A computer protocol to predict myocardial infarction in emergency department patients with chest pain

To achieve more appropriate triage to the coronary care unit of patients presenting with acute chest pain, we used clinical data on 1379 patients at two hospitals to construct a simple computer protocol to predict the presence of myocardial infarction. When we tested this protocol prospectively in 4770 patients at two university hospitals and four community hospitals, the computer-derived protocol had a significantly higher specificity (74 vs. 71 percent) in predicting the absence of infarction than physicians deciding whether to admit patients to the coronary care unit, and it had a similar sensitivity in detecting the presence of infarction (88.0 vs. 87.8 percent). Decisions based solely on the computer protocol would have reduced the admission of patients without infarction to the coronary care unit by 11.5 percent without adversely affecting the admission of patients in whom emergent complications developed that required intensive care. Although this protocol should not be used to override careful clinical judgment in individual cases, the computer protocol for the most part yields accurate estimates of the probability of myocardial infarction. Decisions about admission to the coronary care unit based on the protocol would have been as effective as those actually made by the unaided physicians who cared for the patients, and less costly. Whether physicians who are aided by the protocol perform better than unaided physicians cannot be determined without further study.     

Factors associated with late presentation to the emergency department in patients complaining of chest pain

ObjectiveWe investigated which factors predict late presentation (LP) to the emergency department (ED) in patients with non-traumatic chest pain (CP).MethodsAll CP cases attended at a single ED (2008–2017) were included. LP was considered if time from CP onset to ED arrival was>6 h. We analyzed associations between 42 patient/CP-related characteristics and LP in the whole cohort and in patients with CP due to acute coronary syndrome (ACS).ResultsThe cohort included 25,693 cases (LP=50.6%; ACS=19.0%). Twenty factors were associated with LP, and 8 were also found in patients with ACS: CP of short-duration, aggravated by exertion or breathing/movement, undulating or recurrent CP increased the risk of LP, whereas CP accompanied by diaphoresis, irradiated to the throat, and chronic treatment with nitrates decreased the risk of LP. Exertional and recurrent CP were associated with both, LP and ACS.ConclusionSome characteristics, mainly CP-related, may lead to LP to the ED. CP aggravated by exercise and recurrent CP were associated with both LP and a final diagnosis of ACS.Practice implicationsPatient educational initiatives should consider these two features as potential warnings for ACS and thereby encourage patients to seek early medical consultation.     

Implementation of a health-literate patient decision aid for chest pain in the emergency department

ObjectiveThe aim of this study was to investigate the implementation of a new health-literacy-tested patient decision aid for chest pain in Emergency Department (ED) patients. Outcomes included disposition, knowledge, decisional conflict and satisfaction prior to discharge. Patient health literacy was explored as a factor that may explain disparities in sub-group analysis of all outcomes.MethodsA health-literacy adapted tool was deployed using a pre/post intervention design. Patients enrolled during the intervention period were given the adapted chest pain decision aid that was used in conversation with their emergency medicine physician to decide on their course of action prior to being discharged.ResultsA total of 169 participants were surveyed and used in the final analysis. Patients in the usual care group were 2.6 times more likely to be admitted for chest pain than patients in the intervention group. Knowledge scores were higher in the intervention group, while no significant differences were observed in decisional conflict and patient satisfaction, or by patient health literacy level.Conclusion and practice implicationsUsing the adapted chest pain decision tool in emergency medicine may improve knowledge and reduce admissions, while addressing known barriers to understanding related to patient health literacy.     

Value of heart-type fatty acid-binding protein (H-FABP) for emergency department patients with suspected acute coronary syndrome

Objective

The aim of this study is testing the value of H-FABP in the early diagnosis of ACS alone or with routinely used biomarkers such as myoglobin, CK-MB, and cTn I in patients who admitted to emergency department (ED) with complaint of chest pain and suspected acute coronary syndrome.

Material and Methods

This prospective and cross-sectional study was performed at the Emergency Department of University hospital between June 2009 and September 2010. Patients who were admitted with chest pain within first 48 hours and suspected ACS were enrolled to the study. Blood samples were taken for CK-MB, myoglobin, cTnI and H-FABP The patients were divided into two groups (ACS and non ACS). Statistical analyse were used for relation of biomarkers with diagnosis of ACS.

Results

A 66 patients were included to the study. H-FAPB values were positive in15.2% patients. When H-FABP was added to routinely used biomarkers in the diagnosis of ACS, increasing was observed in all sensitivity, specificity, PPV and NPV values. However, this increase was not stastistically significant.

Conclusion

H-FABP did not provide any significant change in early diagnosis and exclusion of ACS diagnosis when used either alone or combination with routinely used biomarkers     

综合医院急诊胸痛患者的心理状态及临床特征

目的:评估胸痛患者的心理状态,分析描述非心源性胸痛(non-cardiac chest pain,NCCP)的临床特征。方法:横断面研究。收集胸痛为主诉连续就诊的急诊患者711人,采用汉密顿焦虑量表(Hamilton Anxiety Rating Scale,HAMA)和汉密顿抑郁量表(Hamilton Depression Rating Scale-17,HAMD-17)评估患者心理状态,比较NCCP与心源性胸痛的临床特点。结果:共231例同意合作的胸痛患者入选,年龄19~79岁,男性106。其中182例为NCCP,49例为有器质性心脏病者(心源性胸痛组)。胸痛患者焦虑抑郁平均分均高于正常界值(HAMA得分≥14;HAMD-17得分≥8),以焦虑症状更明显,NCCP组有明显焦虑症状的患者比例高于心源性胸痛组(64.3%vs.57.1%,P0.01)。与心脏病患者相比,NCCP组年龄较小[(48.1±11.7)岁vs.(55.5±10.0)岁,P0.01],≤45岁者较多(37.9%vs.16.3%,P0.01),胸痛发作时更易出现死亡恐惧(59.3%vs.40.8%)、害怕(69.8%vs.34.7%)、失控感(31.9%vs.10.2%)、过度换气(37.4%vs.16.3%)和手脚麻木(37.4%vs.14.3%)等伴随症状(Ps0.05);伴随症状成组出现(≥4个)的比例更高(29.7%vs.10.2%,P0.01),发作时心电图正常、病程≥6月者更多(49.5%vs.30.6%,P0.05)。结论:急诊胸痛患者焦虑症状明显,其中大多数为非心源性胸痛,主要临床特征为年龄较轻、心电图正常、发作时常有特征性伴随症状,或特征性伴随症状成组出现。     

A rapid point-of-care cardiac marker testing strategy facilitates the rapid diagnosis and management of chest pain patients in the emergency department

We compared a rapid, point-of-care multimarker protocol with a single and serial troponin I (TnI)-only protocol in 5,244 patients admitted to the emergency department with chest pain. The diagnosis of acute myocardial infarction (AMI) was based on a doubling myoglobin level accompanied by at least a 50% increase in the creatine kinase (CK)-MB level with no detectable TnI; a doubling of myoglobin level together with any detectable TnI; or a TnI level of 0.4 ng/mL (0.4 microg/L) or more, irrespective of myoglobin or CK-MB results. By using these new criteria, 145 of 148 cases were positive for AMI (positive predictive value [PPV], 92.4%) and 3 were negative, which were also negative by the core laboratory TnI assay. Twelve confirmed non-AMI cases were positive by the new protocol, with 10 of 12 confirmed by the core laboratory as positive for TnI. The negative predictive value (NPV) was 99.9% the overall diagnostic accuracy was 99.7%. The TnI-only protocol had a sensitivity of 68.2% with an NPV of 99.1%. With lower TnI-only cutoffs, 4 patients had false-negative results, and a PPV of 36.4% was observed. Our rapid multimarker protocol seems superior to a TnI-only approach for rapidly triaging patients with chest pain or AMI.     

TIMI、PURSUIT和GRACE评分对急诊非ST段抬高急性冠脉综合征患者风险预测的比较

目的探讨NSTE-ACS评分GRACE、PURSUIT和TIMI在急诊非ST段抬高急性冠脉综合征（NSTE-ACS）患者风险预测上的价值。方法在PubMed上检索TIMI、PURSUIT和GRACE风险评分对NSTE-ACS患者风险预测的研究。比较不同评分对患者院内、短期（30-day）、长期（360-day）的心血管事件的预测效果。运用X^2检验和威尔克森统计值进行统计分析。结果共有8个研究符合检索条件,共计25247例NSTE—ACS患者被正式评估。依据TIMI、PURSUIT和GRACE评分患者被相对地划分为低危组、中危组和高危组。院内心血管事件发生率在各评分、各组别间差异无统计学意义（P〉0．05）。30d内的主要心血管风险预测,对于低、中危组患者,TIMI评分优于GRACE和PURSUIT（P〈0．05）;但对于高危组患者,PURSUIT评分预测效果较好（P〈0．05）。1年内主要心血管风险预测,低危组内各评分未见统计学差异（P〉0．05）,TIMI和PURSUIT评分对中危组患者的风险预测优于GRACE（P〈0．05）;对于高危组,PURSUIT和GRACE的风险预测效果优于TIMI（P〈0．05）。结论TIMI风险评分适用于NSTE-ACS患者的院内、短期和长期心血管事件的预测．但对于30d内主要心血管事件风险的预测PURSUIT评分优于TIMI和GRACE。高危组1年内主要心血管事件风险的预测。GRACE评分优于PURSUIT和TIMI。     

Causes of chest pain and symptoms suggestive of acute cardiac ischemia in African-American patients presenting to the emergency department: a multicenter study.

This study examines whether race is a significant determinant of the diagnoses of acute myocardial infarction or angina pectoris in patients with symptoms suggestive of acute cardiac ischemia. The study population was comprised of 3401 (34%) African-American and 6600 (66%) white patients who presented to emergency departments with symptoms suggestive of acute cardiac ischemia. The main outcome measure was a diagnosis of acute myocardial infarction or angina pectoris. African Americans were younger, predominantly female, and more often had hypertension, diabetes mellitus, or smoked. The diagnosis of acute myocardial infarction was confirmed in 6% of African-American and 12% of white men, and in 4% of African-American and 8% of white women. After adjusting for age, gender, medical history, signs and symptoms, and hospital, African Americans were half as likely to develop acute myocardial infarction and were 60% as likely to have acute cardiac ischemia. Despite having less acute cardiac ischemia, African Americans in this study had high risk levels for coronary artery disease.     

Prevalence and prognosis of non-specific chest pain among patients hospitalized for suspected acute coronary syndrome - a systematic literature search

Background

Very recent acts of terrorism in the UK were perpetrated by 'homegrown', well educated young people, rather than by foreign Islamist groups; consequently, a process of violent radicalization was proposed to explain how ordinary people were recruited and persuaded to sacrifice their lives.

Discussion

Counterterrorism approaches grounded in the criminal justice system have not prevented violent radicalization. Indeed there is some evidence that these approaches may have encouraged membership of radical groups by not recognizing Muslim communities as allies, citizens, victims of terrorism, and victims of discrimination, but only as suspect communities who were then further alienated. Informed by public health research and practice, a new approach is proposed to target populations vulnerable to recruitment, rather than rely only on research of well known terrorist groups and individual perpetrators of terrorist acts.

Conclusions

This paper proposes public health research and practice to guard against violent radicalization.     

Association of social support during emergency department evaluation for acute coronary syndrome with subsequent posttraumatic stress symptoms

We examined the associations of different aspects of social support during emergency department (ED) evaluation for an acute cardiac event with perceptions of threat in the ED and subsequent posttraumatic stress symptoms (PSS) in 484 patients. Participants were enrolled in the ED where they reported on their perceptions of threat in the ED. Social support in the ED and PSS were assessed at inpatient bedside or by telephone a median of 3 days later. Positive aspects of social support were not associated with subsequent PSS. Anxiety-provoking social support was significantly associated with increased PSS at follow-up. Greater ED threat perception partially mediated that relationship.     

多层螺旋CT在急诊胸痛患者中的诊断价值

目的：探讨多层螺旋CT(multi-slice computer tomography,MSCT)在急诊胸痛患者诊断中的临床价值。方法：对本院急诊收治的162例胸痛患者进行MSCT平扫、增强扫描和血管造影成像,并对数据进行容积再现、曲面重组、多平面重组、最大密度投影等方法观察冠状动脉、主动脉、肺动脉。结果：急诊收治的162例胸痛患者中,所有患者可以清晰显示冠状动脉左右主干及主要分支、胸主动脉以及肺动脉段以上分支。发现冠状动脉狭窄者129例(79.6%),主动脉夹层18例(11.1%),肺动脉栓塞15例(9.3%)。结论：多层螺旋CT能够一次性完成对常见胸痛病因的鉴别诊断,迅速提供清晰、高质图像,是急诊胸痛患者的理想影像学检查方法。     

Ruling out coronary heart disease in primary care patients with chest pain: a clinical prediction score

Background  

Chest pain raises concern for the possibility of coronary heart disease. Scoring methods have been developed to identify coronary heart disease in emergency settings, but not in primary care.     

A behavioral analysis of chest pain in patients suspected of having coronary artery disease

A group of 83 men and women who had been referred to Johns Hopkins Hospital for cardiac catheterization for evaluation of chest pain and possible coronary artery bypass surgery were assessed behaviorally for their chest pains. During the approximately 2-week period between clinical evaluation and catheterization, the patients completed self-report forms about their chest pains. Patients completed one form for each episode of chest pain. Referring physicians also completed a form about the patients "typical" chest pain. The data were analyzed in terms of the antecedents, concomitants, and consequences of the chest pain, and patients' reports were compared to physicians' judgments. Major findings were as follows: 1) Antecedents--most episodes occurred while the patient was at home at times when his mood was one of contentment. 2) Concomitants--the average patient reported fewer than one episode per day which persisted for about 4 min and was rated as 36 on a scale of 0 to 100. The most common physical symptoms accompanying the episode were breathlessness and weakness, and the most common pain sensations were reported to be pressing or aching. There was no consistency among patients either in primary location or path of radiation of the pain. Duration of pain did not correlate significantly either with sensation or symptoms; however, severity rating did correlate with symptoms and sensations. 3) Consequences--most episodes were self-treated with nitroglycerin or rest. Patients typically returned to their ongoing activities; however, there were a number of interactions between the likelihood of returning to ones ongoing activity and the antecedents of the episodes. 4) The referring physicians significantly overestimated the frequency and severity of their patients' episodes; furthermore, they were selective in their abilities to identify correctly the antecedents or concomitants associated with their patients' pain--e.g., they were reliable in their judgments about subjects who had sleep-related episodes; however, they were inaccurate in characterizing the typical sensations or symptoms reported by their patients. It is suggested that a behavioral analysis may enable a physician to characterize his patient's chest complaints better, and perhaps also may facilitate the differentiation between chest complaints indicative of coronary artery disease and chest complaints of a noncoronary origin.     

The significance of ST and T changes for the development of coronary events in patients with acute coronary chest pain, treated in a coronary care unit without verified acute myocardial infarction

The one-year prognosis for patients with a confirmed diagnosis of acute myocardial infarction (AMI) was compared with that of non-AMI patients treated in the coronary care unit (CCU). The one-year incidence of coronary events (CE) after discharge from CCU was 37% in the 51 AMI patients and 20% in the 81 non-AMI patients. The one-year mortality rates were 27 and 4%, respectively. Among the non-AMI patients, well known risk factors such as hypertension, previous AMI, congestive heart failure, smoking, diabetes and hyperlipaemia were not more common in those who developed a CE. ST segment depression and T wave inversion, each of at least 0.1 mV, in three or more ECG leads were selective criteria for a high-risk group with respect to CE. Preventive measures should be considered in this group of patients without verified AMI.     

Evaluation of exhaled nitric oxide measurements in the emergency department for patients with acute asthma

BACKGROUND: Fraction of exhaled nitric oxide (FE(NO)) measurements performed on patients with acute asthma in the emergency department (ED) have previously shown poor reproducibility. OBJECTIVES: To evaluate the reproducibility of FE(NO) measurements in the ED using a new monitoring device, to evaluate any factors that may correlate with FE(NO) measurements, and to investigate if FE(NO) levels predict the need for admission to the hospital. METHODS: Thirty-five adult patients with asthma seen in the ED performed FE(NO), forced expiratory volume in 1 second, and peak expiratory flow rate maneuvers in triplicate. Reproducibility was evaluated using the intraclass correlation coefficient and the coefficient of variation. Associations between FE(NO), demographic, and traditional asthma measurements were investigated. The FE(NO) levels between patients admitted for further care and those discharged home were compared. RESULTS: The FE(NO) measurements showed acceptable intraclass correlation coefficient and coefficient of variation values (0.98 and 9.42%, respectively) for reproducibility. These values were superior to the values obtained for forced expiratory volume in 1 second and peak expiratory flow rate. No correlation was found between FE(NO) and traditional asthma factors, although length of the asthma attack trended toward statistical significance (P = .08). The FE(NO) levels did not differ between those admitted and those discharged home (P = .53). CONCLUSIONS: Fraction of exhaled nitric oxide measurements can be obtained in the ED setting with good reproducibility. These measurements may provide useful information not obtainable by other means. Further research is needed to determine how best to incorporate FE(NO) values into the ED setting.     

A simple model for prediction postpartum PTSD in high-risk pregnancies

This study aimed to examine the prevalence and possible antepartum risk factors of complete and partial post-traumatic stress disorder (PTSD) among women with complicated pregnancies and to define a predictive model for postpartum PTSD in this population. Women attending the high-risk pregnancy outpatient clinics at Sheba Medical Center completed the Edinburgh Postnatal Depression Scale (EPDS) and a questionnaire regarding demographic variables, history of psychological and psychiatric treatment, previous trauma, previous childbirth, current pregnancy medical and emotional complications, fears from childbirth, and expected pain. One month after delivery, women were requested to repeat the EPDS and complete the Post-traumatic Stress Diagnostic Scale (PDS) via telephone interview. The prevalence rates of postpartum PTSD (9.9 %) and partial PTSD (11.9 %) were relatively high. PTSD and partial PTSD were associated with sadness or anxiety during past pregnancy or childbirth, previous very difficult birth experiences, preference for cesarean section in future childbirth, emotional crises during pregnancy, increased fear of childbirth, higher expected intensity of pain, and depression during pregnancy. We created a prediction model for postpartum PTSD which shows a linear growth in the probability for developing postpartum PTSD when summing these seven antenatal risk factors. Postpartum PTSD is extremely prevalent after complicated pregnancies. A simple questionnaire may aid in identifying at-risk women before childbirth. This presents a potential for preventing or minimizing postpartum PTSD in this population.