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The Value of Symptoms and Signs in the Emergent Diagnosis of Acute Coronary Syndromes
396
Abstracts
Comments: This study is limited by all of the problems inherent in an observational study. Nonetheless, it seems that PCT, when incorporated into a scoring system that includes CRP and physical symptoms, may provide useful information as to the likelihood and severity of infection. Further prospective trials will be necessary to corroborate these findings. , THE VALUE OF SYMPTOMS AND SIGNS IN THE EMERGENT DIAGNOSIS OF ACUTE CORONARY SYNDROMES. Body R, Carley S, Wibberley C, et al. Resuscitation 2010;81:281e6. This study from the United Kingdom identified 796 patients above age 25 years who presented to the emergency department with chest pain in the last 24 h and investigated the value of symptoms and examinations to predict acute myocardial infarction (AMI) or future cardiac events. AMI was diagnosed in 148 patients with troponin elevation above 0.035 ng/mL, and at the 6-month follow-up, 179 patients had developed adverse events (death, AMI, need for urgent coronary revascularization). Using binary logistic regression to determine odds ratio and 95% confidence intervals, the researchers were able to identify symptoms and examination findings that correlated with AMI. Overall, AMI was found to be more likely in patients with pain radiating to the right arm or both arms, emesis, and observed diaphoresis. Interestingly, left chest pain and pain that mimicked prior MI were both discovered to be negative predictors of AMI. Hypotension and bradycardia were associated with posterior or inferior, right ventricular MI, whereas elevated jugular venous pressure and tachycardia were associated with anterior or anteriolateral MI. The authors conclude that their findings question the assertions made by the American Heart Association and the European Society of Cardiology, which state, respectively, that “chest or left arm pain or discomfort as the chief symptom reproducing prior documented angina” and that “retrosternal pressure or heaviness radiating to left arm, neck, or jaw” as well as pain at rest are associated with high likelihood of acute coronary syndrome. [Morgan Eutermoser, MD Denver Health Medical Center, Denver, CO] Comment: Although limited by its small size and potential lack of generalizability, this study does raise important questions about the assumptions made by physicians when confronted with traditional patient complaints generally assumed to be harbingers of cardiac disease. , THE VALUE OF SEQUENTIAL COMPUTED TOMOGRAPHY SCANNING IN ANTICOAGULATED PATIENTS SUFFERING FROM MINOR HEAD INJURY. Kaen A, Jimenez-Roldan L, Arrese I, et al. J Trauma 2010;68:895e6.
This study from Spain examined 137 patients older than 16 years, with an average age of 76 years, head trauma within 48 h, an initial Glasgow Coma Scale (GCS) score of at least 14, and a normal initial head computed tomography (CT) scan on anticoagulation who had suffered from mild head injury (MHI) between October 2005 and December 2006. The purpose was to determine the need to repeat CT scans on these patients if their first CT scan was negative and they didn’t have neurological changes during their stay. Neurosurgical residents collected an initial and ongoing GCS score, mechanism of injury, and reason for anticoagulation. They also assessed for symptoms of headache, vomiting, loss of consciousness, post-traumatic amnesia, and sensory or motor deficits. Each participant had an initial, non-contrast, cranial CT scan with a standardized protocol. Participants were excluded if they had any intracranial abnormality on initial CT. The remaining patients were then admitted to the hospital for a 24-h observation. During this period, the patients’ had coagulation tests and serial, neurologic examinations every 4e6 h. Between 20 and 24 h they had a repeat CT scan. The patients continued to take their anticoagulation medications. Demographic information and comparisons between initial and final CT scans were analyzed with chi-squared and Fisher’s exact tests. Forty-five subjects (33%) were men. Falls accounted for 89% of the injuries. Most patients were on anticoagulation for their atrial fibrillation, and their mean international normalized ratio was 3.8. One hundred thirty-five (98.6%) had no intracranial lesions on either CT scan and no neurological changes during their stay. Two patients (1.4%) showed evidence of intracranial hemorrhages on their second CT scan. These 2 patients were both on aspirin and either heparin or warfarin. In addition, these 2 were also among the 14 (10%) who had a loss of consciousness. The researchers concluded that a combination of advanced age and anticoagulation does not necessarily increase the risk for intracranial hemorrhage in patients with MHI and a normal initial CT scan. Therefore, patients with MHI and anticoagulation alone do not need a second CT scan before discharge. However, if the patient is on anticoagulation and anti-aggregation (aspirin), a second CT scan should be done. [Bonnie Kaplan, MD Denver Health Medical Center, Denver, CO] Comment: This study was very small and purely observational. Furthermore, there is substantial room for bias in patient reporting or physician recording of symptoms. Nonetheless, the results at the very least suggest that this is a question that warrants further investigation. There is currently no widely accepted algorithm for the management of these patients. Having a sense of who needs repeat CT scans in this population could improve care.
Abstracts
Comments: This study is limited by all of the problems inherent in an observational study. Nonetheless, it seems that PCT, when incorporated into a scoring system that includes CRP and physical symptoms, may provide useful information as to the likelihood and severity of infection. Further prospective trials will be necessary to corroborate these findings. , THE VALUE OF SYMPTOMS AND SIGNS IN THE EMERGENT DIAGNOSIS OF ACUTE CORONARY SYNDROMES. Body R, Carley S, Wibberley C, et al. Resuscitation 2010;81:281e6. This study from the United Kingdom identified 796 patients above age 25 years who presented to the emergency department with chest pain in the last 24 h and investigated the value of symptoms and examinations to predict acute myocardial infarction (AMI) or future cardiac events. AMI was diagnosed in 148 patients with troponin elevation above 0.035 ng/mL, and at the 6-month follow-up, 179 patients had developed adverse events (death, AMI, need for urgent coronary revascularization). Using binary logistic regression to determine odds ratio and 95% confidence intervals, the researchers were able to identify symptoms and examination findings that correlated with AMI. Overall, AMI was found to be more likely in patients with pain radiating to the right arm or both arms, emesis, and observed diaphoresis. Interestingly, left chest pain and pain that mimicked prior MI were both discovered to be negative predictors of AMI. Hypotension and bradycardia were associated with posterior or inferior, right ventricular MI, whereas elevated jugular venous pressure and tachycardia were associated with anterior or anteriolateral MI. The authors conclude that their findings question the assertions made by the American Heart Association and the European Society of Cardiology, which state, respectively, that “chest or left arm pain or discomfort as the chief symptom reproducing prior documented angina” and that “retrosternal pressure or heaviness radiating to left arm, neck, or jaw” as well as pain at rest are associated with high likelihood of acute coronary syndrome. [Morgan Eutermoser, MD Denver Health Medical Center, Denver, CO] Comment: Although limited by its small size and potential lack of generalizability, this study does raise important questions about the assumptions made by physicians when confronted with traditional patient complaints generally assumed to be harbingers of cardiac disease. , THE VALUE OF SEQUENTIAL COMPUTED TOMOGRAPHY SCANNING IN ANTICOAGULATED PATIENTS SUFFERING FROM MINOR HEAD INJURY. Kaen A, Jimenez-Roldan L, Arrese I, et al. J Trauma 2010;68:895e6.
This study from Spain examined 137 patients older than 16 years, with an average age of 76 years, head trauma within 48 h, an initial Glasgow Coma Scale (GCS) score of at least 14, and a normal initial head computed tomography (CT) scan on anticoagulation who had suffered from mild head injury (MHI) between October 2005 and December 2006. The purpose was to determine the need to repeat CT scans on these patients if their first CT scan was negative and they didn’t have neurological changes during their stay. Neurosurgical residents collected an initial and ongoing GCS score, mechanism of injury, and reason for anticoagulation. They also assessed for symptoms of headache, vomiting, loss of consciousness, post-traumatic amnesia, and sensory or motor deficits. Each participant had an initial, non-contrast, cranial CT scan with a standardized protocol. Participants were excluded if they had any intracranial abnormality on initial CT. The remaining patients were then admitted to the hospital for a 24-h observation. During this period, the patients’ had coagulation tests and serial, neurologic examinations every 4e6 h. Between 20 and 24 h they had a repeat CT scan. The patients continued to take their anticoagulation medications. Demographic information and comparisons between initial and final CT scans were analyzed with chi-squared and Fisher’s exact tests. Forty-five subjects (33%) were men. Falls accounted for 89% of the injuries. Most patients were on anticoagulation for their atrial fibrillation, and their mean international normalized ratio was 3.8. One hundred thirty-five (98.6%) had no intracranial lesions on either CT scan and no neurological changes during their stay. Two patients (1.4%) showed evidence of intracranial hemorrhages on their second CT scan. These 2 patients were both on aspirin and either heparin or warfarin. In addition, these 2 were also among the 14 (10%) who had a loss of consciousness. The researchers concluded that a combination of advanced age and anticoagulation does not necessarily increase the risk for intracranial hemorrhage in patients with MHI and a normal initial CT scan. Therefore, patients with MHI and anticoagulation alone do not need a second CT scan before discharge. However, if the patient is on anticoagulation and anti-aggregation (aspirin), a second CT scan should be done. [Bonnie Kaplan, MD Denver Health Medical Center, Denver, CO] Comment: This study was very small and purely observational. Furthermore, there is substantial room for bias in patient reporting or physician recording of symptoms. Nonetheless, the results at the very least suggest that this is a question that warrants further investigation. There is currently no widely accepted algorithm for the management of these patients. Having a sense of who needs repeat CT scans in this population could improve care.