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Comparing an Unstructured Risk Stratification to Published Guidelines in Acute Coronary Syndromes.

Beck AJ, Hagemeijer A, Tortolani B, Byrd BA, Parekh A, Datillo P, Birkhahn R - West J Emerg Med (2015)

Bottom Line: The patient's ACS risk stratification classified by the EP was compared to AHA/ACC/ACEP guidelines.In the ED, physicians are more efficient at correctly placing patients with underlying ACS into a high-risk category.A small percentage of patients were considered low risk when applying AHA/ACC/ACEP guidelines, which demonstrates how clinical insight is often required to make an efficient assessment of cardiac risk and established criteria may be overly conservative when applied to an acute care population.

View Article: PubMed Central - PubMed

Affiliation: New York Methodist Hospital, Department of Emergency Medicine, Brooklyn, New York.

ABSTRACT

Introduction: Guidelines are designed to encompass the needs of the majority of patients with a particular condition. The American Heart Association (AHA) in conjunction with the American College of Cardiology (ACC) and the American College of Emergency Physicians (ACEP) developed risk stratification guidelines to aid physicians with accurate and efficient diagnosis and management of patients with acute coronary syndrome (ACS). While useful in a primary care setting, in the unique environment of an emergency department (ED), the feasibility of incorporating guidelines into clinical workflow remains in question. We aim to compare emergency physicians' (EP) clinical risk stratification ability to AHA/ACC/ACEP guidelines for ACS, and assessed each for accuracy in predicting ACS.

Methods: We conducted a prospective observational cohort study in an urban teaching hospital ED. All patients presenting to the ED with chest pain who were evaluated for ACS had two risk stratification scores assigned: one by the treating physician based on clinical evaluation and the other by the AHA/ACC/ACEP guideline aforementioned. The patient's ACS risk stratification classified by the EP was compared to AHA/ACC/ACEP guidelines. Patients were contacted at 30 days following the index ED visit to determine all cause mortality, unscheduled hospital/ED revisits, and objective cardiac testing performed.

Results: We enrolled 641 patients presenting for evaluation by 21 different EPs. There was a difference between the physician's clinical assessment used in the ED, and the AHA/ACC/ACEP task force guidelines. EPs were more likely to assess patients as low risk (40%), while AHA/ACC/ACEP guidelines were more likely to classify patients as intermediate (45%) or high (45%) risk. Of the 119 (19%) patients deemed high risk by EP evaluation, 38 (32%) were diagnosed with ACS. AHA/ACC/ACEP guidelines classified only 57 (9%) patients low risk with 56 (98%) of those patients diagnosed with no ACS.

Conclusion: In the ED, physicians are more efficient at correctly placing patients with underlying ACS into a high-risk category. A small percentage of patients were considered low risk when applying AHA/ACC/ACEP guidelines, which demonstrates how clinical insight is often required to make an efficient assessment of cardiac risk and established criteria may be overly conservative when applied to an acute care population.

No MeSH data available.


Related in: MedlinePlus

Patient’s risk assessment value versus final ACS diagnosis.AHA, American Heart Association; ACC, American College of Cardiology; ACEP, American College of Emergency Physicians; ACS, Acute Coronary Syndrome; EP, emergency physicians
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Related In: Results  -  Collection

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f1-wjem-16-683: Patient’s risk assessment value versus final ACS diagnosis.AHA, American Heart Association; ACC, American College of Cardiology; ACEP, American College of Emergency Physicians; ACS, Acute Coronary Syndrome; EP, emergency physicians

Mentions: When considering the patient’s ACS diagnosis and its relation to the risk assessment value (Table 3), AHA/ACC/ACEP guidelines proved better at identifying low-risk patients who did not have ACS (only 2% had ACS vs. 8% for EPs), while EPs proved better predictors of high-risk patients who in fact had ACS (68% had no ACS vs 87% for AHA/ACC/ACEP guidelines). Of all enrolled patients, 119 (17%) were determined by the EP to be at high risk for ACS; 38 (32%) of the 119 high-risk patients were diagnosed with ACS. The AHA/ACC/ACEP guidelines classified 294 (45%) patients high risk, with 74 (25%) of those patients diagnosed with ACS. AHA/ACC/ACEP guidelines classified only 57 (9%) patients low risk, with 56 (98%) of those patients diagnosed with no ACS. In contrast, physicians classified 257 (40%) of the sample as low risk for ACS, of whom 20 (8%) actually had ACS. Chi-square test of independence identified a difference in physician and AHA/ACC/ACEP scores, and their relation to ACS diagnosis (p≤0.05). Graphical representation of the physician risk assessment and guideline classification stratified by final diagnosis is shown in Figure 1. The receiver operating characteristic curves showing the performance for either the EP clinical impression or the AHA/ACC/ACEP scores for identifying patients with underlying ACS are shown in Figure 2.


Comparing an Unstructured Risk Stratification to Published Guidelines in Acute Coronary Syndromes.

Beck AJ, Hagemeijer A, Tortolani B, Byrd BA, Parekh A, Datillo P, Birkhahn R - West J Emerg Med (2015)

Patient’s risk assessment value versus final ACS diagnosis.AHA, American Heart Association; ACC, American College of Cardiology; ACEP, American College of Emergency Physicians; ACS, Acute Coronary Syndrome; EP, emergency physicians
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4644035&req=5

f1-wjem-16-683: Patient’s risk assessment value versus final ACS diagnosis.AHA, American Heart Association; ACC, American College of Cardiology; ACEP, American College of Emergency Physicians; ACS, Acute Coronary Syndrome; EP, emergency physicians
Mentions: When considering the patient’s ACS diagnosis and its relation to the risk assessment value (Table 3), AHA/ACC/ACEP guidelines proved better at identifying low-risk patients who did not have ACS (only 2% had ACS vs. 8% for EPs), while EPs proved better predictors of high-risk patients who in fact had ACS (68% had no ACS vs 87% for AHA/ACC/ACEP guidelines). Of all enrolled patients, 119 (17%) were determined by the EP to be at high risk for ACS; 38 (32%) of the 119 high-risk patients were diagnosed with ACS. The AHA/ACC/ACEP guidelines classified 294 (45%) patients high risk, with 74 (25%) of those patients diagnosed with ACS. AHA/ACC/ACEP guidelines classified only 57 (9%) patients low risk, with 56 (98%) of those patients diagnosed with no ACS. In contrast, physicians classified 257 (40%) of the sample as low risk for ACS, of whom 20 (8%) actually had ACS. Chi-square test of independence identified a difference in physician and AHA/ACC/ACEP scores, and their relation to ACS diagnosis (p≤0.05). Graphical representation of the physician risk assessment and guideline classification stratified by final diagnosis is shown in Figure 1. The receiver operating characteristic curves showing the performance for either the EP clinical impression or the AHA/ACC/ACEP scores for identifying patients with underlying ACS are shown in Figure 2.

Bottom Line: The patient's ACS risk stratification classified by the EP was compared to AHA/ACC/ACEP guidelines.In the ED, physicians are more efficient at correctly placing patients with underlying ACS into a high-risk category.A small percentage of patients were considered low risk when applying AHA/ACC/ACEP guidelines, which demonstrates how clinical insight is often required to make an efficient assessment of cardiac risk and established criteria may be overly conservative when applied to an acute care population.

View Article: PubMed Central - PubMed

Affiliation: New York Methodist Hospital, Department of Emergency Medicine, Brooklyn, New York.

ABSTRACT

Introduction: Guidelines are designed to encompass the needs of the majority of patients with a particular condition. The American Heart Association (AHA) in conjunction with the American College of Cardiology (ACC) and the American College of Emergency Physicians (ACEP) developed risk stratification guidelines to aid physicians with accurate and efficient diagnosis and management of patients with acute coronary syndrome (ACS). While useful in a primary care setting, in the unique environment of an emergency department (ED), the feasibility of incorporating guidelines into clinical workflow remains in question. We aim to compare emergency physicians' (EP) clinical risk stratification ability to AHA/ACC/ACEP guidelines for ACS, and assessed each for accuracy in predicting ACS.

Methods: We conducted a prospective observational cohort study in an urban teaching hospital ED. All patients presenting to the ED with chest pain who were evaluated for ACS had two risk stratification scores assigned: one by the treating physician based on clinical evaluation and the other by the AHA/ACC/ACEP guideline aforementioned. The patient's ACS risk stratification classified by the EP was compared to AHA/ACC/ACEP guidelines. Patients were contacted at 30 days following the index ED visit to determine all cause mortality, unscheduled hospital/ED revisits, and objective cardiac testing performed.

Results: We enrolled 641 patients presenting for evaluation by 21 different EPs. There was a difference between the physician's clinical assessment used in the ED, and the AHA/ACC/ACEP task force guidelines. EPs were more likely to assess patients as low risk (40%), while AHA/ACC/ACEP guidelines were more likely to classify patients as intermediate (45%) or high (45%) risk. Of the 119 (19%) patients deemed high risk by EP evaluation, 38 (32%) were diagnosed with ACS. AHA/ACC/ACEP guidelines classified only 57 (9%) patients low risk with 56 (98%) of those patients diagnosed with no ACS.

Conclusion: In the ED, physicians are more efficient at correctly placing patients with underlying ACS into a high-risk category. A small percentage of patients were considered low risk when applying AHA/ACC/ACEP guidelines, which demonstrates how clinical insight is often required to make an efficient assessment of cardiac risk and established criteria may be overly conservative when applied to an acute care population.

No MeSH data available.


Related in: MedlinePlus