Factors influencing physician risk estimates for acute cardiac events in emergency patients with suspected acute coronary syndrome

Abstract

BackgroundEmergency physicians frequently assess risk of acute cardiac events (ACEs) in patients with undifferentiated chest pain. Such estimates have been shown to have moderate to high sensitivity for ACE but are conservative. Little is known about the factors implicitly used by physicians to determine the pretest probability of risk. This study sought to identify the accuracy of physician risk estimates for ACE in patients presenting to the ED with chest pain and to identify the demographic and clinical information emergency physicians use in their determination of patient risk.MethodsThis study used data from two prospective studies of consenting adult patients presenting to the ED with symptoms of possible acute coronary syndrome. ED physicians estimated the pretest probability of ACE. Multiple linear regression analysis was used to identify predictors of physician risk estimates. Logistic regression was used to determine whether there was a correlation between physicians’ estimated risk and ACE.ResultsIncreasing age, male sex, abnormal ECG features, heavy/crushing chest pain and risk factors were correlated with physician risk estimates. Physician risk estimates were consistently found to be higher than the expected proportion of ACE from the sampled population.ConclusionPhysicians systematically overestimate ACE risk. A range of factors are associated with physician risk estimates. These include factors strongly predictive of ACE, such as age and ECG characteristics. They also include other factors that have been shown to be unreliable predictors of ACE in an ED setting, such as typicality of pain and risk factors.

Machine learning-based CT fractional flow reserve assessment in acute chest pain: first experience

“…Patients with no relevant coronary artery stenosis <25% (n=141, 19%) and patients with a history of coronary revascularization (by either percutaneous coronary intervention or coronary artery bypass grafting) were excluded (n=21, 3%). Each patient's electronic medical files was reviewed for cardiovascular risk factors, ECG changes, cardiac biomarkers, and any further cardiac imaging performed (including ICA; cardiac magnetic resonance imaging, MRI; and myocardial perfusion single-photon emission CT, SPECT) (26). The final diagnosis of ACS results from all information available within 3 months of follow-up.…”

Role of cardiological specialistic evaluation in patients with chest pain presenting in the emergency department

“…In addition, ED physicians have been shown to systematically overestimate acute cardiac events in the ED due to different factors, including patients' increasing age and abnormal ECG characteristics. 4 The aim of the present study was to evaluate the diagnostic and prognostic accuracy of a standard clinical and instrumental approach in patients with CP presenting to a single ED of a tertiary referral university hospital, where cardiologist consultancy is requested at the discretion of the emergency physician.…”

“…However, the impact of these approaches on the potential burden of improper hospital admissions [positive predictive value (PPV)] and the additional role of early cardiologic consultancy is still unclear. In addition, ED physicians have been shown to systematically overestimate acute cardiac events in the ED due to different factors, including patients’ increasing age and abnormal ECG characteristics 4 …”