Emergency physician high pretest probability for acute coronary syndrome correlates with adverse cardiovascular outcomes

Abhinav Chandra, Christopher J. Lindsell, Alexander Limkakeng, Deborah B. Diercks, James W. Hoekstra, Judd E. Hollander, J. Douglas Kirk, W. Frank Peacock, W. Brian Gibler, Charles V. Pollack

Research output: Contribution to journalArticle

20 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)740-748
Number of pages9
JournalAcademic Emergency Medicine
Volume16
Issue number8
DOIs
StatePublished - Aug 2009

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Acute Coronary Syndrome
Emergencies
Physicians
Confidence Intervals
Unstable Angina
Registries
Hospital Emergency Service
Electrocardiography
Myocardial Revascularization
Lost to Follow-Up

Keywords

  • Acute coronary syndrome
  • Chest pain
  • Risk stratification

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Emergency physician high pretest probability for acute coronary syndrome correlates with adverse cardiovascular outcomes. / Chandra, Abhinav; Lindsell, Christopher J.; Limkakeng, Alexander; Diercks, Deborah B.; Hoekstra, James W.; Hollander, Judd E.; Kirk, J. Douglas; Peacock, W. Frank; Gibler, W. Brian; Pollack, Charles V.

In: Academic Emergency Medicine, Vol. 16, No. 8, 08.2009, p. 740-748.

Research output: Contribution to journalArticle

Chandra, A, Lindsell, CJ, Limkakeng, A, Diercks, DB, Hoekstra, JW, Hollander, JE, Kirk, JD, Peacock, WF, Gibler, WB & Pollack, CV 2009, 'Emergency physician high pretest probability for acute coronary syndrome correlates with adverse cardiovascular outcomes', Academic Emergency Medicine, vol. 16, no. 8, pp. 740-748. https://doi.org/10.1111/j.1553-2712.2009.00470.x
Chandra, Abhinav ; Lindsell, Christopher J. ; Limkakeng, Alexander ; Diercks, Deborah B. ; Hoekstra, James W. ; Hollander, Judd E. ; Kirk, J. Douglas ; Peacock, W. Frank ; Gibler, W. Brian ; Pollack, Charles V. / Emergency physician high pretest probability for acute coronary syndrome correlates with adverse cardiovascular outcomes. In: Academic Emergency Medicine. 2009 ; Vol. 16, No. 8. pp. 740-748.
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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.",
keywords = "Acute coronary syndrome, Chest pain, Risk stratification",
author = "Abhinav Chandra and Lindsell, {Christopher J.} and Alexander Limkakeng and Diercks, {Deborah B.} and Hoekstra, {James W.} and Hollander, {Judd E.} and Kirk, {J. Douglas} and Peacock, {W. Frank} and Gibler, {W. Brian} and Pollack, {Charles V.}",
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T1 - Emergency physician high pretest probability for acute coronary syndrome correlates with adverse cardiovascular outcomes

AU - Chandra, Abhinav

AU - Lindsell, Christopher J.

AU - Limkakeng, Alexander

AU - Diercks, Deborah B.

AU - Hoekstra, James W.

AU - Hollander, Judd E.

AU - Kirk, J. Douglas

AU - Peacock, W. Frank

AU - Gibler, W. Brian

AU - Pollack, Charles V.

PY - 2009/8

Y1 - 2009/8

N2 - 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.

AB - 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.

KW - Acute coronary syndrome

KW - Chest pain

KW - Risk stratification

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