Prospective Validation of the Thrombolysis in Myocardial Infarction Risk Score in the Emergency Department Chest Pain Population

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

doi:10.1016/j.annemergmed.2006.01.032

Cited by 187 publications

(138 citation statements)

References 29 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%

“…The protocol for coronary CTA included patients with a TIMI risk score of 0-2 at the time the scan was ordered (approximately 60%-70% of potential ACS patients) 11,12 with a serum creatinine less than or equal to 1.5 mg ⁄ dL and without active asthma, pregnancy, or an iodinated contrast allergy. Providers were allowed to order coronary CTA in higher TIMI risk score patients at their discretion; this typically occurred in patients with recent negative provocative tests.…”

Section: Study Protocolmentioning

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

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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%

Section: Study Protocolmentioning

confidence: 99%

mentioning

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

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116

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“…13 The seven-variable Thrombolysis-in-Myocardial-Infarction (TIMI) risk score aids in prognostication of adverse events in patients with ACS, including undifferentiated ED populations, but has not been found to have sufficient sensitivity to be used as a triage tool. [14][15][16] The Vancouver Chest Pain Rule identified a group of patients with undifferentiated chest pain who could be discharged early from the ED with minimal testing, but this rule remains to be validated in a multicentre study. 11 The common components of these clinical rules are objective patient-oriented variables such as demographics, risk factor burden, and cardiac biomarkers.…”

Section: Ré Sumémentioning

confidence: 99%

Emergency physician estimates of the probability of acute coronary syndrome in a cohort of patients enrolled in a study of coronary computed tomographic angiography

Lee

Hoffmann²,

Bamberg³

et al. 2012

CJEM

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Introduction: Little information exists regarding how accurately emergency physicians (EPs) predict the probability of acute coronary syndrome (ACS). Our objective was to determine if EPs can accurately predict ACS in a prospectively identified cohort of emergency department (ED) patients who met enrolment criteria for a study of coronary computed tomographic angiography (CCTA) and were admitted for a ''rule out ACS'' protocol. Methods: A prospective observational pilot study in an academic medical centre was carried out. EPs caring for patients with chest pain provided whole-number estimates of the probability of ACS after clinical review. This substudy was part of the now published Rule Out Myocardial Infarction/ Ischemia Using Computer Assisted Tomography (ROMICAT) study, a study of CCTA and admission of patients for a rule out ACS protocol after a nondiagnostic evaluation. Predictions were grouped into probability groups based on the validated Goldman criteria. ACS was determined by an adjudication committee using American Heart Association/American College of Cardiology/European Society of Cardiology guidelines. Results: A total of 334 predictions were obtained for a study population with a mean age of 54 (SD 12) years, 63% of whom were male. There were 35 ACS events. EPs predicted ACS better than by chance, and increasingly higher estimates were associated with a higher incidence of ACS (p 5 0.0004). The percentage of patients with ACS was 0%, 6%, 7%, and 17%, respectively, for very low, low, intermediate, and high probability groups. EPs' estimates had a sensitivity of 63% using a . 20% probability of ACS to define a positive test. Lowering this threshold to . 7% to define a test as positive increased the sensitivity of physician estimates to 89% but lowered specificity from 65% to 24%.

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“…The protocol for coronary CTA included patients with a TIMI risk score of 0-2 (approximately 50-70% of patients being evaluated for ACS) [21][22]. All patients provided verbal consent to receive coronary CTA according to standard radiology department procedure.…”

Section: Coronary Ctamentioning

confidence: 99%

Coronary computerized tomography angiography for rapid discharge of low-risk patients with cocaine-associated chest pain

et al. 2009

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Background: Most patients presenting to emergency departments (EDs) with cocaine-associated chest pain are admitted for at least 12 hours and receive a "rule out acute coronary syndrome" protocol, often with noninvasive testing prior to discharge. In patients without cocaine use, coronary computerized tomography angiography (CTA) has been shown to be useful for identifying a group of patients at low risk for cardiac events who can be safely discharged. It is unclear whether a coronary CTA strategy would be efficacious in cocaine-associated chest pain, as coronary vasospasm may account for some of the ischemia. We studied whether a negative coronary CTA in patients with cocaine-associated chest pain could identify a subset safe for discharge.Methods: We prospectively evaluated the safety of coronary CTA for low-risk patients who presented to the ED with cocaineassociated chest pain (self-reported or positive urine test). Consecutive patients received either immediate coronary CTA in the ED (without serial markers) or underwent coronary CTA after a brief observation period with serial cardiac marker measurements. Patients with negative coronary CTA (maximal stenosis less than 50%) were discharged. The main outcome was 30-day cardiovascular death or myocardial infarction.Results: A total of 59 patients with cocaine-associated chest pain were evaluated. Patients had a mean age of 45.6 Ϯ 6.6 yrs and were 86% black, 66% male. Seventy-nine percent had a normal or nonspecific ECG and 85% had a TIMI score <2. Twenty patients received coronary CTA immediately in the ED, 18 of whom were discharged following CTA (90%). Thirty-nine received coronary CTA after a brief observation period, with 37 discharged home following CTA (95%). Six patients had coronary stenosis Ն50%. During the 30-day follow-up period, no patients died of a cardiovascular event (0%; 95% CI, 0-6.1%) and no patient sustained a nonfatal myocardial infarction (0%; 95% CI, 0-6.1%).Conclusions: Although cocaine-associated myocardial ischemia can result from coronary vasoconstriction, patients with cocaineassociated chest pain, a non-ischemic ECG, and a TIMI risk score <2 may be safely discharged from the ED after a negative coronary CTA with a low risk of 30-day adverse events.

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Prospective Validation of the Thrombolysis in Myocardial Infarction Risk Score in the Emergency Department Chest Pain Population

Cited by 187 publications

References 29 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

Emergency physician estimates of the probability of acute coronary syndrome in a cohort of patients enrolled in a study of coronary computed tomographic angiography

Coronary computerized tomography angiography for rapid discharge of low-risk patients with cocaine-associated chest pain

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