Identifying patients for early discharge

Performance of decision rules among patients with acute chest pain

Simon A. Mahler, Chadwick D. Miller, Judd E. Hollander, John T. Nagurney, Robert Birkhahn, Adam J. Singer, Nathan I. Shapiro, Ted Glynn, Richard Nowak, Basmah Safdar, Mary Peberdy, Francis L. Counselman, Abhinav Chandra, Joshua Kosowsky, James Neuenschwander, Jon W. Schrock, Stephen Plantholt, Deborah B. Diercks, W. Frank Peacock

Research output: Contribution to journalArticle

69 Citations (Scopus)

Abstract

Background: The HEART score and North American Chest Pain Rule (NACPR) are decision rules designed to identify acute chest pain patients for early discharge without stress testing or cardiac imaging. This study compares the clinical utility of these decision rules combined with serial troponin determinations. Methods and results: A secondary analysis was conducted of 1005 participants in the Myeloperoxidase In the Diagnosis of Acute coronary syndromes Study (MIDAS). MIDAS is a prospective observational cohort of Emergency Department (ED) patients enrolled from 18 US sites with symptoms suggestive of acute coronary syndrome (ACS). The ability to identify participants for early discharge and the sensitivity for ACS at 30 days were compared among an unstructured assessment, NACPR, and HEART score, each combined with troponin measures at 0 and 3 h. ACS, defined as cardiac death, acute myocardial infarction, or unstable angina, occurred in 22% of the cohort. The unstructured assessment identified 13.5% (95% CI 11.5-16%) of participants for early discharge with 98% (95% CI 95-99%) sensitivity for ACS. The NACPR identified 4.4% (95% CI 3-6%) for early discharge with 100% (95% CI 98-100%) sensitivity for ACS. The HEART score identified 20% (95% CI 18-23%) for early discharge with 99% (95% CI 97-100%) sensitivity for ACS. The HEART score had a net reclassification improvement of 10% (95% CI 8-12%) versus unstructured assessment and 19% (95% CI 17-21%) versus NACPR. Conclusions: The HEART score with 0 and 3 hour serial troponin measures identifies a substantial number of patients for early discharge while maintaining high sensitivity for ACS.

Original languageEnglish (US)
Pages (from-to)795-802
Number of pages8
JournalInternational Journal of Cardiology
Volume168
Issue number2
DOIs
StatePublished - Sep 30 2013

Fingerprint

Patient Discharge
Acute Pain
Acute Coronary Syndrome
Chest Pain
Troponin
Peroxidase
Unstable Angina
Hospital Emergency Service
Myocardial Infarction

Keywords

  • Acute coronary syndrome
  • Chest pain
  • Clinical decision rules
  • Risk stratification

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Mahler, S. A., Miller, C. D., Hollander, J. E., Nagurney, J. T., Birkhahn, R., Singer, A. J., ... Peacock, W. F. (2013). Identifying patients for early discharge: Performance of decision rules among patients with acute chest pain. International Journal of Cardiology, 168(2), 795-802. https://doi.org/10.1016/j.ijcard.2012.10.010

Identifying patients for early discharge : Performance of decision rules among patients with acute chest pain. / Mahler, Simon A.; Miller, Chadwick D.; Hollander, Judd E.; Nagurney, John T.; Birkhahn, Robert; Singer, Adam J.; Shapiro, Nathan I.; Glynn, Ted; Nowak, Richard; Safdar, Basmah; Peberdy, Mary; Counselman, Francis L.; Chandra, Abhinav; Kosowsky, Joshua; Neuenschwander, James; Schrock, Jon W.; Plantholt, Stephen; Diercks, Deborah B.; Peacock, W. Frank.

In: International Journal of Cardiology, Vol. 168, No. 2, 30.09.2013, p. 795-802.

Research output: Contribution to journalArticle

Mahler, SA, Miller, CD, Hollander, JE, Nagurney, JT, Birkhahn, R, Singer, AJ, Shapiro, NI, Glynn, T, Nowak, R, Safdar, B, Peberdy, M, Counselman, FL, Chandra, A, Kosowsky, J, Neuenschwander, J, Schrock, JW, Plantholt, S, Diercks, DB & Peacock, WF 2013, 'Identifying patients for early discharge: Performance of decision rules among patients with acute chest pain', International Journal of Cardiology, vol. 168, no. 2, pp. 795-802. https://doi.org/10.1016/j.ijcard.2012.10.010
Mahler, Simon A. ; Miller, Chadwick D. ; Hollander, Judd E. ; Nagurney, John T. ; Birkhahn, Robert ; Singer, Adam J. ; Shapiro, Nathan I. ; Glynn, Ted ; Nowak, Richard ; Safdar, Basmah ; Peberdy, Mary ; Counselman, Francis L. ; Chandra, Abhinav ; Kosowsky, Joshua ; Neuenschwander, James ; Schrock, Jon W. ; Plantholt, Stephen ; Diercks, Deborah B. ; Peacock, W. Frank. / Identifying patients for early discharge : Performance of decision rules among patients with acute chest pain. In: International Journal of Cardiology. 2013 ; Vol. 168, No. 2. pp. 795-802.
@article{11dda927480c424e93e589c095fa9ce4,
title = "Identifying patients for early discharge: Performance of decision rules among patients with acute chest pain",
abstract = "Background: The HEART score and North American Chest Pain Rule (NACPR) are decision rules designed to identify acute chest pain patients for early discharge without stress testing or cardiac imaging. This study compares the clinical utility of these decision rules combined with serial troponin determinations. Methods and results: A secondary analysis was conducted of 1005 participants in the Myeloperoxidase In the Diagnosis of Acute coronary syndromes Study (MIDAS). MIDAS is a prospective observational cohort of Emergency Department (ED) patients enrolled from 18 US sites with symptoms suggestive of acute coronary syndrome (ACS). The ability to identify participants for early discharge and the sensitivity for ACS at 30 days were compared among an unstructured assessment, NACPR, and HEART score, each combined with troponin measures at 0 and 3 h. ACS, defined as cardiac death, acute myocardial infarction, or unstable angina, occurred in 22{\%} of the cohort. The unstructured assessment identified 13.5{\%} (95{\%} CI 11.5-16{\%}) of participants for early discharge with 98{\%} (95{\%} CI 95-99{\%}) sensitivity for ACS. The NACPR identified 4.4{\%} (95{\%} CI 3-6{\%}) for early discharge with 100{\%} (95{\%} CI 98-100{\%}) sensitivity for ACS. The HEART score identified 20{\%} (95{\%} CI 18-23{\%}) for early discharge with 99{\%} (95{\%} CI 97-100{\%}) sensitivity for ACS. The HEART score had a net reclassification improvement of 10{\%} (95{\%} CI 8-12{\%}) versus unstructured assessment and 19{\%} (95{\%} CI 17-21{\%}) versus NACPR. Conclusions: The HEART score with 0 and 3 hour serial troponin measures identifies a substantial number of patients for early discharge while maintaining high sensitivity for ACS.",
keywords = "Acute coronary syndrome, Chest pain, Clinical decision rules, Risk stratification",
author = "Mahler, {Simon A.} and Miller, {Chadwick D.} and Hollander, {Judd E.} and Nagurney, {John T.} and Robert Birkhahn and Singer, {Adam J.} and Shapiro, {Nathan I.} and Ted Glynn and Richard Nowak and Basmah Safdar and Mary Peberdy and Counselman, {Francis L.} and Abhinav Chandra and Joshua Kosowsky and James Neuenschwander and Schrock, {Jon W.} and Stephen Plantholt and Diercks, {Deborah B.} and Peacock, {W. Frank}",
year = "2013",
month = "9",
day = "30",
doi = "10.1016/j.ijcard.2012.10.010",
language = "English (US)",
volume = "168",
pages = "795--802",
journal = "International Journal of Cardiology",
issn = "0167-5273",
publisher = "Elsevier Ireland Ltd",
number = "2",

}

TY - JOUR

T1 - Identifying patients for early discharge

T2 - Performance of decision rules among patients with acute chest pain

AU - Mahler, Simon A.

AU - Miller, Chadwick D.

AU - Hollander, Judd E.

AU - Nagurney, John T.

AU - Birkhahn, Robert

AU - Singer, Adam J.

AU - Shapiro, Nathan I.

AU - Glynn, Ted

AU - Nowak, Richard

AU - Safdar, Basmah

AU - Peberdy, Mary

AU - Counselman, Francis L.

AU - Chandra, Abhinav

AU - Kosowsky, Joshua

AU - Neuenschwander, James

AU - Schrock, Jon W.

AU - Plantholt, Stephen

AU - Diercks, Deborah B.

AU - Peacock, W. Frank

PY - 2013/9/30

Y1 - 2013/9/30

N2 - Background: The HEART score and North American Chest Pain Rule (NACPR) are decision rules designed to identify acute chest pain patients for early discharge without stress testing or cardiac imaging. This study compares the clinical utility of these decision rules combined with serial troponin determinations. Methods and results: A secondary analysis was conducted of 1005 participants in the Myeloperoxidase In the Diagnosis of Acute coronary syndromes Study (MIDAS). MIDAS is a prospective observational cohort of Emergency Department (ED) patients enrolled from 18 US sites with symptoms suggestive of acute coronary syndrome (ACS). The ability to identify participants for early discharge and the sensitivity for ACS at 30 days were compared among an unstructured assessment, NACPR, and HEART score, each combined with troponin measures at 0 and 3 h. ACS, defined as cardiac death, acute myocardial infarction, or unstable angina, occurred in 22% of the cohort. The unstructured assessment identified 13.5% (95% CI 11.5-16%) of participants for early discharge with 98% (95% CI 95-99%) sensitivity for ACS. The NACPR identified 4.4% (95% CI 3-6%) for early discharge with 100% (95% CI 98-100%) sensitivity for ACS. The HEART score identified 20% (95% CI 18-23%) for early discharge with 99% (95% CI 97-100%) sensitivity for ACS. The HEART score had a net reclassification improvement of 10% (95% CI 8-12%) versus unstructured assessment and 19% (95% CI 17-21%) versus NACPR. Conclusions: The HEART score with 0 and 3 hour serial troponin measures identifies a substantial number of patients for early discharge while maintaining high sensitivity for ACS.

AB - Background: The HEART score and North American Chest Pain Rule (NACPR) are decision rules designed to identify acute chest pain patients for early discharge without stress testing or cardiac imaging. This study compares the clinical utility of these decision rules combined with serial troponin determinations. Methods and results: A secondary analysis was conducted of 1005 participants in the Myeloperoxidase In the Diagnosis of Acute coronary syndromes Study (MIDAS). MIDAS is a prospective observational cohort of Emergency Department (ED) patients enrolled from 18 US sites with symptoms suggestive of acute coronary syndrome (ACS). The ability to identify participants for early discharge and the sensitivity for ACS at 30 days were compared among an unstructured assessment, NACPR, and HEART score, each combined with troponin measures at 0 and 3 h. ACS, defined as cardiac death, acute myocardial infarction, or unstable angina, occurred in 22% of the cohort. The unstructured assessment identified 13.5% (95% CI 11.5-16%) of participants for early discharge with 98% (95% CI 95-99%) sensitivity for ACS. The NACPR identified 4.4% (95% CI 3-6%) for early discharge with 100% (95% CI 98-100%) sensitivity for ACS. The HEART score identified 20% (95% CI 18-23%) for early discharge with 99% (95% CI 97-100%) sensitivity for ACS. The HEART score had a net reclassification improvement of 10% (95% CI 8-12%) versus unstructured assessment and 19% (95% CI 17-21%) versus NACPR. Conclusions: The HEART score with 0 and 3 hour serial troponin measures identifies a substantial number of patients for early discharge while maintaining high sensitivity for ACS.

KW - Acute coronary syndrome

KW - Chest pain

KW - Clinical decision rules

KW - Risk stratification

UR - http://www.scopus.com/inward/record.url?scp=84885312506&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84885312506&partnerID=8YFLogxK

U2 - 10.1016/j.ijcard.2012.10.010

DO - 10.1016/j.ijcard.2012.10.010

M3 - Article

VL - 168

SP - 795

EP - 802

JO - International Journal of Cardiology

JF - International Journal of Cardiology

SN - 0167-5273

IS - 2

ER -