Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain

Goodacre, Steve; Angelini, Karen; Arnold, Jane; Revill, Susan M.; Morris, Francis

doi:10.1093/qjmed/hcg152

Cited by 61 publications

(43 citation statements)

References 11 publications

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“…Most often the patient will note chest or upper body discomfort and dyspnea as the predominant presenting symptoms accompanied by diaphoresis, nausea, vomiting, and dizziness. [17][18][19] Isolated diaphoresis, nausea, vomiting, or dizziness are unusual predominant presenting symptoms. 20 Atypical or unusual symptoms are more common in women, the elderly, and diabetic patients.…”

Section: Prehospital Management Patient and Healthcare Provider Recogmentioning

confidence: 99%

“…Although the presence of clinical signs and symptoms may increase suspicion of ACS, evidence does not support the use of any single sign or combination of clinical signs and symptoms alone to confirm the diagnosis. [17][18][19]112 When the patient presents with symptoms and signs of potential ACS, the clinician uses ECG findings (Figure 1, Box 4) to classify the patient into 1 of 3 groups: The interpretation of the 12-lead ECG is a key step in this process, allowing not only for this classification but also the selection of the most appropriate diagnostic and management strategies. Not all providers are skilled in the interpretation of the ECG; as a consequence, the use of computer-aided ECG interpretation has been studied.…”

Section: Ed Evaluation and Risk Stratification (Figure 1 Boxes 3 Andmentioning

confidence: 99%

See 1 more Smart Citation

Part 10: Acute Coronary Syndromes

O’Connor¹,

Brady²,

Brooks³

et al. 2010

Circulation

238

167

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Section: Prehospital Management Patient and Healthcare Provider Recogmentioning

confidence: 99%

Section: Ed Evaluation and Risk Stratification (Figure 1 Boxes 3 Andmentioning

confidence: 99%

Part 10: Acute Coronary Syndromes

O’Connor¹,

Brady²,

Brooks³

et al. 2010

Circulation

238

167

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“…Numerous studies do not support the use of any clinical signs and symptoms independent of electrocardiograph (ECG) tracings, cardiac biomarkers, or other diagnostic tests to rule in or rule out ACS in prehospital or emergency department (ED) settings. [215][216][217][218][219][220][221][222][223][224][225][226][227][228] To improve ACS outcome, all dispatchers and EMS providers must be trained to recognize ACS symptoms, even if atypical. It is reasonable for dispatchers to advise patients with potential cardiac symptoms to chew an aspirin (160 to 325 mg), providing the patient has no history of aspirin allergy and no signs of active or recent gastrointestinal bleeding (Class IIa, LOE C).…”

Section: Special Resuscitation Situations Acute Coronary Syndromesmentioning

confidence: 99%

Part 5: Adult Basic Life Support

Berg¹,

Robin²,

Abella³

et al. 2010

Circulation

698

495

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Basic life support (BLS) is the foundation for saving lives following cardiac arrest. Fundamental aspects of BLS include immediate recognition of sudden cardiac arrest (SCA) and activation of the emergency response system, early cardiopulmonary resuscitation (CPR), and rapid defibrillation with an automated external defibrillator (AED). Initial recognition and response to heart attack and stroke are also considered part of BLS. This section presents the 2010 adult BLS guidelines for lay rescuers and healthcare providers. Key changes and continued points of emphasis from the 2005 BLS Guidelines include the following:• Immediate recognition of SCA based on assessing unresponsiveness and absence of normal breathing (ie, the victim is not breathing or only gasping) Despite important advances in prevention, SCA continues to be a leading cause of death in many parts of the world. 1 SCA has many etiologies (ie, cardiac or noncardiac causes), circumstances (eg, witnessed or unwitnessed), and settings (eg, out-of-hospital or in-hospital). This heterogeneity suggests that a single approach to resuscitation is not practical, but a core set of actions provides a universal strategy for achieving successful resuscitation. These actions are termed the links in the "Chain of Survival." For adults they include When these links are implemented in an effective way, survival rates can approach 50% following witnessed out-ofhospital ventricular fibrillation (VF) arrest. 2 Unfortunately survival rates in many out-of-hospital and in-hospital settings fall far short of this figure. For example, survival rates following cardiac arrest due to VF vary from approximately 5% to 50% in both out-of-hospital and in-hospital settings. 3,4 This variation in outcome underscores the opportunity for improvement in many settings.Recognition of cardiac arrest is not always straightforward, especially for laypersons. Any confusion on the part of a rescuer can result in a delay or failure to activate the emergency response system or to start CPR. Precious time is lost if bystanders are too confused to act. Therefore, these adult BLS Guidelines focus on recognition of cardiac arrest with an appropriate set of rescuer actions. Once the lay bystander recognizes that the victim is unresponsive, that bystander must immediately activate (or send someone to activate) the emergency response system. Once the healthcare provider recognizes that the victim is unresponsive with no breathing or no normal breathing (ie, only gasping) the healthcare provider will activate the emergency response system. After activation, rescuers should immediately begin CPR.Early CPR can improve the likelihood of survival, and yet CPR is often not provided until the arrival of professional emergency responders. 5 Chest compressions are an especially critical component of CPR because perfusion during CPR

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“…[20][21][22] Using combinations of history and physical examination findings to discriminate patients with serious causes of chest pain is often not possible. 23 In our study, we demonstrated wide variation in the decision to hospitalize Medicare beneficiaries with chest pain, nearly twofold in the lowest and highest quintile of hospitals and that patients treated in hos- pitals with higher admission rates for chest pain are less likely to have AMI within 30 days of their index events and less likely to die.…”

Section: Discussionmentioning

confidence: 99%

Variation in Chest Pain Emergency Department Admission Rates and Acute Myocardial Infarction and Death Within 30 Days in the Medicare Population

et al. 2015

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Objectives: The objective was to assess the relationship between emergency department (ED) admission rates for Medicare beneficiaries with chest pain and outcomes, specifically 30-day rates of acute myocardial infarction (AMI) and mortality.Methods: Using a 20% random sample of Medicare beneficiaries in 2009, 158,295 beneficiaries with a primary diagnosis of chest pain at the conclusion of their ED visits were selected to assess outcomes based on the decision to hospitalize or discharge home. The proportions of these patients admitted to inpatient or observation status at 2,219 U.S. hospitals were calculated, adjusting for differences in patient and hospital characteristics. Both bivariate analysis and multivariable logistic regression were used to estimate the effect of the adjusted admission rates (designed to be a measure of care intensity) on patient outcomes. Other covariates in the multivariable model included patient demographics, medical conditions, and hospital utilization in the 30 days prior to the ED visits. Results from the bivariate and multivariable analyses were compared for consistency.Results: The adjusted Medicare admission rate for ED patients with chest pain averaged 63% for the middle quintile of the patient sample and ranged from 38% to 81% in the lowest and highest quintiles. The multivariable model yielded estimates of 3.6 fewer cases of AMI (95% confidence interval [CI] = 1.5 to 5.1 cases) and 2.8 fewer deaths (95% CI = 0.6 to 4.1 deaths) per 1,000 chest pain patients associated with an admission rate of 81% versus 38%. The estimates from the bivariate analysis were of similar magnitude.Conclusions: Considerable variation exists across U.S. hospitals in ED admission rates for Medicare patients with chest pain. Hospitals that approach admissions more conservatively (i.e., higher admission rates) in this population have lower rates of AMI and mortality.ACADEMIC EMERGENCY MEDICINE 2015;22:955-964 © 2015 by the Society for Academic Emergency Medicine T here were 7 million emergency department (ED) visits for chest pain in the United States in 2010. 1Chest pain ranked first among the principal reasons for ED visits by men and women over the age of 65, who accounted for more than 1.5 million (22%) of all ED visits for chest pain.1 Medicare beneficiaries comprised about 22% of all ED visits, which equates to more than 1.5 million annual Medicare visits with a presenting complaint of chest pain.2 The chest pain admission rate among Medicare beneficiaries is more than

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Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain

Cited by 61 publications

References 11 publications

Part 10: Acute Coronary Syndromes

Part 10: Acute Coronary Syndromes

Part 5: Adult Basic Life Support

Variation in Chest Pain Emergency Department Admission Rates and Acute Myocardial Infarction and Death Within 30 Days in the Medicare Population

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