Cardiac risk factors and risk scores vs cardiac computed tomography angiography: a prospective cohort study for triage of ED patients with acute chest pain

Halpern, Ethan J.; Deutsch, Jacob; Hannaway, Maria M.; Estepa, Adrian; Kenia, Anand S.; Neuburger, Kenneth J.; Levin, David C.

doi:10.1016/j.ajem.2013.08.001

Cited by 7 publications

(9 citation statements)

References 33 publications

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“…Previous studies showed that more than 80% of patients with symptoms suspected of cardiac ischemia visiting the ED do not have diagnostic changes on the ECG. [ 13 , 26 , 27 ] In addition, in chest pain patients with a negative Troponin the adverse event rate is still 5–9%. [ 28 , 29 ] Thus a major diagnostic dilemma exists in patients with suspected ischemic symptoms, but normal ECG and Troponin at the ED.…”

Section: Discussionmentioning

confidence: 99%

The Diagnostic Value of Clinical Symptoms in Women and Men Presenting with Chest Pain at the Emergency Department, a Prospective Cohort Study

et al. 2015

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BackgroundPrevious studies suggested that diagnosing coronary artery disease (CAD) is more difficult in women than in men. Studies investigating the predictive value of clinical signs and symptoms and compare its combined diagnostic value between women and men are lacking.MethodologyData from a large multicenter prospective study was used. Patients admitted to the emergency department (ED) with chest pain but without ST-elevation were eligible. The endpoint was proven CAD, defined as a significant stenosis at angiography or the diagnosis of a non-ST-elevation myocardial infarction or cardiovascular death within six weeks after presentation at the ED. Twelve clinical symptoms and seven cardiovascular risk factors were collected. Potential predictors of CAD with a p-value <0.15 in the univariable analysis were included in a multivariable model. The diagnostic value of clinical symptoms and cardiovascular risk factors was quantified in women and men separately and areas under the curve (AUC) were compared between sexes.ResultsA total of 2433 patients were included. We excluded 102 patients (4%) with either an incomplete follow up or ST-elevation. Of the remaining 2331 patients 43% (1003) were women. CAD was present in 111 (11%) women and 278 (21%) men. In women 11 out of 12 and in men 10 out of 12 clinical symptoms were univariably associated with CAD. The AUC of symptoms alone was 0.74 (95%CI: 0.69-0.79) in women and 0.71 (95%CI: 0.68-0.75) in men and increased to respectively 0.79 (95%CI: 0.74-0.83) in women versus 0.75 (95%CI: 0.72-0.78) in men after adding cardiovascular risk factors. The AUCs of women and men were not significantly different (p-value symptoms alone: 0.45, after adding cardiovascular risk factors: 0.11).ConclusionThe diagnostic value of clinical symptoms and cardiovascular risk factors for the diagnosis of CAD in chest pain patients presenting on the ED was high in women and men. No significant differences were found between sexes.

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Section: Discussionmentioning

confidence: 99%

The Diagnostic Value of Clinical Symptoms in Women and Men Presenting with Chest Pain at the Emergency Department, a Prospective Cohort Study

et al. 2015

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“…Initially, 952 articles were identified for screening, 81 met criteria for full‐text review, and 33 articles were included in this meta‐analysis. Of the 33 studies, seven were randomized controlled trials, 30–36 17 were prospective cohort studies, 37–53 and the remaining nine were retrospective cohort studies 54–62 …”

Section: Resultsmentioning

confidence: 99%

“…Of the 33 studies, 30 provided age and gender estimates capable of pooling with an overall mean (±SD) age of 54 (±11) years with 47% female. Twenty‐one studies evaluated MACE events occurring at a 1‐month follow‐up endpoint 30,31,33–35,37–40,42–49,54,56–58 …”

Section: Resultsmentioning

confidence: 99%

“…There were 17 studies included for the 1-month endpoint. 30,31,33,34,[37][38][39][40][42][43][44][45][46][47]54,[56][57][58] There were five studies included for the 12-month endpoint. 41,43,46,47,56 Pooled analysis showed a low heterogeneity overall at both 1-month and 12-month endpoints with an overall event rate of 0.09% (95% CI = 0.03% to 0.27%) and 0.5% (95% CI = 0.21% to 1.2%), respectively.…”

Section: Discussionmentioning

confidence: 99%

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Major adverse cardiac events after emergency department evaluation of chest pain patients with advanced testing: Systematic review and meta‐analysis

Mehta

McDonald

Hirani

et al. 2021

Academic Emergency Medicine

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Objectives Our primary objective was to describe the risk of major adverse cardiac events (MACE) at 1, 6, and 12 months after a negative coronary computed tomography angiogram (cCTA), electrocardiogram (ECG) stress test, stress echocardiography, and myocardial perfusion scintigraphy (MPS) in low‐ to intermediate‐risk patients. Methods Initially, 952 articles were identified for screening, 81 met criteria for full‐text review, and once risk of bias was assessed, 33 articles were included in this meta‐analysis. We utilized a random‐effects model to assess pooled MACE event proportion for patients undergoing evaluation of acute coronary syndrome (ACS) when risk stratified to a low‐ to intermediate‐risk category after undergoing standard testing. Heterogeneity analysis was performed using Cochrane's Q‐test and I2 statistic. Results Twenty‐one studies evaluated follow‐up at 1 month with cCTA having a 0.09% (95% confidence interval [CI] = 0.03% to 0.26%) pooled MACE compared to 0.23% (95% CI = 0.01% to 5.8%) of the exercise stress testing (p = 1). MPS and cCTA had an overall event rate of 0.15% (95% CI = 0.06% to 0.41%) at 6 months (I2 = 0%). At 12 months, a subgroup analysis found a pooled cCTA MACE of 0.16% (95% CI = 0.04% to 0.65%) compared to 1.68% (95% CI = 0.01% to 2.6%) for stress echocardiography with low within‐group heterogeneity (I2 = 0%). Subgroup analysis of cCTA with no disease versus nonobstructive disease (<50% stenosis) did not find statistical difference in the MACE at both 1 month (0.17% [95% CI = 0.04% to 0.67%] vs. 0.06% [95% CI = 0.01% to 0.34%]) and 12 months (0.44% [95% CI = 0.09% to 2.2% vs. 0.54% [95% CI = 0.19% to 1.5%]). Conclusions Patients presenting with chest pain who have a coronary CTA showing < 50% stenosis, negative ECG stress test, stress echocardiography, or stress myocardial perfusion scan in the past 12 months can be discharged without any further risk stratification if their ECG and troponin are reassuring given low MACE.

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“…5,6 In the setting of negative initial biomarker results and a nonischemic ECG result, the 30-day risk profile of ED patients with chest pain is favorable. [7][8][9] Most patients can be risk stratified to a less than 1% chance of adverse event, although no patients can be stratified to zero risk. 2,3,10 Considerable resources are therefore devoted to pursuing further evaluation through accelerated diagnostic protocols either in observation units or inpatient settings to further risk-stratify, potentially manage short-term events, and identify patients who may benefit from revascularization.…”

Section: Discussionmentioning

confidence: 99%

Quantifying Patient-Physician Communication and Perceptions of Risk During Admissions for Possible Acute Coronary Syndromes

Newman

Ackerman

Kraushar

et al. 2015

Annals of Emergency Medicine

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Cardiac risk factors and risk scores vs cardiac computed tomography angiography: a prospective cohort study for triage of ED patients with acute chest pain

Cited by 7 publications

References 33 publications

The Diagnostic Value of Clinical Symptoms in Women and Men Presenting with Chest Pain at the Emergency Department, a Prospective Cohort Study

The Diagnostic Value of Clinical Symptoms in Women and Men Presenting with Chest Pain at the Emergency Department, a Prospective Cohort Study

Major adverse cardiac events after emergency department evaluation of chest pain patients with advanced testing: Systematic review and meta‐analysis

Quantifying Patient-Physician Communication and Perceptions of Risk During Admissions for Possible Acute Coronary Syndromes

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