Validation of the new Vancouver Chest Pain Rule in Asian chest pain patients presenting at the emergency department

Abstract

Objectives: The new Vancouver Chest Pain (VCP) Rule recommends early discharge for chest pain patients who are at low risk of developing acute coronary syndrome (ACS), and thus can be discharged within 2 hours of arrival at the emergency department (ED). This study aimed to assess the performance of the new VCP Rule for Asian patients presenting with chest pain at the ED. Methods: This prospective cohort study involved patients attended to at the ED of a large urban centre. Patients of at least 25 years old, presenting with stable chest pain and a non-diagnostic ECG, and with no history of active coronary artery disease were included in the study. The main outcome measures were cardiac events, angioplasty, or coronary artery bypass within 30 days of enrolment. Results: The study included 1690 patients from 27 August 2000 to 1 May 2002, with 661 patients fulfilling the VCP criteria. Of those for early discharge, 24 had cardiac events and 13 had angioplasty or bypass at 30 days, compared to 91 and 41, respectively, for those unsuitable for discharge. This gave the rule a sensitivity of 78.1% for cardiac events, including angioplasty and bypass. Specificity was 41.0%, and negative predictive value (NPV) was 94.4%. Conclusion: We found the new VCP Rule to have moderate sensitivity and poor specificity for adverse cardiac events in our population. With an NPV of less than 100%, this means that a small proportion of patients sent home with early discharge would still have adverse cardiac events. RÉSUMÉObjectifs: Selon la nouvelle règle de Vancouver sur la douleur thoracique, il est recommandé que les patients qui présentent des douleurs thoraciques mais qui connaissent un faible risque de syndrome coronarien aigu puissent être renvoyés peu de temps après leur arrivée au service des urgences (SU), soit dans les deux heures suivantes. L'étude visait à évaluer la performance de la nouvelle règle de Vancouver chez des patients d'origine asiatique présentant des douleurs thoraciques, au SU. Méthode: Il s'agit d'une étude de cohorte, prospective, à laquelle ont participé des patients traités dans un SU d'un important centre urbain. Ont été sélectionnés des patients âgés d'au moins 25 ans, qui présentaient une douleur thoracique stable mais chez qui l'ECG s'est révélé non concluant et qui n'avaient pas d'antécédents de coronaropathie active. Les principaux critères d'évaluation consistaient en la survenue d'événements cardiaques ou encore en la réalisation d'une angioplastie ou d'un pontage coronarien dans les 30 jours suivant l'inclusion dans l'étude. Résultats: Au total, 1690 patients ont participé à l'étude, du 27 août 2000 au 1 er mai 2002, dont 661 répondaient aux critères de la nouvelle règle de Vancouver. Parmi ceux qui ont été renvoyés peu de temps après leur arrivée, 24 ont subi un événement cardiaque et 13 autres, une angioplastie ou un pontage coronarien au bout de 30 jours contre 91 et 41 respectivement parmi ceux qui n'étaient pas en état de quitter l'hôpital. Ainsi, la sensibilité de la règle s'est étab...

The low accuracy of the non-ST-elevation myocardial infarction electrocardiograph criteria of the fourth universal definition of myocardial infarction

“…3,13,14,18,21,22 The method for analysing the index test, the ECG, was unclear in several papers but the majority of queries were cleared up thanks to beneficial responses via email. 4,13,14,[18][19][20] Only four papers had the treating clinician reviewing the ECG; the remainder were evaluated by independent investigators affecting the applicability of their findings. 13,19,20,22 A number of the papers used low sensitivity troponins or failed to define AMI using the universal definition of myocardial infarction, meaning that the reference standard may incorrectly diagnose the target condition, although once again most queries were resolved via email.…”

“…4,13,14,[18][19][20] Only four papers had the treating clinician reviewing the ECG; the remainder were evaluated by independent investigators affecting the applicability of their findings. 13,19,20,22 A number of the papers used low sensitivity troponins or failed to define AMI using the universal definition of myocardial infarction, meaning that the reference standard may incorrectly diagnose the target condition, although once again most queries were resolved via email. The use of different assays affected the applicability of the reference standard in several papers.…”

“…3,7 ,13, 22 The other papers reported a higher sensitivity of 25.7%-58.6% but a lower specificity of 86%-91.2%. 3,4,14,[18][19][20] One article had an impressive combination of sensitivity and specificity, but this was a small study with a remarkably high prevalence. 21 The vast disparities may be due to certain papers with high sensitivity using Cardiologist 18 Bias Bias Good Good Bias Bias Fleischmann et al 21 Bias Good Unclear Good Bias Bias Hess et al 7 Bias Good Good Good Good Bias Backus et al 4 Good Good Good Good Good Bias Six et al 19 Bias Good Good Good Bias Good Melki and Jernberg 3 Good Unclear Bias Bias Good Bias Visser et al 22 Good Good Good Good Good Good Liu et al 13 Bias Good Bias Bias Bias Good Ong et al 20 Bias 4 Patients who presented to a cardiology emergency room with chest pain…”

“…The method for analysing the index test, the ECG, was unclear in several papers but the majority of queries were cleared up thanks to beneficial responses via email. 4,13,14,18–20 Only four papers had the treating clinician reviewing the ECG; the remainder were evaluated by independent investigators affecting the applicability of their findings. 13,19,20,22…”

“…This variability was similar in the T wave inversion articles, with only two papers using T wave inversion of 0.1 mV in two contiguous leads. 18,20…”