Use of the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) To Assist with Triage of Patients with Chest Pain or Other Symptoms Suggestive of Acute Cardiac Ischemia: A Multicenter, Controlled Clinical Trial

Selker, Harry P.; Beshansky, Joni R.; Griffith, John L.; Aufderheide, Tom P.; Ballin, Daniel S.; Bernard, Sheilah; Crespo, Steven G.; Feldman, James A.; Fish, Susan S.; Gibler, W. Brian; Kiez, Debra A.; McNutt, Robert A.; Moulton, Anne W.; Ornato, Joseph P.; Podrid, Philip J.; Pope, Jennifer; Salem, Deeb N.; Sayre, Michael R.; Woolard, Robert

doi:10.7326/0003-4819-129-11_part_1-199812010-00002

Cited by 314 publications

(204 citation statements)

References 21 publications

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“…[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%

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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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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“…4,29,30 The challenge is to safely identify the subset of low-risk patients who do not require such lengthy and costly rule-out evaluations. 1,31,32 The VCP Rule shows some promise in identifying this group. However, the rule is still limited by the requirement for sampling of cardiac enzymes at 2 hours post initial evaluation, which practically means that the patient needs to be observed in the ED for a minimum of a 3-to 4-hour period.…”

Section: Discussionmentioning

confidence: 99%

Validation of the new Vancouver Chest Pain Rule in Asian chest pain patients presenting at the emergency department

Ong

Ying

Yap

et al. 2016

CJEM

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Objectives: The new Vancouver Chest Pain (VCP) Rule recommends early discharge for chest pain patients who are at low risk of developing acute coronary syndrome (ACS), and thus can be discharged within 2 hours of arrival at the emergency department (ED). This study aimed to assess the performance of the new VCP Rule for Asian patients presenting with chest pain at the ED. Methods: This prospective cohort study involved patients attended to at the ED of a large urban centre. Patients of at least 25 years old, presenting with stable chest pain and a non-diagnostic ECG, and with no history of active coronary artery disease were included in the study. The main outcome measures were cardiac events, angioplasty, or coronary artery bypass within 30 days of enrolment. Results: The study included 1690 patients from 27 August 2000 to 1 May 2002, with 661 patients fulfilling the VCP criteria. Of those for early discharge, 24 had cardiac events and 13 had angioplasty or bypass at 30 days, compared to 91 and 41, respectively, for those unsuitable for discharge. This gave the rule a sensitivity of 78.1% for cardiac events, including angioplasty and bypass. Specificity was 41.0%, and negative predictive value (NPV) was 94.4%. Conclusion: We found the new VCP Rule to have moderate sensitivity and poor specificity for adverse cardiac events in our population. With an NPV of less than 100%, this means that a small proportion of patients sent home with early discharge would still have adverse cardiac events. RÉSUMÉObjectifs: Selon la nouvelle règle de Vancouver sur la douleur thoracique, il est recommandé que les patients qui présentent des douleurs thoraciques mais qui connaissent un faible risque de syndrome coronarien aigu puissent être renvoyés peu de temps après leur arrivée au service des urgences (SU), soit dans les deux heures suivantes. L'étude visait à évaluer la performance de la nouvelle règle de Vancouver chez des patients d'origine asiatique présentant des douleurs thoraciques, au SU. Méthode: Il s'agit d'une étude de cohorte, prospective, à laquelle ont participé des patients traités dans un SU d'un important centre urbain. Ont été sélectionnés des patients âgés d'au moins 25 ans, qui présentaient une douleur thoracique stable mais chez qui l'ECG s'est révélé non concluant et qui n'avaient pas d'antécédents de coronaropathie active. Les principaux critères d'évaluation consistaient en la survenue d'événements cardiaques ou encore en la réalisation d'une angioplastie ou d'un pontage coronarien dans les 30 jours suivant l'inclusion dans l'étude. Résultats: Au total, 1690 patients ont participé à l'étude, du 27 août 2000 au 1 er mai 2002, dont 661 répondaient aux critères de la nouvelle règle de Vancouver. Parmi ceux qui ont été renvoyés peu de temps après leur arrivée, 24 ont subi un événement cardiaque et 13 autres, une angioplastie ou un pontage coronarien au bout de 30 jours contre 91 et 41 respectivement parmi ceux qui n'étaient pas en état de quitter l'hôpital. Ainsi, la sensibilité de la règle s'est étab...

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“…In practice, a small, but significant, proportion of patients is sent home inappropriately [14] leading to potentially serious clinical errors and litigation. On the other hand, many relatively low-risk patients are inappropriately admitted to telemetry and high dependency units to rule out acute cardiac ischaemia [15]. In the centres used for that study, around 2% of patients were inappropriately discharged from emergency departments, while about 30% of patients presenting with acute chest pain were admitted with possible acute coronary syndrome but ultimately had the diagnosis ruled out.…”

Section: Clinical Motivationmentioning

confidence: 99%

“…Various statistical and computer-based methods have been used to analyze clinical and ECG data from chest pain patients with a view to improving identification of high-risk patients at presentation. These methods include logistic regression [15,9] classification trees [18,19], and artificial neural networks (ANNs) [11,20]. Each of these methods has advantages and disadvantages although, suitably optimized, they can all provide accurate classification of low-and high-risk patients from data available at presentation.…”

Section: Clinical Motivationmentioning

confidence: 99%

“…The authors of [15] have described a simple logistic regression model using mainly ECG data, the Acute Cardiac Ischaemia-Time Insensitive Predictive Instrument (ACI-TIPI), to identify patients with acute cardiac ischaemia. Use of ACI-TIPI in ten U.S. hospitals, increased the rate of discharge while decreasing inappropriate admission to high-dependency beds.…”

Section: Clinical Motivationmentioning

confidence: 99%

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Automatic covariate selection in logistic models for chest pain diagnosis: A new approach

Harrison

Kennedy

2008

Computer Methods and Programs in Biomedicine

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A newly established method for optimizing logistic models via a minorizationmajorization procedure is applied to the problem of diagnosing acute coronary syndromes (ACS). The method provides a principled approach to the selection of covariates which would otherwise require the use of a suboptimal method owing to the size of the covariate set. A strategy for building models is proposed and two models optimized for performance and for simplicity are derived via ten-fold crossvalidation. These models confirm that a relatively small set of covariates including clinical and electrocardiographic features can be used successfully in this task.The performance of the models is comparable with previously published models using less principled selection methods. The models prove to be portable when tested on data gathered from three other sites. Whilst diagnostic accuracy and calibration diminishes slightly for these new settings, it remains satisfactory overall.The prospect of building predictive models that are as simple as possible for a required level of performance is valuable if data-driven decision aids are to gain wide acceptance in the clinical situation owing to the need to minimize the time taken to gather and enter data at the bedside.

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Use of the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) To Assist with Triage of Patients with Chest Pain or Other Symptoms Suggestive of Acute Cardiac Ischemia: A Multicenter, Controlled Clinical Trial

Cited by 314 publications

References 21 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

Validation of the new Vancouver Chest Pain Rule in Asian chest pain patients presenting at the emergency department

Automatic covariate selection in logistic models for chest pain diagnosis: A new approach

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