Patient‐reported symptoms improve prediction of acute coronary syndrome in the emergency department

Abstract

Early diagnosis is critical in the management of patients with acute coronary syndrome (ACS), particularly ST-elevation myocardial infarction (STEMI), because effective therapies are time-dependent. Aims of this secondary analysis were to determine: (i) the prognostic value of symptoms for an ACS diagnosis in conjunction with electrocardiographic (ECG) and troponin results; and (ii) if any of 13 symptoms were associated with prehospital delay in those presenting to the emergency department (ED) with potential ACS. Patients receiving a cardiac evaluation in the ED were eligible for the study. Thirteen patient-reported symptoms were assessed in triage. Prehospital delay time was calculated as the time from symptom onset until registration in the ED. A total of 1,064 patients were enrolled in five EDs. The sample was 62% male, 70% white, and had a mean age of 60.2 years. Of 474 participants diagnosed with ACS, 118 (25%) had STEMI; 251 (53%) had non-ST elevation myocardial infarction (NSTEMI); and 105 (22%) had unstable angina. Sweating (OR = 1.42 CI [1.01, 2.00]) and shoulder pain (OR = 1.64 CI [1.13, 2.38]) added to the predictive value of an ACS diagnosis when combined with ECG and troponin results. Shortness of breath (OR = 0.71 CI [0.50, 1.00]) and unusual fatigue (OR = 0.60 CI [0.42, 0.84]) were predictive of a non-ACS diagnosis. Sweating predicted shorter prehospital delay (HR = 1.35, CI [1.10, 1.67]); shortness of breath (HR = 0.73 CI [0.60, 0.89]) and unusual fatigue (HR = 0.72, CI [0.57, 0.90]) were associated with longer prehospital delay. Patient-reported symptoms are significantly associated with ACS diagnoses and prehospital delay. Sweating and shoulder pain combined with ECG signs of ischemia may improve the timely detection of ACS in the ED.

Prevalence and Predictors of Delay in Seeking Emergency Care in Patients Who Call 9-1-1 for Chest Pain

“…For instance, a recent prospective study by Zègre-Hemsey et al examined delay > 3 h in a cohort of 590 non-ACS controls and 474 ACS cases (21). They found that 63% of non-ACS patients and 49% of ACS patients had a delayed presentation > 3 h (21). When compared to our study, we found an overall prevalence of > 2 h delay in 46% of patients in our cohort (Figure 1).…”

“…However, it is worth noting that delay has been defined differently throughout literature. For instance, a recent prospective study by Zègre-Hemsey et al examined delay > 3 h in a cohort of 590 non-ACS controls and 474 ACS cases (21). They found that 63% of non-ACS patients and 49% of ACS patients had a delayed presentation > 3 h (21).…”

“…Compared to our data, we found that only 14% of ACS patients waited for > 12 h. It is worth noting that we did not stratify this group based on acute MI subtype due to sample size issues. In fact, previous studies suggest no difference among non-STEMI, unstable angina, and non-ACS patients in terms of prehospital delay in seeking care (21,27,28). It is important that the prevalent delay in presentation in ACS patients raises significant concerns; time from symptom onset to reperfusion therapy has been associated with increased infarct size and mortality (5,13).…”

Prognostic value of GRACE score for in-hospital and 6 months outcomes after non-ST elevation acute coronary syndrome

“…The clinical characteristics of ACS, including ST segment elevation of myocardial infarction (STEMI), non-STEMI, and unstable angina, is known to be widespread causes for disability and mortality [ 1 ]. Life-saving therapies for ACS patients are strongly dependent on early and prompt identification of signs and symptoms, whereas atypical appearance of ACS symptoms may lead to delayed diagnosis, delayed care, less evidence-based approaches, and increased morbidity and mortality [ 2 ].…”

Fatigue Is Associated With Diminished Cardiovascular Response to Anticipatory Stress in Patients With Coronary Artery Disease

“…In patients with CAD, the prevalence of moderate to severe fatigue has been reported to be as high as 39% during cardiac rehabilitation (CR), remaining up to 28% after 1 year (van Geffen et al, 2015). Meanwhile, mental fatigue is considered a risk factor for the development of heart diseases (Guan et al, 2017), while unusual fatigue is a strong predictor of longer prehospital delay (Zègre-Hemsey et al, 2018), poor health-related outcomes, and increased mortality (Irvine et al, 1999). Considering fatigue within the context of emotional stress, it may not only be a distressing symptom itself but also may play an important role in determining the effort and motivation to perform a task (Wright, 2014), and so in turn may shape variations of cardiovascular response to stress (Wright, 2009).…”