State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

Abstract

ABSTRACT:It is well established that clinicians cannot use clinical judgment alone to determine whether an individual patient who presents to the emergency department has an acute coronary syndrome. The history and physical examination do not distinguish sufficiently between the many conditions that can cause acute chest pain syndromes. Cardiac risk factors do not have sufficient discriminatory ability in symptomatic patients presenting to the emergency department. Most patients with non-ST-segment-elevation myocardial infarction do not present with electrocardiographic evidence of active ischemia. The improvement in cardiac troponin assays, especially in conjunction with well-validated clinical decision algorithms, now enables the clinician to rapidly exclude myocardial infarction. In patients in whom unstable angina remains a concern or there is a desire to evaluate for underlying coronary artery disease, coronary computed tomography angiography can be used in the emergency department. Once a process that took ≥24 hours, computed tomography angiography now can rapidly exclude myocardial infarction and coronary artery disease in patients in the emergency department.A bout 20 million patients present with symptoms possibly suggestive of acute coronary syndrome (ACS) to emergency departments (ED) in North America and Europe each year.1-3 Patients with ACS and acute myocardial infarction (AMI) present with a wide variety of symptoms such as chest pain, shortness of breath, weakness, nausea, vomiting, and even fatigue, making the diagnosis difficult. Demographics, cardiac risk factors, chest pain characteristics, and physical examination can assist disposition decisions but are insufficient to identify who does and does not have an ACS.4-7 Some patients may have objective evidence of a clearcut diagnosis, but the majority do not. 8 The majority ultimately will be found not to have ACS, but symptoms caused by noncardiac and often benign disorders such as musculoskeletal pain, pleuritis, or gastroesophageal reflux make the rapid rule-out of ACS more difficult and result in huge medical expenses. Safe and early rule-out of ACS contributes to more efficient and high-value healthcare delivery. History And PHysicAl ExAminAtionClinical features, alone or in combination with an ECG, are poorly predictive for AMI (Table 1). 9,10 In addition, they have variable reliability. Features classically associated with a lower probability of AMI such as pleuritic, positional, and sharp chest pain have poor to fair interphysician reliability (κ=0.27-0.44), 11 whereas high-risk features (radiation to left arm, substernal location, and history of AMI) are more reliable (κ=0.74-0.89). 11Traditional cardiac risk factors, derived from population-based longitudinal cohort studies of asymptomatic patients, are poor predictors of risk for AMI or ACS in symptomatic patients in the ED. 6,7 Similarly, the physical examination seldom is useful for distinguishing patients with ACS from patients with noncardiac chest pain.Trials of medications, onc...

Comparison of usual care and the HEART score for effectively and safely discharging patients with low‐risk chest pain in the emergency department: would the score always help?

“…However, the unstructured assessment used in these studies is generally a scale or an impression code of ACS probability completed based on history, symptoms, and physical examination performed by physicians. It has been shown that medical history, risk factors, symptoms, and physical examination do not have a sufficient discriminatory ability to “rule‐in” or “rule‐out” ACS in the ED . Furthermore, this kind of gestalt is mainly presented as an initial judgment after patients' arrival and does not convey the sophisticated evaluation performed after making a series of observations of various aspects before the discharge decision.…”

“…In our analysis, the incidence of MACE in patients with a low HEART score would have been much higher (5.2%) with lower sensitivity and specificity than the pooled values mentioned above. The possible reasons for these disparities may be the different definition of MACE and ACS prevalence . After all, the percent of patients suffering 30‐day MACE in our study was 28.2%, which was higher than that in most prior research …”

“…It has been shown that medical history, risk factors, symptoms, and physical examination do not have a sufficient discriminatory ability to "rule-in" or "rule-out" ACS in the ED. 32 Furthermore, this kind of gestalt is mainly presented as an initial judgment after patients' arrival and does not convey the sophisticated evaluation performed after making a series of observations of various aspects before the discharge decision. Although usual care in this study cannot be structurally described, it combined clinical manifestations with the initial ECG and cTn levels and, if necessary, with the serial ECG and cTn levels.…”

Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association

“…142–146 Although the role of CCTA in patients with uncertain ACS diagnoses is promising, no dedicated study has addressed CCTA in the setting of acute SCAD. CCTA is generally contraindicated in patients presenting with high-risk ACS and is not recommended as the first-line investigation for suspected acute SCAD.…”

Use of the HEART Pathway with high sensitivity cardiac troponins: A secondary analysis

“…Numerous studies have demonstrated that hs-cTn assays are more sensitive for the early detection and early rule out of MI than contemporary cTn assays [17–19]. For example, Neumann et al, have confirmed that hs-cTnI measured at baseline and 1 hour after presentation have a very high negative (99.0%) and positive predictive value (87.1%) for AMI; enabling rapid, safe treatment [20].…”