Relationship between a Clear‐cut Alternative Noncardiac Diagnosis and 30‐day Outcome in Emergency Department Patients with Chest Pain

Hollander, Judd E.; Robey, Jennifer L.; Chase, Maureen; Brown, Aaron; Zogby, Kara E.; Shofer, Frances S.

doi:10.1197/j.aem.2006.09.053

Cited by 25 publications

(13 citation statements)

References 26 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…This accounts for more than 50% of patients with acute chest pain 11,12 and is typical of broad based ED chest pain patient populations that have only a 5% to 20% risk of an ACS. 3,[5][6][7][8][11][12][13][14] Coronary CTA has high diagnostic accuracy. Janne d'Othee et al, 21 in a meta-analysis of 41 trials with over 2,500 patients, found a sensitivity of 95% and specificity of 85% relative to cardiac catheterization.…”

Section: Discussionmentioning

confidence: 99%

“…[2][3][4][5][6][7][8][9][10][11][12][13] Although clinical algorithms can successfully risk stratify patients, they have not typically been considered useful in identifying a group of patients with a 30-day 1% risk for an adverse event who can safely be discharged from the ED. [2][3][4][5][6][7][8][9][10][11][12][13][14] Coronary computerized tomographic angiography (CTA) has been shown to have excellent diagnostic accuracy when compared to cardiac catheterization [15][16][17][18][19][20][21] and appears to perform as well as myocardial perfusion imaging in identifying patients at low risk for cardiovascular events. [22][23][24][25][26] Observational studies of coronary CTA have found that patients with normal coronary CTA results are at low risk for adverse events over 1-2 years; however, these studies either were small or involved patients who had other standard assessments to aid in clinical management.…”

mentioning

confidence: 99%

See 1 more Smart Citation

One‐year Outcomes Following Coronary Computerized Tomographic Angiography for Evaluation of Emergency Department Patients with Potential Acute Coronary Syndrome

Hollander

Chang

Shofer

et al. 2009

Academic Emergency Medicine

Self Cite

115

View full text Add to dashboard Cite

Objectives: Coronary computerized tomographic angiography (CTA) has high correlation with cardiac catheterization and has been shown to be safe and cost-effective when used for rapid evaluation of lowrisk chest pain patients from the emergency department (ED). The long-term outcome of patients discharged from the ED with negative coronary CTA has not been well studied. Methods:The authors prospectively evaluated consecutive low-to intermediate-risk patients who received coronary CTA in the ED for evaluation of a potential acute coronary syndrome (ACS). Patients with cocaine use, known cancer, and significant comorbidity reducing life expectancy and those found to have significant disease (stenosis ‡ 50% or ejection fraction < 30%) were excluded. Demographics, medical and cardiac history, labs, and electrocardiogram (ECG) results were collected. Patients were followed by telephone contact and record review for 1 year. The main outcome was 1-year cardiovascular death or nonfatal acute myocardial infarction (AMI).Results: Of 588 patients who received coronary CTA in the ED, 481 met study criteria. They had a mean (±SD) age of 46.1 (±8.8) years, 63% were black or African American, and 60% were female. There were 53 patients (11%) rehospitalized and 51 patients (11%) who received further diagnostic testing (stress or catheterization) over the subsequent year. There was one death (0.2%; 95% confidence interval [CI] = 0.01% to 1.15%) with unclear etiology, no AMI (0%; 95% CI = 0 to 0.76%), and no revascularization procedures (0%; 95% CI = 0 to 0.76%) during this time period.Conclusions: Low-to intermediate-risk patients with a Thrombosis In Myocardial Infarction (TIMI) score of 0 to 2 who present to the ED with potential ACS and have a negative coronary CTA have a very low likelihood of cardiovascular events over the ensuing year.ACADEMIC EMERGENCY MEDICINE 2009; 16:693-698 ª

show abstract

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

One‐year Outcomes Following Coronary Computerized Tomographic Angiography for Evaluation of Emergency Department Patients with Potential Acute Coronary Syndrome

Hollander

Chang

Shofer

et al. 2009

Academic Emergency Medicine

Self Cite

115

View full text Add to dashboard Cite

show abstract

“…8 The majority ultimately will be found not to have ACS, but symptoms caused by noncardiac and often benign disorders such as musculoskeletal pain, pleuritis, or gastroesophageal reflux make the rapid rule-out of ACS more difficult and result in huge medical expenses. Safe and early rule-out of ACS contributes to more efficient and high-value healthcare delivery.…”

Section: Introductionmentioning

confidence: 99%

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

2016

Self Cite

View full text Add to dashboard Cite

ABSTRACT:It is well established that clinicians cannot use clinical judgment alone to determine whether an individual patient who presents to the emergency department has an acute coronary syndrome. The history and physical examination do not distinguish sufficiently between the many conditions that can cause acute chest pain syndromes. Cardiac risk factors do not have sufficient discriminatory ability in symptomatic patients presenting to the emergency department. Most patients with non-ST-segment-elevation myocardial infarction do not present with electrocardiographic evidence of active ischemia. The improvement in cardiac troponin assays, especially in conjunction with well-validated clinical decision algorithms, now enables the clinician to rapidly exclude myocardial infarction. In patients in whom unstable angina remains a concern or there is a desire to evaluate for underlying coronary artery disease, coronary computed tomography angiography can be used in the emergency department. Once a process that took ≥24 hours, computed tomography angiography now can rapidly exclude myocardial infarction and coronary artery disease in patients in the emergency department.A bout 20 million patients present with symptoms possibly suggestive of acute coronary syndrome (ACS) to emergency departments (ED) in North America and Europe each year.1-3 Patients with ACS and acute myocardial infarction (AMI) present with a wide variety of symptoms such as chest pain, shortness of breath, weakness, nausea, vomiting, and even fatigue, making the diagnosis difficult. Demographics, cardiac risk factors, chest pain characteristics, and physical examination can assist disposition decisions but are insufficient to identify who does and does not have an ACS.4-7 Some patients may have objective evidence of a clearcut diagnosis, but the majority do not. 8 The majority ultimately will be found not to have ACS, but symptoms caused by noncardiac and often benign disorders such as musculoskeletal pain, pleuritis, or gastroesophageal reflux make the rapid rule-out of ACS more difficult and result in huge medical expenses. Safe and early rule-out of ACS contributes to more efficient and high-value healthcare delivery. History And PHysicAl ExAminAtionClinical features, alone or in combination with an ECG, are poorly predictive for AMI (Table 1). 9,10 In addition, they have variable reliability. Features classically associated with a lower probability of AMI such as pleuritic, positional, and sharp chest pain have poor to fair interphysician reliability (κ=0.27-0.44), 11 whereas high-risk features (radiation to left arm, substernal location, and history of AMI) are more reliable (κ=0.74-0.89). 11Traditional cardiac risk factors, derived from population-based longitudinal cohort studies of asymptomatic patients, are poor predictors of risk for AMI or ACS in symptomatic patients in the ED. 6,7 Similarly, the physical examination seldom is useful for distinguishing patients with ACS from patients with noncardiac chest pain.Trials of medications, onc...

show abstract

“…Although the recognition of patients at high risk of ACS has improved steadily, identifying the majority of chest pain presentations who fall into the low‐risk group remains a challenge 5,6 . The process of assessing patients in the ED with possible ACS remains time‐consuming and is not without controversy.…”

Section: Introductionmentioning

confidence: 99%

“…[1][2][3][4][5] Although the recognition of patients at high risk of ACS has improved steadily, identifying the majority of chest pain presentations who fall into the low-risk group remains a challenge. 5,6 The process of assessing patients in the ED with possible ACS remains time-consuming and is not without controversy. Many key questions remain unanswered, such as the role of accelerated biomarker risk stratification as early as 2 h following ED presentation, the added value of multiple biomarker assays including change in their absolute levels (delta values) and the clinical utility of early (within 72 h) provocation testing such as an exercise ECG, particularly in patients under 40 years of age without risk factors who present with normal serial ECG and biomarkers (see Discussion).…”

Section: Introductionmentioning

confidence: 99%

Comprehensive standardized data definitions for acute coronary syndrome research in emergency departments in Australasia

Cullen

Than

Brown

et al. 2010

Emerg Medicine Australasia

View full text Add to dashboard Cite

Patients with chest discomfort or other symptoms suggestive of acute coronary syndrome are one of the most common categories seen in many Emergency Departments (EDs). Although the recognition of patients at high risk of acute coronary syndrome has improved steadily, identifying the majority of chest pain presentations who fall into the low-risk group remains a challenge. Research in this area needs to be transparent, robust, applicable to all hospitals from large tertiary centres to rural and remote sites, and to allow direct comparison between different studies with minimum patient spectrum bias. A standardized approach to the research framework using a common language for data definitions must be adopted to achieve this. The aim was to create a common framework for a standardized data definitions set that would allow maximum value when extrapolating research findings both within Australasian ED practice, and across similar populations worldwide. Therefore a comprehensive data definitions set for the investigation of non-traumatic chest pain patients with possible acute coronary syndrome was developed, specifically for use in the ED setting. This standardized data definitions set will facilitate 'knowledge translation' by allowing extrapolation of useful findings into the real-life practice of emergency medicine.

show abstract

Relationship between a Clear‐cut Alternative Noncardiac Diagnosis and 30‐day Outcome in Emergency Department Patients with Chest Pain

Cited by 25 publications

References 26 publications

One‐year Outcomes Following Coronary Computerized Tomographic Angiography for Evaluation of Emergency Department Patients with Potential Acute Coronary Syndrome

One‐year Outcomes Following Coronary Computerized Tomographic Angiography for Evaluation of Emergency Department Patients with Potential Acute Coronary Syndrome

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

Comprehensive standardized data definitions for acute coronary syndrome research in emergency departments in Australasia

Contact Info

Product

Resources

About