A Predictive Instrument to Improve Coronary-Care-Unit Admission Practices in Acute Ischemic Heart Disease

Abstract

Each year 1.5 million patients are admitted to coronary-care units (CCUs) for suspected acute ischemic heart disease; for half of these, the diagnosis is ultimately "ruled out." In this study, conducted in the emergency rooms of six New England hospitals ranging in type from urban teaching centers to rural nonteaching hospitals, we sought to develop a diagnostic aid to help emergency room physicians reduce the number of their CCU admissions of patients without acute cardiac ischemia. From data on 2801 patients, we developed a predictive instrument for use in a hand-held programmable calculator, which requires only 20 seconds to compute a patient's probability of having acute cardiac ischemia. In a prospective trial that included 2320 patients in the six hospitals, physicians' diagnostic specificity for acute ischemia increased when the probability value determined by the instrument was made available to them. Rates of false-positive diagnosis decreased without any increase in rates of false-negative diagnosis. Among study patients with a final diagnosis of "not acute ischemia," the number of CCU admissions decreased 30 per cent, without any increase in missed diagnoses of ischemia. The proportion of CCU admissions that represented patients without acute ischemia dropped from 44 to 33 per cent. Widespread use of this predictive instrument could reduce the number of CCU admissions in this country by more than 250,000 per year.

Chest pain in the emergency room. Importance of a systematic approach

“…In addition to this, a smaller rate of hospitalization in the coronary unit of patients non-bearers of acute myocardial infarction or unstable angi- AMI-acute myocardial infarction; ACS-acute coronary syndrome; Indetindeterminate; ECG-electrocardiogram; UA-unstable angina; LBBB-left bundle-branch block. na has also been observed 5,22,27,28 as well as a reduction in the length of hospitalization 8,28,29 . These facts have been shown to be responsible for the considerable reduction in hospital costs, of 40-60% without an increase in the rate of cardiovascular events inside or outside of the hospital 8,9,28,29 .…”

“…Studies have demonstrated that when comparing patients with chest pain, evaluated in chest pain units with those evaluated in the conventional way (hospitalized), significant reduction occurs in the rate of coronary unit use, during the period of hospitalization and the number of coronary angiographies and other exams carried out. 4,8,22,27,28,33,34 . This results in a significant hospital cost reduction, around 40-60% 8,9,28,33,34 .…”

“…In the same way, algorithms or clinical decision trees and probability evaluations of the disease have been created by several authors to help in this task, besides identifying those who need to or need not to be transferred to a coronary unit or to undergo expensive examinations 5,6,17,[22][23][24][25] . Consequently, this has resulted in the evaluation and treatment of many coronary patients changed from being in the coronary units to intermediate units or to the emergency rooms.…”

A Computer Based Telemedicine Protocol to Predict Acute Coronary Syndrome in Patients With Chest Pain at Home

“…Therefore, an early diagnosis of ACS is very important. In past studies, 1) it has been seen that the diagnosis of more than half of the patients who are admitted to an emergency department as having ACS is incor-rect, and the cost of such mistakes has been determined as costing around 8 billion dollars annually in the USA.…”

“…[5][6][7] Some algorithms and computer programs have been developed to make the diagnosis of patients with chest pain easier. 1,[8][9][10][11][12][13][14] All of the protocols have been developed to guide the physician in the emergency department. In all of these studies, there is no protocol that has been prepared that takes into account patients with chest pain at home.…”