The Continuing Search to Identify the Very‐low‐risk Chest Pain Patient

Hollander, Judd E.

doi:10.1111/j.1553-2712.1999.tb01177.x

Cited by 42 publications

(28 citation statements)

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“…[4][5][12][13][14] Recent research has investigated the role of computerized algorithms, [16][17][18] neural networks, 19 specialized evaluation and observation units, [20][21][22][23][24][25] and cardiac imaging. [26][27][28][29][30][31][32] Although all of these techniques offer distinct advantages, none has been universally implemented. 26 In terms of ease of use, few have improved upon the algorithm proposed by Goldman et al, which uses history, physical, and electrocardiogram (ECG) characteristics to stratify patients into different levels of risk.…”

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confidence: 99%

“…[26][27][28][29][30][31][32] Although all of these techniques offer distinct advantages, none has been universally implemented. 26 In terms of ease of use, few have improved upon the algorithm proposed by Goldman et al, which uses history, physical, and electrocardiogram (ECG) characteristics to stratify patients into different levels of risk. [1][2][3] In their proposed algorithm, however, some low-risk groups still had a risk of AMI as high as 1-7%.…”

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confidence: 99%

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Combination of Goldman Risk and Initial Cardiac Troponin I for Emergency Department Chest Pain Patient Risk Stratification

Gibler

Pollack

Hoekstra

et al. 2001

Academic Emergency Medicine

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Abstract. Background: Accurate identification of low-risk emergency department (ED) chest pain patients who may be safe for discharge has not been well defined. Goldman criteria have reliably riskstratified patients but have not identified any subset safe for ED release. Cardiac troponin I (cTnI) values have also been shown to risk-stratify patients but have not identified a subset safe for ED release. Objective: To test the hypothesis that ED chest pain patients with a Goldman risk of Յ4% and a single negative cTnI (Յ0.3 ng/mL) at the time of ED presentation would be safe for discharge [<1% risk for death, acute myocardial infarction (AMI), revascularization]. Methods: A prospective cohort study was performed in which consecutive ED chest pain patients were enrolled from July 1999 to November 2000. Data collected included patient demographics, medical and cardiac history, electrocardiogram, and creatine kinase-MB and cTnI. Goldman risk stratification score was calculated while patients were still in the ED. Hospital course was followed daily. Telephone follow-up occurred at 30 days. The main outcome was death, AMI, or revascularization (percutaneous transluminal coronary angioplasty/stents/ coronary artery bypass grafting) within 30 days. Results: Of 2,322 patients evaluated, 998 had both a Goldman risk Յ4% and a cTnI Յ0.3 ng/mL. During the initial hospitalization, 37 patients met the composite endpoint (3.7%): 6 deaths (0.7%), 17 AMIs (1.7%), 18 revascularizations (1.8%). Between the time of hospital discharge and 30-day follow-up, 15 patients met the composite endpoint: 4 deaths (0.4%), 6 AMIs (0.6%), and 5 revascularizations (0.5%). Overall, 49 patients met the composite endpoint (4.9%; 95% CI = 3.6% to 6.2%): 10 deaths (1.0%; 95% CI = 0.4% to 1.6%); 23 AMIs (2.3%; 95% CI = 1.4% to 3.2%), and 23 revascularizations (2.3%; 95% CI = 1.4% to 3.2%) within 30 days of presentation. Conclusions: The combination of two risk stratification modalities for ED chest pain patients (Goldman risk Յ4% and cTnI Յ0.3 ng/mL) did not identify a subgroup of chest pain patients at <1% risk for death, AMI, or revascularization within 30 days.

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Combination of Goldman Risk and Initial Cardiac Troponin I for Emergency Department Chest Pain Patient Risk Stratification

Gibler

Pollack

Hoekstra

et al. 2001

Academic Emergency Medicine

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“…[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.…”

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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

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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

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“…Thus, in the United States (US) 8-10 million patients are evaluated yearly in the ED with symptoms that might indicate the presence of an acute coronary syndrome (ACS) (Owens et al 2010). However, up to 85% of these patients are ultimately diagnosed with a variety of non-ACS diagnoses (Hollander 1999, Chase et al 2006, Pollack et al 2006. There have been advances in technology that have increased the sensitivity of troponin assays with measurements reported below the 99th percentile (99th %) in over 50% of an apparently normal healthy reference population (Apple and Collinson 2011).…”

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High sensitivity cardiac troponin T in patients not having an acute coronary syndrome: results from the TRAPID-AMI study

et al. 2017

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The Continuing Search to Identify the Very‐low‐risk Chest Pain Patient

Cited by 42 publications

References 9 publications

Combination of Goldman Risk and Initial Cardiac Troponin I for Emergency Department Chest Pain Patient Risk Stratification

Combination of Goldman Risk and Initial Cardiac Troponin I for Emergency Department Chest Pain Patient Risk Stratification

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

High sensitivity cardiac troponin T in patients not having an acute coronary syndrome: results from the TRAPID-AMI study

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