Unspecified Chest Pain Research Articles

Are Routinely Collected NHS Administrative Records Suitable for Endpoint Identification in Clinical Trials? Evidence from the West of Scotland Coronary Prevention Study

BackgroundRoutinely collected electronic patient records are already widely used in epidemiological research. In this work we investigated the potential for using them to identify endpoints in clinical trials.MethodsThe events recorded in the West of Scotland Coronary Prevention Study (WOSCOPS), a large clinical trial of pravastatin in middle-aged hypercholesterolaemic men in the 1990s, were compared with those in the record-linked deaths and hospitalisations records routinely collected in Scotland.ResultsWe matched 99% of fatal study events by date. We showed excellent matching (97%) of the causes of fatal endpoint events and good matching (>80% for first events) of the causes of nonfatal endpoint events with a slightly lower rate of mismatching of record linkage than study events (19% of first study myocardial infarctions (MI) and 4% of first record linkage MIs not matched as MI). We also investigated the matching of non-endpoint events and showed a good level of matching, with >78% of first stroke/TIA events being matched as stroke/TIA. The primary reasons for mismatches were record linkage data recording readmissions for procedures or previous events, differences between the diagnoses in the routinely collected data and the conclusions of the clinical trial expert adjudication committee, events occurring outside Scotland and therefore being missed by record linkage data, miscoding of cardiac events in hospitalisations data as ‘unspecified chest pain’, some general miscoding in the record linkage data and some record linkage errors.ConclusionsWe conclude that routinely collected data could be used for recording cardiovascular endpoints in clinical trials and would give very similar results to rigorously collected clinical trial data, in countries with unified health systems such as Scotland. The endpoint types would need to be carefully thought through and an expert endpoint adjudication committee should be involved.

National Growth in Intensive Care Unit Admissions From Emergency Departments in the United States from 2002 to 2009

The authors describe national trends in use, reasons for visit, most common diagnoses, and resource utilization in patients admitted to intensive care units (ICUs) from hospital-based emergency departments (EDs) in the United States. This was an observational study using data from the National Hospital Ambulatory Care Survey, a nationally representative, weighted sample of U.S. hospital-based EDs from 2002 through 2009. The sample comprised a total of 4,267 patients aged 18 years or older admitted to the ICU from the ED, which represent over 14.5 million ED encounters from 2002 through 2009. Over the study period, ICU admissions from EDs increased from 2.79 million in 2002/2003, to 4.14 million in 2008/2009, an absolute increase of 48.8% and a mean biennial increase of 14.2%. By comparison, overall ED visits increased a mean of 5.8% per biennial period. The three most common diagnoses for ICU admissions were unspecified chest pain, congestive heart failure, and pneumonia. Utilization rates of most tests and services delivered to patients admitted to the ICU from the ED increased, with the largest increase occurring in computed tomography (CT) and magnetic resonance imaging (MRI), which increased from 16.8% in 2002/2003 to 37.4% in 2008/2009, a 6.9% mean biennial increase. Across all years, mean ED length of stay (LOS) for ICU admissions was 304 minutes (95% confidence interval [CI] = 286 to 323 minutes), and mean hospital LOS was 6.6 days (95% CI = 6.2 to 7.0 days). There was no significant change in either mean ED or hospital LOS over the study period. Intensive care unit admissions from EDs are increasing at a greater rate than both population growth and overall ED visits. ED resource use, specifically advanced diagnostic imaging, has increased markedly among ICU admissions. While mean ED and hospital LOS have not changed significantly, the mean ICU admission spends over 5 hours in the ED prior to transfer to an ICU bed. A greater emphasis on the ED-ICU interface and critical care delivered in the ED may be warranted.

Evaluation of an Australian chest pain assessment unit

In order to mitigate the risk of missing atypical or low probability presentations of acute coronary syndromes (ACS), many hospitals have designated resources specifically for the assessment of chest pain. This study aims to evaluate the introduction of a chest pain assessment unit (CPAU) in a North Queensland hospital. Information on admission status, diagnosis, procedures, length of stay and chest pain representation rates was obtained for patients presenting with chest pain to the emergency department (ED) at The Townsville Hospital in the 2.5 years prior to the introduction of a CPAU in March 2007 (n = 6665). This was compared with information on chest pain patients (n = 7885) presenting to the ED in the 2.5 years after it opened. The CPAU resulted in a reduction in the percentage of 'missed' cases of ACS. The rate of people who represented with chest pain at 3 months and who ultimately received an ACS diagnosis reduced from 1.9% to 1.4%. There was an increased rate of apparently appropriate angiograms from 6.7% to 9.4% of chest pain admissions. The admission rate of ED chest pain presentations was stable as was the median length of stay (1.14-1.16 days). A relative decrease in the proportion of admitted patients diagnosed with ACS compared with those with unspecified chest pain was observed. The implementation of a CPAU at The Townsville Hospital resulted in improved care of those presenting to the ED with chest pain. Further Australian CPAU evaluations are recommended.

Diagnostic efficacy of myeloperoxidase for the detection of acute coronary syndromes

Early diagnosis of acute coronary syndrome (ACS) is frequently a challenging task, while immediate risk stratification remains crucial for the prompt implementation of appropriate therapy in this setting. Employing markers that increase rapidly after the symptom onset may enhance triage and therapeutic decision-making in patients suspected for ACS. Myeloperoxidase (MPO) exerting proinflammatory and pro-oxidative properties is suggested as a reliable early marker for ACS associated with unfavourable clinical outcome. We assessed the diagnostic efficacy of plasma MPO alone or in combination with cardiac troponin I (cTnI) for detecting ACS in patients presenting with chest pain initiating within 6h before the hospital admission. A study group consisted of 253 patients diagnosed with ACS and 47 subjects having other heart disease or unspecified chest pain. Clinically healthy volunteers (n=124) served as controls. MPO concentration was measured in plasma (Abbott Diagnostics, USA), while serum was assayed for cTnI, creatine-kinase MB, lipids, glucose, creatinine, brain natriuretic peptide type B and C-reactive protein. Both MPO and cTnI values were significantly lower in non-ACS subjects than in patients with ACS. At 97·5th percentile as cut-off, the superiority of MPO over cTnI was observed in patients with unstable angina and non-ACS subjects. Considerably higher MPO concentrations were demonstrated in the troponin-negative ACS patients on admission who became troponin-positive after 6h. Combined evaluation of MPO and cTnI possessed remarkably higher sensitivity than assessment of cTnI alone in all patients with ACS. Myeloperoxidase substantially facilitates the early diagnosis of ACS.

Economic Burden of not Recognizing Panic Disorder in the Emergency Department

The objective of this cohort study was to examine the diagnostic patterns and resource utilization of patients presenting to the Emergency Department with chest pain of unknown origin who may be experiencing a panic attack. Patients were excluded if they had coronary artery disease. In the 155 patients meeting study criteria, unspecified chest pain (78%) was the most common diagnostic code assigned. Total charges for the index hospitalization were $1,263,391 (median/visit = $7340). During the 1-year follow-up, 41% of patients had at least one repeat hospital visit and generated $1.6 million in charges. Patients on Medicare or Medicaid were more likely to have multiple hospital visits during the follow-up (odds ratio = 11.7). In conclusion, Emergency Department patients admitted with non-cardiac chest pain account for a significant amount of hospital resource use.

Using ED Observation Units to Decrease Length of Stay in Chest Pain Patients

The purpose of this study was to compare the hospital length of stay in patients presenting to the emergency department (ED) with unspecified chest pain who were admitted through the ED to an inpatient bed prior to the initiation of the emergency department observation unit (EDOBS) and compare those patients admitted after the implementation of the EDOBS. A retrospective, randomized descriptive study using chart review was performed at a large hospital system in the metropolitan Detroit region. Charts with an admission [International Classification of Diseases–9 Code 786.5, unspecified chest pain (n = 92)] were randomly selected. For the inpatient group, ED registration time to unit was 6.4 hr and time from the unit to discharge was 80 hr (i.e., 3.3 days). For the EDOBS group, ED registration time to unit was 3.5 hr and time from EDOBS to discharge was 16 hr (i.e., 0.67 days). Length of stay decreased by 2.7 days overall. Using EDOBS for patients with unspecified chest pain provides for prompt and complete cardiac evaluation. Furthermore, the utilization of the emergency nurse practitioner helped alleviate the increased workload placed on the ED physicians in this type of unit. For example, the emergency nurse practitioner facilitated consults, reviewed diagnostic and laboratory findings (e.g., serial cardiac enzymes), and expedited hospital admission or discharge from the EDOBS. Study limitations included a small random selection sample from one institution. Data collection was limited to review of the medical record and the accuracy of documentation.

Epidemiology of angina pectoris: Role of natural language processing of the medical record

The diagnosis of angina is challenging because it relies on symptom descriptions. Natural language processing (NLP) of the electronic medical record (EMR) can provide access to such information contained in free text that may not be fully captured by conventional diagnostic coding. To test the hypothesis that NLP of the EMR improves angina pectoris ascertainment over diagnostic codes. Billing records of inpatients and outpatients were searched for International Classification of Diseases, Ninth Revision (ICD-9) codes for angina pectoris, chronic ischemic heart disease, and chest pain. EMR clinical reports were searched electronically for 50 specific nonnegated natural language synonyms to these ICD-9 codes. The 2 methods were compared to a standardized assessment of angina by Rose questionnaire for 3 diagnostic levels: unspecified chest pain, exertional chest pain, and Rose angina. Compared with the Rose questionnaire, the true-positive rate of EMR-NLP for unspecified chest pain was 62% (95% CI 55-67) versus 51% (95% CI 44-58) for diagnostic codes (P < .001). For exertional chest pain, the EMR-NLP true-positive rate was 71% (95% CI 61-80) versus 62% (95% CI 52-73) for diagnostic codes (P = .10). Both approaches had 88% (95% CI 65-100) true-positive rate for Rose angina. The EMR-NLP method consistently identified more patients with exertional chest pain over a 28-month follow-up. EMR-NLP method improves the detection of unspecified and exertional chest pain cases compared to diagnostic codes. These findings have implications for epidemiological and clinical studies of angina pectoris.

Chest pain in general practice: incidence, comorbidity and mortality

Chest pain is a common symptom that presents the primary care physician with a complex diagnostic and therapeutic challenge. To evaluate the natural history and management of patients diagnosed with chest pain of unspecified type or origin in primary care. Population-based case-control study. The study included 13,740 patients with a first diagnosis of unspecified chest pain and 20,000 age- and sex-matched controls identified from the UK General Practice Research Database. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed using unconditional logistic regression. Risk estimates were adjusted for age, sex and number of physician visits. The incidence of a new diagnosis of chest pain was 15.5 per 1000 person-years and increased with age, particularly in men. The risk of a chest pain diagnosis was greatest in patients with prior diagnoses of coronary heart disease (OR: 7.1; 95% CI: 6.1-8.2) and gastroesophageal reflux disease (OR: 2.0; 95% CI: 1.7-2.3). In the year after diagnosis, chest pain patients were more likely than controls to be newly diagnosed with coronary heart disease (OR: 14.9; 95% CI: 12.7-17.4) and heart failure (OR: 4.7; 95% CI: 3.6-6.1). A new diagnosis of chest pain was associated with an increased risk of death in the following year (RR: 2.3; 95% CI: 1.9-2.8). Some causes of chest pain are underdiagnosed in primary care. This is of particular consequence for the minority of chest pain patients with cardiac disease.

Experiences and concerns among patients being treated for atypical chest pain

Background Many patients who are discharged from the hospital without receiving a clear-cut diagnosis of their chest pain continue to consume health care because of disabling physical and psychological symptoms. By identifying their experiences and concerns following hospitalization, an empirical basis for discussions on ways of improving the care of these particular patients will be obtained. Methods A qualitative analysis of semi-structured interviews with 38 patients with a diagnosis of unspecified chest pain was carried out. Results Two-thirds of the respondents had unanswered questions and concerns that had not been addressed. They found it difficult to understand why they had not undergone more tests. They requested an explanation for their chest pain, at the very least, or were worried about the future. Some respondents accepted the fact that they had not been given a sufficient amount of time and information. They referred to the stressful working situation of the physicians, the view that their admission could be regarded as unnecessary or that physicians at the hospital could not be expected to do more than exclude serious diseases. Conclusions Health professionals should address their patients' questions and fears properly and provide them with the most probable explanation for their symptoms. When taking the harmlessness of their symptoms or the situation of their caregivers into account, patients may find it inappropriate to impose further demands on care.

PHYSICAL PAIN ≠ SUFFERING: A PERSONAL COMMENTARY ON COPING

A saga of coping with severe, chronic, unspecified chest pain is chronicled. Physical pain is described as reflecting the raw, hurtful sensation, whereas suffering taps the more pernicious and negative implications of the pain in the larger life context. It is suggested that improved coping rests on learning this distinction between pain and suffering. Other lessons derived from the physical pain experiences are reviewed. “Pain gains its power when I let it become suffering…”