A Computer-Derived Protocol to Aid in the Diagnosis of Emergency Room Patients with Acute Chest Pain

Goldman, Lee; Weinberg, M; Weisberg, Monica; Olshen, Richard A.; Ef, Cook; Rk, Sargent; Ga, Lamas; Dennis, Clarence; Wilson, Clyde R.; Deckelbaum, Lawrence I.; Fineberg, Harvey V.; Stiratelli, R

doi:10.1056/nejm198209023071004

Cited by 480 publications

(161 citation statements)

References 23 publications

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“…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.…”

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confidence: 99%

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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

116

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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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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

116

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“…In spite of previous studies 1, [8][9][10][11][12][13][14] that proposed computer protocols for emergency department physicians to diagnose patients with chest pain, this study is the first study proposing a computer protocol for diagnosing patients with chest pain at home. Because of the high incidence today of coronary cardiac disease, there is an increase in the number of people who visit an emergency department with complaints of noncardiac chest pain.…”

Section: Discussionmentioning

confidence: 92%

“…[5][6][7] Some algorithms and computer programs have been developed to make the diagnosis of patients with chest pain easier. 1,[8][9][10][11][12][13][14] All of the protocols have been developed to guide the physician in the emergency department. In all of these studies, there is no protocol that has been prepared that takes into account patients with chest pain at home.…”

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confidence: 99%

A Computer Based Telemedicine Protocol to Predict Acute Coronary Syndrome in Patients With Chest Pain at Home

Coşkun

Eren

2006

Int. Heart J.

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SUMMARYThe decision to admit a patient to a coronary care unit for acute coronary syndrome (ACS) has serious medical and financial consequences. In this study, we aimed to develop a computer program to predict the existence of ACS in patients with chest pain at home; it is intended that patients will be able to access the program via the website to test its validity.This study proceeded in two phases. In the first phase, a computer-based decision protocol was developed using recursive-partitioning analysis to predict ACS in 250 patients with chest pain on the basis of their historical data. In the second phase, this protocol was tested in 115 patients for diagnosis of ACS prospectively. Thirty-two of the patients answered the algorithm questions on the website. All of the patients who visited the website of this study were advised to go to the emergency department.Although the algorithm showed the presence of ACS in 82 of 115 patients, 60 of 115 patients were diagnosed as having ACS in the emergency department (n = 55) or at follow-up. The agreement between the diagnosis of the algorithm and the true diagnosis was moderate and statistically significant (Kappa coefficient 0.61, P < 0.001). The sensitivity of the algorithm was 100%, although its specificity was 60%. The accuracy of the algorithm in diagnosing ACS was 81%.The algorithm diagnoses patients with ACS at a high ratio and decreases the number of patients being unnecessarily admitted to the emergency with non-ACS. (Int Heart J 2006; 47: 491-500)

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“…[1][2][3][4][5] Some of these rapid rule-out protocols have reported high sensitivity and specificity in diagnosing patients with cardiac origin of chest pain. 6,7 Nevertheless, uncertainty still exists regarding the optimal combination of diagnostic tools that should be used in patients with chest pain, particularly in those considered at low risk of complications, 8,9 in whom, by definition, the ECG is normal or unchanged.…”

Section: Introductionmentioning

confidence: 99%

Continuous 12‐lead st‐segment monitoring improves identification of low‐risk patients with chest pain and a worse in‐hospital outcome

Pelliccia

Cianfrocca

Marazzi³

et al. 2002

Clinical Cardiology

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Background: Various strategies have been proposed to improve diagnosis and triage of patients with chest pain at low risk, but uncertainty still exists on the optimal combination of diagnostic tools that should be used in this subset of patients. Hypothesis: The aim of this study was to evaluate the incremental benefit of continuous 12‐lead ST‐segment monitoring over that provided by conventional diagnostic tools in patients with chest pain. Methods: Of 232 consecutive patients referred because of chest pain, 52 were classified as low‐risk according to the Agency for Health Care Policy and Research unstable angina guidelines and observed for 12 h with serial cardiac enzymes and electrocardiograms (ECG) (every 3 h). All patients also underwent both echocardiography at entry and continuous 12‐lead ST‐segment monitoring during the observation period. Results: During a mean hospital stay of 3.7 days (range 1‐14 days), a benign outcome was observed in 37 patients (71%), whereas 15 patients (29%) had major cardiac events or recurrence of chest pain of ischemic origin. Addition of ST‐segment monitoring findings to baseline clinical data as well as to serial enzymes and ECG features added significant incremental prognostic value (p < 0.001). Multivariate analysis showed reproduction of pain by chest pressure (p < 0.05) and presence of ST‐segment changes (≥ 0.1 mV) during 12‐lead ST‐segment monitoring (p < 0.001) as independent predictors of a benign or unfavorable outcome. Conclusions: In low‐risk patients with chest pain, continuous 12‐lead ST‐segment monitoring provides significant incremental diagnostic and prognostic information to currently used clinical, enzymatic, and ECG data, and is helpful in identifying the subset of patients with a worse in‐hospital outcome.

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A Computer-Derived Protocol to Aid in the Diagnosis of Emergency Room Patients with Acute Chest Pain

Cited by 480 publications

References 23 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

A Computer Based Telemedicine Protocol to Predict Acute Coronary Syndrome in Patients With Chest Pain at Home

Continuous 12‐lead st‐segment monitoring improves identification of low‐risk patients with chest pain and a worse in‐hospital outcome

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