The Erlanger chest pain evaluation protocol: A one-year experience with serial 12-lead ECG monitoring, two-hour delta serum marker measurements, and selective nuclear stress testing to identify and exclude acute coronary syndromes

Fesmire, Francis M.; Hughes, A.D.; Fody, Edward P.; Jackson, Alan P.; Fesmire, Connie E.; Gilbert, Mark; Stout, Paul K.; Wojcik, James F.; Wharton, David R.; Creel, James H.

doi:10.1067/mem.2002.129506

Cited by 100 publications

(66 citation statements)

References 40 publications

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“…10 The Erlanger protocol allows physicians to use objective criteria or clinical judgment to discharge or provocatively test patients at 2 hours from ED presentation but does not provide criteria to forego additional testing. 11 Few studies have attempted to derive a clinical prediction rule to identify patients who can be safely discharged without further investigations, such as provocative testing or imaging. Bassan and colleagues developed a decision rule incorporating the clinical likelihood of ACS-patients selectively received investigations to confirm or refute the presence of disease, ensuring a varying ''gold standard'' for ACS diagnosis, 12 whereas Fernandez Portales and colleagues had cardiologists enrol patients with a high clinical suspicion of ACS 13 ; hence, the resulting rule may have limited generalizability in an ED setting.…”

Section: Comparison With Other Studiesmentioning

confidence: 99%

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

Scheuermeyer

Wong

et al. 2014

CJEM

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Objectives: Current guidelines emphasize that emergency department (ED) patients at low risk for potential ischemic chest pain cannot be discharged without extensive investigations or hospitalization to minimize the risk of missing acute coronary syndrome (ACS). We sought to derive and validate a prediction rule that permitted 20 to 30% of ED patients without ACS safely to be discharged within 2 hours without further provocative cardiac testing. Methods: This prospective cohort study enrolled 1,669 chest pain patients in two blocks in 2000-2003 (development cohort) and 2006 (validation cohort). The primary outcome was 30-day ACS diagnosis. A recursive partitioning model incorporated reliable and predictive cardiac risk factors, pain characteristics, electrocardiographic findings, and cardiac biomarker results. Results: In the derivation cohort, 165 of 763 patients (21.6%) had a 30-day ACS diagnosis. The derived prediction rule was 100.0% sensitive and 18.6% specific. In the validation cohort, 119 of 906 patients (13.1%) had ACS, and the prediction rule was 99.2% sensitive (95% CI 95.4-100.0) and 23.4% specific (95% CI 20.6-26.5). Patients have a very low ACS risk if arrival and 2-hour troponin levels are normal, the initial electrocardiogram is nonischemic, there is no history of ACS or nitrate use, age is , 50 years, and defined pain characteristics are met. The validation of the rule was limited by the lack of consistency in data capture, incomplete follow-up, and lack of evaluation of the accuracy, comfort, and clinical sensibility of this clinical decision rule. Conclusion: The Vancouver Chest Pain Rule may identify a cohort of ED chest pain patients who can be safely discharged within 2 hours without provocative cardiac testing. Further validation across other centres with consistent application and comprehensive and uniform follow-up of all eligible and enrolled patients, in addition to measuring and reporting the accuracy of and comfort level with applying the rule and the clinical sensibility, should be completed prior to adoption and implementation. RÉ SUMÉObjectif: D'aprè s les lignes directrices actuelles, on ne peut renvoyer du service des urgences (SU) les patients qui souffrent de douleurs thoraciques de nature probablement isché mique mais qui connaissent un faible risque de maladie cardiaque sans d'abord leur faire subir une exploration approfondie ou sans les hospitaliser afin de ré duire le plus possible le risque de syndrome coronarien aigu (SCA) passé inaperç u. Aussi avons-nous tenté d'é laborer et de valider une rè gle pré visionnelle qui permettrait de renvoyer en toute sé curité de 20 à 30% des patients ne souffrant pas d'un SCA au cours des 2 heures suivant leur arrivé e au SU, et ce, sans leur faire subir d'autres é preuves d'exploration cardiaque. August 20, 2012) suggest over 600,000 annual ED visits. Between 2 and 5% of patients with acute coronary syndrome (ACS) may be discharged with an incorrect non-ACS diagnosis and no further follow-up, 3,4 leading to adverse patient ...

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Section: Comparison With Other Studiesmentioning

confidence: 99%

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

Scheuermeyer

Wong

et al. 2014

CJEM

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“…Although the mean age of the population studied was higher than in other studies carried out in a chest pain unit 20,22 , stress myocardial scintigraphy proved viable, safe and effective in the determination of the prognosis.…”

Section: Discussionmentioning

confidence: 61%

“…MPS has been increasingly used to diagnose ACS in the CPU, and many protocols for chest pain assessment use this method to assess the prognosis of these patients [18][19][20] . MPS has proved effective in reducing the number of undue discharges and unnecessary admissions 18,21,22 .…”

Section: Introductionmentioning

confidence: 99%

Prognóstico em médio prazo da cintilografia de perfusão miocárdica de estresse na unidade de dor torácica

Azevedo¹,

Felix²,

Corrêa³

et al. 2007

Arq. Bras. Cardiol.

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SummaryObjective: To evaluate the prognostic value of stress myocardial perfusion scintigraphy (MPS) applied to patients with suspected acute coronary syndrome (ACS).Methods: Retrospective study. Patients with suspected acute coronary syndrome (ACS) admitted into the chest pain unit angina they underwent stress MPS. Results:Conclusion: Presence of ISQ was the major independent factor in prediction of adverse events for patients admitted into the CPU.

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“…In an urban emergency room setting, serial electrocardioram, 2-hour serum marker measurements, and selective nuclear stress testing in conjunction with physician judgment identifies and excludes myocardial infarction and 30-day ACS during the initial evaluation of patients with chest pain. 18 In our study, the negative likelihood ratio for those who were assigned to the low-risk category was 0 for developing positive troponin-I, so patients in this category could possibly be discharged from the emergency department without admission to the hospital. This strategy could be especially beneficial to patients followed by family physicians who have strong patient relationships.…”

Section: Discussionmentioning

confidence: 98%

2002 ACC/AHA Guideline Versus Clinician Judgment as Diagnostic Tests for Chest Pain

Hagberg

Woitalla²,

Crawford³

2008

The Journal of the American Board of Family Medicine

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The Erlanger chest pain evaluation protocol: A one-year experience with serial 12-lead ECG monitoring, two-hour delta serum marker measurements, and selective nuclear stress testing to identify and exclude acute coronary syndromes

Cited by 100 publications

References 40 publications

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

Prognóstico em médio prazo da cintilografia de perfusão miocárdica de estresse na unidade de dor torácica

2002 ACC/AHA Guideline Versus Clinician Judgment as Diagnostic Tests for Chest Pain

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