- Email: [email protected]
Prophylactic aspirin use in an emergency department population
RESEARCH FORUM ABSTRACTS
medication before administration of tPA. One patient received therapy in-flight for a blood pressure reading of 180/98 mm Hg. Three additional patients should have received antihypertensive medication for elevated blood pressure per protocol. No patients required intubation and had in-flight neurologic deterioration. Discharge NIHSS demonstrated 12 patients with no or mild deficit (NIHSS <4), 3 had moderate deficit (NIHSS ->5 and <13), and 1 had a fatal intracerebral hemorrhage. Conclusion: HT is rapid and safe. It may extend the use of tPA to acute stroke victims in community and rural settings who require specialized care. Additional training of flight crews is necessary.
409 ,nACUtecardiaTriagecentersSCOres cMI for Emergency Medical System Bypass Zalenski RJ, Blaustein N, Shamsa F, Waselewsky D, Beck B, PenumaleeS/Wayne State University, Grace Hospital, Detroit, MI; WilliamBeaumontHospital, RoyalOak, MI; Huron Valley Hospital, CommerceTownship, MI The prehospital triage of patients for bypass from commnnity hospitals to cardiac centers may improve cardiac survival. Study objective: To examine the prognostic value of 3 ECG-based scoring methods for patients with acute myocardial infarction (AMI). Methods: This was a retrospective study of 280 AMI patients transported by ambulance during 1996-1997 to comnmnity hospitals or cardiac centers. Inclusion criteria were age older than 18 years, chest pain or dyspnea, ECG findings of 0.1 mV of STsegment elevation in 2 leads or positive cmatine kinase isoenayme (CPK-MB). All first performed ED ECGs were interpreted and scored by a reader blinded to clinical outcomes. The Aldrich M1 score was assigned using ST elevation, abnormal Q waves, and tall T waves; QRS distortion was present or absent based on morphologic characteristics of the terminal QRS; TIMI classification of "low risk" was modified for prehospital signs. Cardiac mortality was determined using tricounty death index. Results: The mean age of 280 AMI patients was 67.6 years (SD 14.5), with 60% male, and 58.6% white, 27.9% black, and 13.5% other; 31.8% of patients were treated with thrumbolytics and 29% with primary angioplasty. The 2-year cardiac mortality rate was 27.9%. On univariate analysis, only the TIM1 score was associated with cardiac mortality (P=.069). A multivariate model incorporated the TIMI score with an odds ratio of 1.96 (P=.082), but not the Aldrich MI score or the terminal QRS. Conclusion: The T1MI risk score has the strongest association with cardiac mortality and may be suitable for identifying higher-risk AMI patients in the prehospital setting.
410 Prophy]actic Aspirin Use in an EmergencyDepartment Population BroderickJ, Cydulka R, Meldon S/Albany Medical Center,Albany, NY; MetroHealth Medical Center, Cleveland,OH Aspirin (ASA) has been shown to decrease cardiac events in people with preexisting cardiovascular disease. The use of ASA as primary and secondary prevention of myocardial infarction (MI) has been found to range from 17% to 56% in community and primary care settings. To our knowledge, the use of ASA in an emergency department population has not been described. Study objective: We designed this study to determine the frequency of ASA use in an ED population. Methods: This was an observational study of 486 patients 40 years or older who presented to 2 urban, university EDs between May 8 and August 1, 1998. Data were collected on a structured closed-question data sheet Prophylactic ASA was defined as not more than daily nor less than every other day use. The following were tested as predictors for ASA use: known coronary artery disease, coronary artery disease risk factors, corttraindications to ASA use, and identified primary care provider (PCP). Data were analyzed using %2 with significance defined as P<.05. Results: Twenty-eight percent of patients queried used prophylactic ASA at the time of this ED "asit. Predictors of ASA use were previous MI (73%), coronary artery disease (62%), cholesterol more than 200 mg/dL (46%), diabetes (46%), hypertension (37%), and family history of coronary artery disease (34%) (P<.001 for all). A PCP was associated with increased prophylactic ASA use (36%, P<.001). Cigarette use was not associated with increased prophylactic ASA use (28%, P>.05). Forty-five percent of subjects reported a contraindication to ASA use; however, 24% of these patients used prophylactic ASA. Conclusion: Prophylactic ASA use in this ED population was similar to that previously described in community and outpatient settings. The use of prophylactic ASA increased with all risk factors of coronary artery disease except cigarette use. Nearly
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half of patients reported a contraindication to ASA use, but many still used it regularly. A PCP was associated with increased use of prophylactic ASA.
411 CoronaryTriage Unit Utility in an lndigent CountyPopulation HendersonSO, OstrzegaE, 6enna T, Kern C, IldefonsoC, Garan-MartinezK/LosAngeles County-Universityof Southern California Medical Center, Los Angeles,CA The utility of chest pain units in private insured settings has been described. In July 1997, a chest pain evaluation unit was established at our facility, a Level I trauma center serving a local population of 1.5 million, with an average annual ED census of approximately 147,000, many of whom are indigent. Infectious disease, drug, alcohol, and psychiatric problems are disproportionate in this patient population. The unit was developed in an effort to more rapidly triage, treat, and discharge patients with lowrisk chest pain, syncope, stable arrhythmias, or mild exacerbation of congestive heart failure. Traditional management of these patients involved muluple day admissions to intensive care or telemetry type settings. The unit was jointly managed and staffed by emergency me&cine and cardiology physicians, and patient workups could include medical therapy, bedside echocardiography, or on-site exercise stress testing. Objective: To review the performance of a chest pain or coronary triage unit (CTU) in a hospital with a large indigent population. Methods: This is a retrospective case review of all patients sent to the CTU during a 20-month period. Data collected included total census, time to rule out myocardial infarction from arrival to the CTU, total length of stay, number of patients discharged, and number of patients admitted to routine, step-down, and intensive care settings. Results: The total CTU census for the months of August 1997 to March 1999 was 2,747 with an average monthly census of I37 (range 110 to 169). Time to rule out myocardial infarction while in the CTU averaged 7.8 hours, and the mean total stay in the unit was 19 7 hours (range 18 to 25.5 hours); 1,510 (55%) of the patients were discharged home. Of the 1,113 patients admitted to the hospital, 325 went to a cardiology setting (29% of those admitted), and 62 (6% of those admitted) went to the intensive care setting. One patient suffered a respiratory arrest, and there were no cardiac arrests. Patient diagnosis unique to this population included a high number of patients with chest pain associated with cocaine and ethanol use, psychogenic causes, and unique infectious disease etiologies such as Chagas' disease. Conclusion: Admission to a CTU is an effective, relatively low-risk method of rapidly evaluating, testing, and diagnosing low-risk cardiac patients (chest pain, cardiac arrhythmias, mild congestive heart failure). Length of stay is decreased and staffing may be tailored to the unique needs of this population. CTU utility easily translated to an urban inner-city facility serving a largely indigent population.
412 Knowledge of Risk Factorsfor CoronaryArtery Disease: ComparisonAmong Gender and Races Diercks DB, Ernst AA/University of California-Davis Medical Center, Sacramento,CA Study objective: To determine emergency department patients' baseline level of knowledge of cardiac disease risk factors and to compare differences among races and gender. Methods: A survey administered to a convenience sampling of adult ED patients. Questions were asked about knowledge of risk factors of coronary artery disease (CAD). One-way analysis of variance and X2 testing was used to compare ages and answers among races and gender for knowledge of risk factors: age older than 60 years, family members with CAD (FHx), hypertension (HTN), high cholesterol, diabetes (DM), and smoking. A P value of less than .05 was considered statistically significant. Results: A total of 433 participated in the study over a 3-month period. Questionnaires were completed in 416 participants; 211 were male and 205 female. There were 212 (51%) white, 57 (14%) Hispanic, 105 (25%) African American, and 42 (10%) other races. Only 47% of participants identified age older than 60 years as a risk factor, 48.3% identified DM as a risk factor, 78.4% identified HTN as a risk factor, 68.2% identified FHx as a risk factor, 70.9% identified high cholesterol, whereas 79% of the participants identified smoking as a risk factor. White patients knew more frequently than African Americans that age older than 60 was a risk factor for CAD (50.9% versus 35.2%, P=.008). White patients knew high cholesterol was a risk for CAD more often than the group defined as other races (76.9% verses 54.8%, P=.003). There was no difference among races regarding the knowledge that HTN, DM, and tobacco use increased risk for CAD. Knowledge base among genders was similar. Participants with a risk factor such as HTN, high cholesterol, DM, and PHx were
ANNALS OF EMERGENCYMEDICINE 34:4 OCTOBER1999, PART 2
medication before administration of tPA. One patient received therapy in-flight for a blood pressure reading of 180/98 mm Hg. Three additional patients should have received antihypertensive medication for elevated blood pressure per protocol. No patients required intubation and had in-flight neurologic deterioration. Discharge NIHSS demonstrated 12 patients with no or mild deficit (NIHSS <4), 3 had moderate deficit (NIHSS ->5 and <13), and 1 had a fatal intracerebral hemorrhage. Conclusion: HT is rapid and safe. It may extend the use of tPA to acute stroke victims in community and rural settings who require specialized care. Additional training of flight crews is necessary.
409 ,nACUtecardiaTriagecentersSCOres cMI for Emergency Medical System Bypass Zalenski RJ, Blaustein N, Shamsa F, Waselewsky D, Beck B, PenumaleeS/Wayne State University, Grace Hospital, Detroit, MI; WilliamBeaumontHospital, RoyalOak, MI; Huron Valley Hospital, CommerceTownship, MI The prehospital triage of patients for bypass from commnnity hospitals to cardiac centers may improve cardiac survival. Study objective: To examine the prognostic value of 3 ECG-based scoring methods for patients with acute myocardial infarction (AMI). Methods: This was a retrospective study of 280 AMI patients transported by ambulance during 1996-1997 to comnmnity hospitals or cardiac centers. Inclusion criteria were age older than 18 years, chest pain or dyspnea, ECG findings of 0.1 mV of STsegment elevation in 2 leads or positive cmatine kinase isoenayme (CPK-MB). All first performed ED ECGs were interpreted and scored by a reader blinded to clinical outcomes. The Aldrich M1 score was assigned using ST elevation, abnormal Q waves, and tall T waves; QRS distortion was present or absent based on morphologic characteristics of the terminal QRS; TIMI classification of "low risk" was modified for prehospital signs. Cardiac mortality was determined using tricounty death index. Results: The mean age of 280 AMI patients was 67.6 years (SD 14.5), with 60% male, and 58.6% white, 27.9% black, and 13.5% other; 31.8% of patients were treated with thrumbolytics and 29% with primary angioplasty. The 2-year cardiac mortality rate was 27.9%. On univariate analysis, only the TIM1 score was associated with cardiac mortality (P=.069). A multivariate model incorporated the TIMI score with an odds ratio of 1.96 (P=.082), but not the Aldrich MI score or the terminal QRS. Conclusion: The T1MI risk score has the strongest association with cardiac mortality and may be suitable for identifying higher-risk AMI patients in the prehospital setting.
410 Prophy]actic Aspirin Use in an EmergencyDepartment Population BroderickJ, Cydulka R, Meldon S/Albany Medical Center,Albany, NY; MetroHealth Medical Center, Cleveland,OH Aspirin (ASA) has been shown to decrease cardiac events in people with preexisting cardiovascular disease. The use of ASA as primary and secondary prevention of myocardial infarction (MI) has been found to range from 17% to 56% in community and primary care settings. To our knowledge, the use of ASA in an emergency department population has not been described. Study objective: We designed this study to determine the frequency of ASA use in an ED population. Methods: This was an observational study of 486 patients 40 years or older who presented to 2 urban, university EDs between May 8 and August 1, 1998. Data were collected on a structured closed-question data sheet Prophylactic ASA was defined as not more than daily nor less than every other day use. The following were tested as predictors for ASA use: known coronary artery disease, coronary artery disease risk factors, corttraindications to ASA use, and identified primary care provider (PCP). Data were analyzed using %2 with significance defined as P<.05. Results: Twenty-eight percent of patients queried used prophylactic ASA at the time of this ED "asit. Predictors of ASA use were previous MI (73%), coronary artery disease (62%), cholesterol more than 200 mg/dL (46%), diabetes (46%), hypertension (37%), and family history of coronary artery disease (34%) (P<.001 for all). A PCP was associated with increased prophylactic ASA use (36%, P<.001). Cigarette use was not associated with increased prophylactic ASA use (28%, P>.05). Forty-five percent of subjects reported a contraindication to ASA use; however, 24% of these patients used prophylactic ASA. Conclusion: Prophylactic ASA use in this ED population was similar to that previously described in community and outpatient settings. The use of prophylactic ASA increased with all risk factors of coronary artery disease except cigarette use. Nearly
S104
half of patients reported a contraindication to ASA use, but many still used it regularly. A PCP was associated with increased use of prophylactic ASA.
411 CoronaryTriage Unit Utility in an lndigent CountyPopulation HendersonSO, OstrzegaE, 6enna T, Kern C, IldefonsoC, Garan-MartinezK/LosAngeles County-Universityof Southern California Medical Center, Los Angeles,CA The utility of chest pain units in private insured settings has been described. In July 1997, a chest pain evaluation unit was established at our facility, a Level I trauma center serving a local population of 1.5 million, with an average annual ED census of approximately 147,000, many of whom are indigent. Infectious disease, drug, alcohol, and psychiatric problems are disproportionate in this patient population. The unit was developed in an effort to more rapidly triage, treat, and discharge patients with lowrisk chest pain, syncope, stable arrhythmias, or mild exacerbation of congestive heart failure. Traditional management of these patients involved muluple day admissions to intensive care or telemetry type settings. The unit was jointly managed and staffed by emergency me&cine and cardiology physicians, and patient workups could include medical therapy, bedside echocardiography, or on-site exercise stress testing. Objective: To review the performance of a chest pain or coronary triage unit (CTU) in a hospital with a large indigent population. Methods: This is a retrospective case review of all patients sent to the CTU during a 20-month period. Data collected included total census, time to rule out myocardial infarction from arrival to the CTU, total length of stay, number of patients discharged, and number of patients admitted to routine, step-down, and intensive care settings. Results: The total CTU census for the months of August 1997 to March 1999 was 2,747 with an average monthly census of I37 (range 110 to 169). Time to rule out myocardial infarction while in the CTU averaged 7.8 hours, and the mean total stay in the unit was 19 7 hours (range 18 to 25.5 hours); 1,510 (55%) of the patients were discharged home. Of the 1,113 patients admitted to the hospital, 325 went to a cardiology setting (29% of those admitted), and 62 (6% of those admitted) went to the intensive care setting. One patient suffered a respiratory arrest, and there were no cardiac arrests. Patient diagnosis unique to this population included a high number of patients with chest pain associated with cocaine and ethanol use, psychogenic causes, and unique infectious disease etiologies such as Chagas' disease. Conclusion: Admission to a CTU is an effective, relatively low-risk method of rapidly evaluating, testing, and diagnosing low-risk cardiac patients (chest pain, cardiac arrhythmias, mild congestive heart failure). Length of stay is decreased and staffing may be tailored to the unique needs of this population. CTU utility easily translated to an urban inner-city facility serving a largely indigent population.
412 Knowledge of Risk Factorsfor CoronaryArtery Disease: ComparisonAmong Gender and Races Diercks DB, Ernst AA/University of California-Davis Medical Center, Sacramento,CA Study objective: To determine emergency department patients' baseline level of knowledge of cardiac disease risk factors and to compare differences among races and gender. Methods: A survey administered to a convenience sampling of adult ED patients. Questions were asked about knowledge of risk factors of coronary artery disease (CAD). One-way analysis of variance and X2 testing was used to compare ages and answers among races and gender for knowledge of risk factors: age older than 60 years, family members with CAD (FHx), hypertension (HTN), high cholesterol, diabetes (DM), and smoking. A P value of less than .05 was considered statistically significant. Results: A total of 433 participated in the study over a 3-month period. Questionnaires were completed in 416 participants; 211 were male and 205 female. There were 212 (51%) white, 57 (14%) Hispanic, 105 (25%) African American, and 42 (10%) other races. Only 47% of participants identified age older than 60 years as a risk factor, 48.3% identified DM as a risk factor, 78.4% identified HTN as a risk factor, 68.2% identified FHx as a risk factor, 70.9% identified high cholesterol, whereas 79% of the participants identified smoking as a risk factor. White patients knew more frequently than African Americans that age older than 60 was a risk factor for CAD (50.9% versus 35.2%, P=.008). White patients knew high cholesterol was a risk for CAD more often than the group defined as other races (76.9% verses 54.8%, P=.003). There was no difference among races regarding the knowledge that HTN, DM, and tobacco use increased risk for CAD. Knowledge base among genders was similar. Participants with a risk factor such as HTN, high cholesterol, DM, and PHx were
ANNALS OF EMERGENCYMEDICINE 34:4 OCTOBER1999, PART 2