Objective To audit the use of management algorithms for chest pain in an emergency department. Design and setting Prospective study of all patients with chest pain presenting to the emergency department of an urban teaching hospital between 12 January and 4 May 1997. Staff were asked to complete a standardised admission form that incorporated the risk stratification algorithms for managing patients with suspected acute coronary syndrome. Main outcome measures Compliance with the use of management algorithms; concordance with a cardiologist's review of the triage grouping and admission/discharge decision; and major cardiovascular events over four months. Results Emergency department staff documented the triage group in 223 of 503 cases (45%). Concordance with the group assigned by a cardiologist was 70% (κ = 0.73; SEκ=0.04). When the management algorithm was applied correctly, 92% of triage decisions were correct (95% confidence interval [CI], 87%–96%). The triage decision was less often correct when risk stratification was not done (78% [73%–83%], P<0.001), overestimated (77% [66%–88%], P<0.01), or underestimated (50% [18%–82%], P<0.001). The proportion of patients free of major cardiovascular events at four‐month follow‐up was 50% for those with myocardial infarction with ST‐segment elevation, 47% for those with a high short‐term risk of an adverse cardiac event, 82% for those with intermediate risk, and 99% for those with a low risk or non‐coronary chest pain (P<0.001). Conclusions Use of management algorithms by emergency staff was poor. When used, triage decisions were more likely to be correct. Subsequent outcome confirms that the NHMRC risk stratification algorithms are useful for prognostic stratification of patients with suspected acute coronary syndrome.
The PARAGON Investigators* Background-Unstable angina and non-Q-wave myocardial infarction involve coronary arterial plaque rupture, platelet activation, and thrombus formation. This study tested the benefit of different doses of lamifiban (a platelet IIb/IIIa antagonist) alone and in combination with heparin in patients with these conditions to select the most promising lamifiban regimen for subsequent evaluation. Methods and Results-At 273 hospitals in 20 countries, 2282 patients were randomly assigned to lamifiban (2ϫ2 factorial design: low-dose [1 g/min] with and without heparin versus high-dose [5 g/min] with and without heparin) or to standard therapy (placebo and heparin). All patients received aspirin. The composite primary end point of death or nonfatal myocardial infarction at 30 days occurred in 11.7% of those receiving standard therapy, 10.6% receiving low-dose lamifiban, and 12.0% receiving high-dose lamifiban (Pϭ0.668). By 6 months, this composite was lowest for those assigned to low-dose lamifiban (Pϭ0.027) and intermediate for those assigned to high-dose lamifiban (Pϭ0.450) compared with control (13.7%, 16.4%, and 17.9%, respectively). Compared with control, the combination of high-dose lamifiban and heparin resulted in more intermediate or major bleeding (12.1% versus 5.5%; Pϭ0.002) and a similar rate of ischemic events. Conversely, low-dose lamifiban and heparin yielded similar bleeding rates as in the control group but fewer ischemic events at 6 months (12.6% versus 17.9%; Pϭ0.025). Conclusions-In unstable angina and non-Q-wave infarction, platelet IIb/IIIa antagonism with lamifiban reduces adverse ischemic events at 6 months beyond that of aspirin and heparin therapy. The role of conjunctive heparin remains uncertain but appears more favorable with low-dose IIb/IIIa antagonism. Larger-scale study is needed to more reliably estimate these effects. (Circulation. 1998;97:2386-2395.)
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