Presented at the American College of Emergency Physicians Scientific Assembly, New Orleans, LA, October 2006.
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Emergency Physician High Pretest Probability for Acute Coronary Syndrome Correlates with Adverse Cardiovascular Outcomes
Article first published online: 28 JUL 2009
DOI: 10.1111/j.1553-2712.2009.00470.x
© 2009 by the Society for Academic Emergency Medicine
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Chandra, A., Lindsell, C. J., Limkakeng, A., Diercks, D. B., Hoekstra, J. W., Hollander, J. E., Douglas Kirk, J., Frank Peacock, W., Brian Gibler, W., Pollack, C. V. and on behalf of the EMCREG i*trACS Investigators (2009), Emergency Physician High Pretest Probability for Acute Coronary Syndrome Correlates with Adverse Cardiovascular Outcomes. Academic Emergency Medicine, 16: 740–748. doi: 10.1111/j.1553-2712.2009.00470.x
The i*trACS project was funded in part by Millennium Pharmaceuticals and Schering-Plough Pharmaceuticals.
Publication History
- Issue published online: 28 JUL 2009
- Article first published online: 28 JUL 2009
- Received January 20, 2009; revision received April 17, 2009; accepted April 20, 2009.
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Keywords:
- chest pain;
- risk stratification;
- acute coronary syndrome
Abstract
Objectives: The value of unstructured physician estimate of risk for disease processes, other than acute coronary syndrome (ACS), has been demonstrated. The authors sought to evaluate the predictive value of unstructured physician estimate of risk for ACS in emergency department (ED) patients without obvious initial evidence of a cardiac event.
Methods: This was a post hoc secondary analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospectively collected multicenter data registry of patients over the age of 18 years presenting to the ED with symptoms of ACS between 1999 and 2001. In this registry, following patient history, physical exam, and electrocardiogram (ECG), the unstructured treating physician estimate of risk was recorded. A 30-day follow-up and a medical record review were used to determine rates of adverse cardiac events, death, myocardial infarction (MI), or revascularization procedure. The analysis included all patients with nondiagnostic ECG changes, normal initial biomarkers, and a non-MI initial impression from the registry and excluded those without complete data or who were lost to follow-up. Data were stratified by unstructured physician risk estimate: noncardiac, low risk, high risk, or unstable angina.
Results: Of 15,608 unique patients in the registry, 10,145 met inclusion/exclusion criteria. Patients were defined as having unstable angina in 6.0% of cases; high risk, 23.5% of cases; low risk, 44.2%; and noncardiac, 26.3% of cases. Adverse cardiac event rates had an inverse relationship, decreasing from 22.0% (95% confidence interval [CI] = 18.8% to 25.6%) for unstable angina, 10.2% (95% CI = 9.0% to 11.5%) for those stratified as high risk, 2.2% (95% CI = 1.8% to 2.6%) for low risk, and to 1.8% (95% CI = 1.4% to 2.4%) for noncardiac. The relative risk (RR) of an adverse cardiac event for those with an initial label of unstable angina compared to those with a low-risk designation was 10.2 (95% CI = 8.0 to 13.0). The RR of an event for those with a high-risk initial impression compared to those with a low-risk initial impression was 4.7 (95% CI = 3.8 to 5.9). The risk of an event among those with a low-risk initial impression was the same as for those with a noncardiac initial impression (RR = 0.83, 95% CI = 0.6 to 1.2).
Conclusions: In ED patients without obvious initial evidence of a cardiac event, unstructured emergency physician (EP) estimate of risk correlates with adverse cardiac outcomes.