was to determine the diagnostic value of the ED physician’s overall assessment of ACS likelihood, and the values of the main diagnostic modalities underlying this assessment, namely the chest pain history, the ECG and the initial troponin result. 1,151 consecutive ED chest pain patients were prospectively included. The ED physician’s interpretation of the chest pain history, the ECG, and the global likelihood of ACS were recorded on special forms. The discharge diagnoses were retrieved from the medical records. A chart review was carried out to determine whether patients with a non-ACS diagnosis at the index visit had ACS or suffered cardiac death within 30 days. The gestalt was better than its components both at ruling in (“Obvious ACS”, LR 29) and at ruling out (“No Suspicion of ACS”, LR 0.01) ACS. In the “Strong suspicion of ACS” group, 60% of the patients did not have ACS. A positive TnT (LR 24.9) and an ischemic ECG (LR 8.3) were strong predictors of ACS and seemed superior to pain history for ruling in ACS. In patients with a normal TnT and non-ischemic ECG, chest pain history typical of AMI was not a significant predictor of AMI (LR 1.9) while pain history typical of unstable angina (UA) was a moderate predictor of UA (LR 4.7). Clinical gestalt was better than its components both at ruling in and at ruling out ACS, but overestimated the likelihood of ACS when cases were assessed as strong suspicion of ACS. Among the components of the gestalt, TnT and ECG were superior to the chest pain history for ruling in ACS, while pain history was superior for ruling out ACS.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-015-0992-9) contains supplementary material, which is available to authorized users.

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.