- Email: [email protected]
38 Exercise Treadmill Is an Appropriate Risk Stratification Tool in Low Risk Chest Pain Patients
Research Forum Abstracts
36
Concomitant Measurement of Copeptin and High Sensitivity Troponin for Fast and Reliable Rule Out of Acute Myocardial Infarction
Freund Y, Chenevier-Gobeaux C, Leumani F, Doumenc B, Claessens Y, Cosson C, Riou B, Ray P/Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Hopital Cochin, Paris, France; Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Hopital Bicêtre, Paris, France
Introduction: Newer assays (high sensitive troponin, HsTnT) and biomarkers (copeptin) recently improved the management of chest pain in the emergency department. Their combination could allow a rapid rule out with an almost perfect negative predictive value (NPV). Study Objectives: To assess the benefit of the association of HsTnT and copeptin for rule out of myocardial infarction. Methods: In consecutive patients presenting into 3 emergency departments with chest pain suggestive of acute myocardial infarction, levels of HsTnT and copeptin were measured at presentation, blinded to the emergency physicians. The medical management of patients was left to the discretion of the attending physicians according to the suspected diagnosis, and result of conventional Troponin I (cTn I). The discharge diagnosis was adjudicated by 2 independent experts using all available data. Results: 317 patients (mean age of 57 ⫾ 17 years) were included. acute myocardial infarction was confirmed in 45 patients (14%), 13 of them were STEMI, and 32 NSTEMI. A copeptin level ⬍ 10.7 pmol/l in combination with a HsTnT ⬍ 0.014 g/l correctly ruled out acute myocardial infarction with a higher sensitivity than cTnI : 1 (95% confidence interval: [0.90-1]) vs. 0.71 [0.55-0.84], p⬍0.001. We observed as well a significant gain in NPV: 1 [0.96-1] for copeptin ⫹ HsTnT vs. 0.95 [0.92-0.97] for cTnI alone (p⫽0.03). Comparison of area under the receiver operating characteristic curves did not showed any difference, with an AUC of 0.92 [0.88-0.94] for copeptin⫹HsTnT vs. 0.94 [091-0.96] for cTnI (p⫽0.3). Conclusion: Copeptin in association with HsTnT is a fast and reliable tool for rule out acute myocardial infarction, with a sensitivity and a NPV of 100% in our sample. Larger studies are warranted to confirm these findings.
37
Variability of Emergency Physicians’ Utilization of Chest Pain Units for “Very Low Risk” Chest Pain Patients
Mahler SA, Goff DC, Hoekstra JW, Miller CD/Wake Forest School of Medicine, Winston Salem, NC
Study Objectives: To quantify the variability in emergency physicians’ utilization of a chest pain unit (CPU) for patients with very low pre-test probability for acute coronary syndrome. Methods: Emergency department (ED) patients at the study institution undergoing evaluation for low risk chest pain based on clinical impression and a TIMI risk score ⬍2 are captured in a data registry. Registry participants from 1/2008 to 4/2010 were included in this analysis. Patients were further stratified as very low risk or low risk. Very low risk was defined as age less than 35 and TIMI risk score of
S190 Annals of Emergency Medicine
zero. Each encounter in the registry was associated with a board certified attending emergency physician allowing calculation of physicians’ CPU utilization rates. For providers with at least 10 CPU admissions, the proportions of admissions qualifying as very low risk were calculated. Physicians were grouped into quartiles based on the proportion of CPU admissions that were very low risk. Chi-squared analysis was used to determine if a significant difference existed between overall CPU utilization rate, for very low risk patients, compared to the highest quartile and lowest quartile physicians. Results: Over 28 months, the registry included 1070 chest pain patients. Of these patients, 11% (95% CI 9-13%) met the study definition of very low risk. There were 26 ED providers included in the analysis. Variability in utilization rates for very low risk patients among ED providers was wide; ranging from 0-23.5%. Among the highest quartile of providers 19% (95%CI 14.5-25%) of CPU admissions were very low risk patients, while in the lowest quartile less than 3% (95%CI 1-7%) of patients admitted to the CPU were very low risk. Utilization rates among the highest and lowest quartile providers significantly differed from the overall utilization rates, p⬍0.001. Serial cardiac markers were obtained on all 114 very low risk patients and 95% (108/114) received objective cardiac testing; none experienced death, myocardial infarction, or coronary revascularization during the index visit. Conclusion: There is significant variability among emergency physicians’ CPU utilization rates for patients with a very low pre-test probability of acute coronary syndrome. These differences could represent an opportunity to improve the efficiency of healthcare delivery.
38
Exercise Treadmill Is an Appropriate Risk Stratification Tool in Low Risk Chest Pain Patients
Chandra A, Limkakeng AT, Barowski J, Freeman D, Drake W, Mani G/Duke University Medical Center, Durham, NC
Study Objective: Access to advanced stress test imaging is limited in many observation units (OU). Electrocardiogram treadmill testing (ETT) with calculation of the Duke Treadmill Score (DTS) is easy to perform but thought to offer insufficient sensitivity and specificity for adequate risk stratification. We evaluated the utility of combining the DTS and TIMI risk score in chest pain patients to predict the need for advanced stress test imaging.
Methods: A retrospective cohort study, using Gilbert and Lowenstein technique, of patients evaluated in an urban academic hospital emergency department OU for acute coronary syndrome during 12/1/2004 to 11/31/2007. We excluded any patient not able to perform a treadmill test. In addition to ETT, patients also received either echocardiogram or nuclear perfusion imaging. A DTS ⬎4 was defined as low risk and TIMI risk score ⬍3 was defined as low risk. Demographics and the rate of 30-day composite outcome of myocardial infarction, coronary artery bypass graft, angioplasty, cardiac stent, or death was calculated with 95% CI using SAS Enterprise Guide 4.2 (Cary, NC). Results: After excluding 21 patients with missing data, 1032 patients were analyzed. 44% were male, the mean age was 51 years old, and 45% were AfricanAmerican, and 48% were Caucasian. 91% had an Echo ETT and 9% a Nuclear ETT. 69 (6.7%) had an abnormal provocative test and 62 (6%) had a 30-day event. Table 1 demonstrates abnormal imaging and 30-day event rates (reported in parenthesis) stratified by DTS and TIMI. Conclusions: While abnormal imaging rates increased with higher DTS and TIMI scores, 30-day events had the opposite pattern. The explanation for this is unclear but it is possibly due to the exclusion of patients who could not do a treadmill tests from this analysis or because the higher risk patients received more definitive care as a result of their abnormal imaging studies. Patients with a low DTS and TIMI score have a low risk of abnormal advanced imaging but should be carefully monitored in follow-up.
Volume , . : October
36
Concomitant Measurement of Copeptin and High Sensitivity Troponin for Fast and Reliable Rule Out of Acute Myocardial Infarction
Freund Y, Chenevier-Gobeaux C, Leumani F, Doumenc B, Claessens Y, Cosson C, Riou B, Ray P/Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Hopital Cochin, Paris, France; Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Hopital Bicêtre, Paris, France
Introduction: Newer assays (high sensitive troponin, HsTnT) and biomarkers (copeptin) recently improved the management of chest pain in the emergency department. Their combination could allow a rapid rule out with an almost perfect negative predictive value (NPV). Study Objectives: To assess the benefit of the association of HsTnT and copeptin for rule out of myocardial infarction. Methods: In consecutive patients presenting into 3 emergency departments with chest pain suggestive of acute myocardial infarction, levels of HsTnT and copeptin were measured at presentation, blinded to the emergency physicians. The medical management of patients was left to the discretion of the attending physicians according to the suspected diagnosis, and result of conventional Troponin I (cTn I). The discharge diagnosis was adjudicated by 2 independent experts using all available data. Results: 317 patients (mean age of 57 ⫾ 17 years) were included. acute myocardial infarction was confirmed in 45 patients (14%), 13 of them were STEMI, and 32 NSTEMI. A copeptin level ⬍ 10.7 pmol/l in combination with a HsTnT ⬍ 0.014 g/l correctly ruled out acute myocardial infarction with a higher sensitivity than cTnI : 1 (95% confidence interval: [0.90-1]) vs. 0.71 [0.55-0.84], p⬍0.001. We observed as well a significant gain in NPV: 1 [0.96-1] for copeptin ⫹ HsTnT vs. 0.95 [0.92-0.97] for cTnI alone (p⫽0.03). Comparison of area under the receiver operating characteristic curves did not showed any difference, with an AUC of 0.92 [0.88-0.94] for copeptin⫹HsTnT vs. 0.94 [091-0.96] for cTnI (p⫽0.3). Conclusion: Copeptin in association with HsTnT is a fast and reliable tool for rule out acute myocardial infarction, with a sensitivity and a NPV of 100% in our sample. Larger studies are warranted to confirm these findings.
37
Variability of Emergency Physicians’ Utilization of Chest Pain Units for “Very Low Risk” Chest Pain Patients
Mahler SA, Goff DC, Hoekstra JW, Miller CD/Wake Forest School of Medicine, Winston Salem, NC
Study Objectives: To quantify the variability in emergency physicians’ utilization of a chest pain unit (CPU) for patients with very low pre-test probability for acute coronary syndrome. Methods: Emergency department (ED) patients at the study institution undergoing evaluation for low risk chest pain based on clinical impression and a TIMI risk score ⬍2 are captured in a data registry. Registry participants from 1/2008 to 4/2010 were included in this analysis. Patients were further stratified as very low risk or low risk. Very low risk was defined as age less than 35 and TIMI risk score of
S190 Annals of Emergency Medicine
zero. Each encounter in the registry was associated with a board certified attending emergency physician allowing calculation of physicians’ CPU utilization rates. For providers with at least 10 CPU admissions, the proportions of admissions qualifying as very low risk were calculated. Physicians were grouped into quartiles based on the proportion of CPU admissions that were very low risk. Chi-squared analysis was used to determine if a significant difference existed between overall CPU utilization rate, for very low risk patients, compared to the highest quartile and lowest quartile physicians. Results: Over 28 months, the registry included 1070 chest pain patients. Of these patients, 11% (95% CI 9-13%) met the study definition of very low risk. There were 26 ED providers included in the analysis. Variability in utilization rates for very low risk patients among ED providers was wide; ranging from 0-23.5%. Among the highest quartile of providers 19% (95%CI 14.5-25%) of CPU admissions were very low risk patients, while in the lowest quartile less than 3% (95%CI 1-7%) of patients admitted to the CPU were very low risk. Utilization rates among the highest and lowest quartile providers significantly differed from the overall utilization rates, p⬍0.001. Serial cardiac markers were obtained on all 114 very low risk patients and 95% (108/114) received objective cardiac testing; none experienced death, myocardial infarction, or coronary revascularization during the index visit. Conclusion: There is significant variability among emergency physicians’ CPU utilization rates for patients with a very low pre-test probability of acute coronary syndrome. These differences could represent an opportunity to improve the efficiency of healthcare delivery.
38
Exercise Treadmill Is an Appropriate Risk Stratification Tool in Low Risk Chest Pain Patients
Chandra A, Limkakeng AT, Barowski J, Freeman D, Drake W, Mani G/Duke University Medical Center, Durham, NC
Study Objective: Access to advanced stress test imaging is limited in many observation units (OU). Electrocardiogram treadmill testing (ETT) with calculation of the Duke Treadmill Score (DTS) is easy to perform but thought to offer insufficient sensitivity and specificity for adequate risk stratification. We evaluated the utility of combining the DTS and TIMI risk score in chest pain patients to predict the need for advanced stress test imaging.
Methods: A retrospective cohort study, using Gilbert and Lowenstein technique, of patients evaluated in an urban academic hospital emergency department OU for acute coronary syndrome during 12/1/2004 to 11/31/2007. We excluded any patient not able to perform a treadmill test. In addition to ETT, patients also received either echocardiogram or nuclear perfusion imaging. A DTS ⬎4 was defined as low risk and TIMI risk score ⬍3 was defined as low risk. Demographics and the rate of 30-day composite outcome of myocardial infarction, coronary artery bypass graft, angioplasty, cardiac stent, or death was calculated with 95% CI using SAS Enterprise Guide 4.2 (Cary, NC). Results: After excluding 21 patients with missing data, 1032 patients were analyzed. 44% were male, the mean age was 51 years old, and 45% were AfricanAmerican, and 48% were Caucasian. 91% had an Echo ETT and 9% a Nuclear ETT. 69 (6.7%) had an abnormal provocative test and 62 (6%) had a 30-day event. Table 1 demonstrates abnormal imaging and 30-day event rates (reported in parenthesis) stratified by DTS and TIMI. Conclusions: While abnormal imaging rates increased with higher DTS and TIMI scores, 30-day events had the opposite pattern. The explanation for this is unclear but it is possibly due to the exclusion of patients who could not do a treadmill tests from this analysis or because the higher risk patients received more definitive care as a result of their abnormal imaging studies. Patients with a low DTS and TIMI score have a low risk of abnormal advanced imaging but should be carefully monitored in follow-up.
Volume , . : October