INTRODUCTION: The majority of patients who present to the Emergency Department (ED) with chest pain, do not have Acute Coronary Syndrome (ACS). Rapid, safe discharge home for this large group is hampered by clinical uncertainty. A pragmatic Accelerated Diagnostic Pathway (ADP) used in our ED achieves this goal. AiIM: To demonstrate the safety and utility of a locally developed ADP. The primary outcome for patients who were identified as non-high risk by our ADP was death or acute myocardial infarction (AMI) at 30 days. Secondary outcomes were ED length of stay, discharge rates, provocative testing and revascularisation rates. METHOD: This is a prospective observational convenience cohort study of chest pain patients presenting to a regional ED excluding ST-elevation myocardial infarction (STEMI). Using a locally derived ADP, patients were classified as high risk or non-high risk for 30-day death or AMI. Patients could be classified as high risk on the basis of ECG change, troponin elevation, or senior clinician "gestalt" irrespective of negative serial ECGs and troponins. All others were classified non-high risk and were followed up at 30 days. RESULTS: There were 452 patient events with the ADP identifying 75% as non-high-risk (93% of these patients were actually discharged). All patients were successfully followed up for 30-day outcomes. The sensitivity and negative predictive value of the ADP was 100% (95% CI: 99-100%). Specificity was 83% (95% CI: 79-87%). The average ED length of stay was 4 hours 5 minutes. There were low rates of revascularisation (1.5%) and provocative testing (6.2%) in the non-high risk group. CONCLUSION: This ED ADP for chest pain rapidly and safely identified patients who were not at high risk of a short-term AMI or death.
INTRODUCTION: The majority of patients who present to the Emergency Department (ED) with chest pain, do not have Acute Coronary Syndrome (ACS). Rapid, safe discharge home for this large group is hampered by clinical uncertainty. A pragmatic Accelerated Diagnostic Pathway (ADP) used in our ED achieves this goal. AiIM: To demonstrate the safety and utility of a locally developed ADP. The primary outcome for patients who were identified as non-high risk by our ADP was death or acute myocardial infarction (AMI) at 30 days. Secondary outcomes were ED length of stay, discharge rates, provocative testing and revascularisation rates. METHOD: This is a prospective observational convenience cohort study of chest painpatients presenting to a regional ED excluding ST-elevation myocardial infarction (STEMI). Using a locally derived ADP, patients were classified as high risk or non-high risk for 30-day death or AMI. Patients could be classified as high risk on the basis of ECG change, troponin elevation, or senior clinician "gestalt" irrespective of negative serial ECGs and troponins. All others were classified non-high risk and were followed up at 30 days. RESULTS: There were 452 patient events with the ADP identifying 75% as non-high-risk (93% of these patients were actually discharged). All patients were successfully followed up for 30-day outcomes. The sensitivity and negative predictive value of the ADP was 100% (95% CI: 99-100%). Specificity was 83% (95% CI: 79-87%). The average ED length of stay was 4 hours 5 minutes. There were low rates of revascularisation (1.5%) and provocative testing (6.2%) in the non-high risk group. CONCLUSION: This ED ADP for chest pain rapidly and safely identified patients who were not at high risk of a short-term AMI or death.
Authors: Andrea Fabbri; Cristina Bachetti; Filippo Ottani; Alice Morelli; Barbara Benazzi; Sergio Spiezia; Marco Cortigiani; Romolo Dorizzi; Allan S Jaffe; Marcello Galvani Journal: Intern Emerg Med Date: 2018-11-29 Impact factor: 3.397