Identifying patients for early discharge: Performance of decision rules among patients with acute chest pain

INTERNATIONAL JOURNAL OF CARDIOLOGY

卷:168

Article

Mahler, Simon A.¹  Miller, Chadwick D.¹  Hollander, Judd E.²  Nagurney, John T.³  Birkhahn, Robert⁴  Singer, Adam J.⁵  Shapiro, Nathan I.⁶  Glynn, Ted⁷  Nowak, Richard⁸  Safdar, Basmah⁹  Peberdy, Mary¹⁰  Counselman, Francis L.¹¹  Chandra, Abhinav¹²  Kosowsky, Joshua¹³  Neuenschwander, James¹⁴  Schrock, Jon W.¹⁵  Plantholt, Stephen¹⁶  Diercks, Deborah B.¹⁷  Peacock, W. Frank¹⁸ 

[1] Wake Forest Sch Med, Winston Salem, NC 27157 USA

[2] Univ Penn, Philadelphia, PA 19104 USA

[3] Massachusetts Gen Hosp, Boston, MA 02114 USA

[4] New York Methodist Hosp, Brooklyn, NY USA

[5] SUNY Stony Brook, Stony Brook, NY 11794 USA

[6] Beth Israel Deaconess Med Ctr, Boston, MA 02215 USA

[7] Ingham Reg Med Ctr, Lansing, MI USA

[8] Henry Ford Hlth Syst, Detroit, MI USA

[9] Yale Univ, New Haven, CT USA

[10] Virginia Commonwealth Univ, Richmond, VA USA

[11] Eastern Virginia Med Sch, Norfolk, VA 23501 USA

[12] Duke Univ, Durham, NC USA

[13] Brigham & Womens Hosp, Boston, MA 02115 USA

[14] Ohio State Univ, Med Ctr, Columbus, OH 43210 USA

[15] Metro Hlth Med Ctr, Cleveland, OH USA

[16] St Agnes Hosp, Baltimore, MD USA

[17] Univ Calif Davis, Sacramento, CA 95817 USA

[18] Cleveland Clin Fdn, Cleveland, OH 44195 USA

关键词: Chest pain;    Risk stratification;    Clinical decision rules;    Acute coronary syndrome;   

DOI  :  10.1016/j.ijcard.2012.10.010

来源: Elsevier

【 摘 要 】

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. (c) 2012 Elsevier Ireland Ltd. All rights reserved.

【 授权许可】

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