Highly Sensitive ED Protocol for Identifying Low-Risk Patients with Chest Pain
Implementation of a new accelerated diagnostic protocol could reduce emergency department length of stay and hospitalization rate.
Protocols to facilitate safe early discharge from the emergency department (ED) for low-risk patients with chest pain have limitations, including lack of validation and variable sensitivity. The prospective, observational, multinational Asia-Pacific Evaluation of Chest Pain Trial assessed a new, accelerated diagnostic protocol in consecutive adult ED patients who had at least 5 minutes of chest, neck, jaw, or arm pain or discomfort without obvious noncardiac cause and who did not have ST-segment-elevation myocardial infarction (STEMI).
The protocol included Thrombolysis In Myocardial Infarction (TIMI) score, electrocardiogram (ECG), and point-of-care biomarker testing (within 2 hours after arrival) for troponin I, creatine kinase MB, and myoglobin. Patients with TIMI scores of 0, no new ischemic changes on initial ECG, and normal biomarker panels were classified as low risk.
Among 3582 patients who completed 30-day follow-up, 421 (11.8%) had major adverse cardiac events within 30 days, most often non-STEMI (10.1%). Of 352 patients (9.8%) who were classified as low risk, 3 (0.9%) had major adverse cardiac events. The protocol had a sensitivity of 99.3% for identifying low-risk patients, a specificity of 11.0%, and a negative predictive value (NPV) of 99.1%. Had TIMI score not been included, NPV would have been 96.7%, and an additional 44 patients with major adverse cardiac events would have been missed.
Comment:
This study demonstrates that the combination of no new ischemic changes on initial ECG, normal point-of-care biomarker panel within 2 hours, and low pretest probability (TIMI score of 0) identifies patients who can safely be discharged from the ED. However, several issues about use of the protocol remain to be addressed, including performance relative to other protocols, whether use of laboratory biomarker testing improves accuracy, effect on patient care costs and hospital stay, and malpractice risk.
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John A. Marx, MD, FAAEMPublished in Journal Watch Emergency Medicine March 25, 2011
Citation(s): Than M et al. A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): A prospective observational validation study. Lancet 2011 Mar 26; 377:107.
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Background
Patients with chest pain contribute substantially to emergency department attendances, lengthy hospital stay, and inpatient admissions. A reliable, reproducible, and fast process to identify patients presenting with chest pain who have a low short-term risk of a major adverse cardiac event is needed to facilitate early discharge. We aimed to prospectively validate the safety of a predefined 2-h accelerated diagnostic protocol (ADP) to assess patients presenting to the emergency department with chest pain symptoms suggestive of acute coronary syndrome.
Methods
This observational study was undertaken in 14 emergency departments in nine countries in the Asia-Pacific region, in patients aged 18 years and older with at least 5 min of chest pain. The ADP included use of a structured pre-test probability scoring method (Thrombolysis in Myocardial Infarction [TIMI] score), electrocardiograph, and point-of-care biomarker panel of troponin, creatine kinase MB, and myoglobin. The primary endpoint was major adverse cardiac events within 30 days after initial presentation (including initial hospital attendance). This trial is registered with the Australia-New Zealand Clinical Trials Registry, number ACTRN12609000283279.
Findings
3582 consecutive patients were recruited and completed 30-day follow-up. 421 (11·8%) patients had a major adverse cardiac event. The ADP classified 352 (9·8%) patients as low risk and potentially suitable for early discharge. A major adverse cardiac event occurred in three (0·9%) of these patients, giving the ADP a sensitivity of 99·3% (95% CI 97·9—99·8), a negative predictive value of 99·1% (97·3—99·8), and a specificity of 11·0% (10·0—12·2).
Interpretation
This novel ADP identifies patients at very low risk of a short-term major adverse cardiac event who might be suitable for early discharge. Such an approach could be used to decrease the overall observation periods and admissions for chest pain. The components needed for the implementation of this strategy are widely available. The ADP has the potential to affect health-service delivery worldwide.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60310-3/abstract
2011年3月25日 星期五
2011年3月12日 星期六
斷層掃描會延誤剖腹手術的時機嗎？
Abdominal Computed Tomography in Hypotensive Trauma Patients Delays Laparotomy and Increases Mortality
Authors urge caution in using this diagnostic tool for patients with blunt or penetrating trauma.
Computed tomography (CT) of the abdomen is being used increasingly in trauma patients, and, although it is highly accurate, its use in certain patients might delay definitive care, specifically laparotomy. To determine the risk that performing abdominal CT will delay laparotomy, researchers reviewed data from the National Trauma Data Bank from 2002 through 2006. Patients (age, above 14 years) with systolic blood pressure below 90 mm Hg on emergency department (ED) arrival and abdominal Abbreviated Injury Scale (AIS) score above 3 who underwent laparotomy within 90 minutes of ED arrival were included in the analysis. Patients transferred from other hospitals and those with significant brain injury (head AIS score above 3) were excluded.
Among 3218 patients, the median Injury Severity Score was 25, and the overall mortality rate was 32%; 446 patients (14%) underwent abdominal CT before laparotomy. The mortality rate was significantly higher in patients who underwent abdominal CT prior to laparotomy than in those who did not (44.8% vs. 29.5%). In logistic regression analysis, abdominal CT was independently associated with risk for death (odds ratio, 1.71), especially among patients who underwent laparotomy within 30 minutes after ED arrival (OR, 7.6).
Comment:
The authors did not assess the influence of ultrasound, diagnostic peritoneal lavage, or presence of pelvic fracture on surgical decision making. However, these findings reinforce that abdominal CT generally is not indicated for hypotensive patients with penetrating trauma or hypotensive patients with blunt trauma and a positive ultrasound or peritoneal lavage result and no pelvic fracture.
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John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine March 11, 2011
Citation(s): Neal MD et al. Over reliance on computed tomography imaging in patients with severe abdominal injury: Is the delay worth the risk? J Trauma 2011 Feb; 70:278.
Authors urge caution in using this diagnostic tool for patients with blunt or penetrating trauma.
Computed tomography (CT) of the abdomen is being used increasingly in trauma patients, and, although it is highly accurate, its use in certain patients might delay definitive care, specifically laparotomy. To determine the risk that performing abdominal CT will delay laparotomy, researchers reviewed data from the National Trauma Data Bank from 2002 through 2006. Patients (age, above 14 years) with systolic blood pressure below 90 mm Hg on emergency department (ED) arrival and abdominal Abbreviated Injury Scale (AIS) score above 3 who underwent laparotomy within 90 minutes of ED arrival were included in the analysis. Patients transferred from other hospitals and those with significant brain injury (head AIS score above 3) were excluded.
Among 3218 patients, the median Injury Severity Score was 25, and the overall mortality rate was 32%; 446 patients (14%) underwent abdominal CT before laparotomy. The mortality rate was significantly higher in patients who underwent abdominal CT prior to laparotomy than in those who did not (44.8% vs. 29.5%). In logistic regression analysis, abdominal CT was independently associated with risk for death (odds ratio, 1.71), especially among patients who underwent laparotomy within 30 minutes after ED arrival (OR, 7.6).
Comment:
The authors did not assess the influence of ultrasound, diagnostic peritoneal lavage, or presence of pelvic fracture on surgical decision making. However, these findings reinforce that abdominal CT generally is not indicated for hypotensive patients with penetrating trauma or hypotensive patients with blunt trauma and a positive ultrasound or peritoneal lavage result and no pelvic fracture.
—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine March 11, 2011
Citation(s): Neal MD et al. Over reliance on computed tomography imaging in patients with severe abdominal injury: Is the delay worth the risk? J Trauma 2011 Feb; 70:278.
2011年3月5日 星期六
20歲以下非心因性OHCA，要壓胸也要吹氣
Compression-Only CPR Is Less Effective Than Conventional CPR in Some Patients
Among patients with out-of-hospital cardiac arrest in Japan, compression-only cardiopulmonary resuscitation was less effective than conventional CPR in patients younger than 20 with noncardiac causes of arrest.
Findings of several large studies led to guideline revisions recommending that untrained bystanders perform compression-only cardiopulmonary resuscitation (CPR) for adults with out-of-hospital cardiac arrest. Researchers in Japan analyzed a nationwide emergency medical services database to compare outcomes between patients with bystander-witnessed out-of-hospital cardiac arrest who received conventional CPR (19,328 patients) and those who received chest compression-only CPR (27,707 patients) during a 3-year period.
Rates of both overall 1-month survival and neurologically favorable 1-month survival were significantly higher in patients who received conventional CPR (adjusted odds ratio, 1.17 in each case). In analysis by age and cause of arrest, the benefit of conventional CPR was limited to patients younger than 20 with noncardiac causes. In analysis by time from arrest to start of CPR and cause of arrest, the benefit of conventional CPR over compression-only CPR increased with time to CPR among patients with noncardiac causes and among patients with all causes combined, but not among those with cardiac causes.
Comment:
This large study confirms that conventional CPR is the preferred technique for children, who have a higher proportion of noncardiac causes of arrest than adults. For adults, evidence supports compression-only CPR by bystanders. Outcomes in adults likely would be better with compression-only CPR by trained providers, too, but this is not yet proven; so guidelines continue to recommend conventional CPR by trained healthcare providers.
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Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine March 4, 2011
Citation(s):
Ogawa T et al. Outcomes of chest compression only CPR versus conventional CPR conducted by lay people in patients with out of hospital cardiopulmonary arrest witnessed by bystanders: Nationwide population based observational study. BMJ 2011 Jan 27; 342:c7106. (http://dx.doi.org/10.1136/bmj.c7106)
Among patients with out-of-hospital cardiac arrest in Japan, compression-only cardiopulmonary resuscitation was less effective than conventional CPR in patients younger than 20 with noncardiac causes of arrest.
Findings of several large studies led to guideline revisions recommending that untrained bystanders perform compression-only cardiopulmonary resuscitation (CPR) for adults with out-of-hospital cardiac arrest. Researchers in Japan analyzed a nationwide emergency medical services database to compare outcomes between patients with bystander-witnessed out-of-hospital cardiac arrest who received conventional CPR (19,328 patients) and those who received chest compression-only CPR (27,707 patients) during a 3-year period.
Rates of both overall 1-month survival and neurologically favorable 1-month survival were significantly higher in patients who received conventional CPR (adjusted odds ratio, 1.17 in each case). In analysis by age and cause of arrest, the benefit of conventional CPR was limited to patients younger than 20 with noncardiac causes. In analysis by time from arrest to start of CPR and cause of arrest, the benefit of conventional CPR over compression-only CPR increased with time to CPR among patients with noncardiac causes and among patients with all causes combined, but not among those with cardiac causes.
Comment:
This large study confirms that conventional CPR is the preferred technique for children, who have a higher proportion of noncardiac causes of arrest than adults. For adults, evidence supports compression-only CPR by bystanders. Outcomes in adults likely would be better with compression-only CPR by trained providers, too, but this is not yet proven; so guidelines continue to recommend conventional CPR by trained healthcare providers.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine March 4, 2011
Citation(s):
Ogawa T et al. Outcomes of chest compression only CPR versus conventional CPR conducted by lay people in patients with out of hospital cardiopulmonary arrest witnessed by bystanders: Nationwide population based observational study. BMJ 2011 Jan 27; 342:c7106. (http://dx.doi.org/10.1136/bmj.c7106)
2011年3月4日 星期五
抽血發現的甲狀腺功能低下〔TSH高〕，要不要治療？
Raised TSH: to treat or not to treat?
Do you treat people with subclinical hypothyroidism?
You are supposed to, according to current guidelines.
The rationale for treating when serum thyroid stimulating hormone (TSH) is above 10 mIU/l is to alleviate mild symptoms, prevent progression to overt hypothyroidism, and lower cardiovascular risk.
Modest TSH elevations (below 7.0 mIU/l) may not warrant treatment. Large scale randomised clinical trials are needed to determine the effects of L-thyroxine treatment on coronary heart disease and related mortality in people who have subclinical hypothyroidism.
The current position seems to be that TSH levels above 10 mIU/l warrant treatment, levels of 7-10 mIU/l warrant consideration, while with levels below 7 mIU/l it may be justifiable to wait and see.
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Source: Evidence-Based Medicine 2011;16:31-32
Do you treat people with subclinical hypothyroidism?
You are supposed to, according to current guidelines.
The rationale for treating when serum thyroid stimulating hormone (TSH) is above 10 mIU/l is to alleviate mild symptoms, prevent progression to overt hypothyroidism, and lower cardiovascular risk.
Modest TSH elevations (below 7.0 mIU/l) may not warrant treatment. Large scale randomised clinical trials are needed to determine the effects of L-thyroxine treatment on coronary heart disease and related mortality in people who have subclinical hypothyroidism.
The current position seems to be that TSH levels above 10 mIU/l warrant treatment, levels of 7-10 mIU/l warrant consideration, while with levels below 7 mIU/l it may be justifiable to wait and see.
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Source: Evidence-Based Medicine 2011;16:31-32
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