Missed myocardial infarctions in ED patients prospectively categorized as low risk by established risk scores
Abstract Study o bjectives Few studies have prospectively compared multiple cardiac risk prediction scores. We compared the rate of missed acute myocardial infarction (AMI) in chest pain patients prospectively categorized as low risk by unstructured clinical impression, and by HEART, TIMI, GRACE, an...
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| Veröffentlicht in: | The American journal of emergency medicine 2017-05, Vol.35 (5), p.704-709 |
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| creator | Singer, A.J Than, M.P Smith, S McCullough, P Barrett, T.W Birkhahn, R Reed, M Thode, H.C Arnold, W.D Daniels, L.B de Filippi, C Headden, G Peacock, W.F |
| description | Abstract Study
o
bjectives Few studies have prospectively compared multiple cardiac risk prediction scores. We compared the rate of missed acute myocardial infarction (AMI) in chest pain patients prospectively categorized as low risk by unstructured clinical impression, and by HEART, TIMI, GRACE, and EDACS scores, in combination with two negative contemporary cardiac troponins (cTn) available in the U.S. Methods We enrolled 434 patients with chest pain presenting to one of seven emergency departments (ED). Risk scores were prospectively calculated and included the first two cTn. Low risk was defined for each score as HEART ≤ 3, TIMI ≤ 0, GRACE ≤ 50, and EDACS ≤ 15. AMI incidence was calculated for low risk patients and compared across scores using Χ2 tests and C statistics. Results The patients
'
median age was 57, 58% were male, 60% white, and 80 (18%) had AMI. The missed AMI rate in low risk patients for each of the scores when combined with 2 cTn were HEART 3.6
%, TIMI 0%, GRACE 6.3%, EDACS 0.9%, and unstructured clinical impression 0%. The C-statistic was greatest for the EDACS score, 0.94 (95% CI, 0.92
–
0.97). Conclusions Using their recommended cutpoints and non high sensitivity cTn, TIMI and unstructured clinical impression were the only scores with no missed cases of AMI. Using lower cutpoints (GRACE ≤ 48, TIMI = 0, EDACS ≤ 11, HEART ≤ 2) missed no case of AMI, but classified less patients as low-risk. |
| doi_str_mv | 10.1016/j.ajem.2017.01.003 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_1861587248</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><els_id>S0735675717300037</els_id><sourcerecordid>1861587248</sourcerecordid><originalsourceid>FETCH-LOGICAL-c439t-47407b7819207ce9d7abeda3f37aceb0c0b576cffd761d43a090ce6a98f777733</originalsourceid><addsrcrecordid>eNp9Uk1v1TAQtBCIvhb-AAdkiQuXhN04iRMJIaHSAlIRB-BsOc4GnObj4c0rCr8eh1dA6gEfbMs7M1rPrBBPEFIELF_0qe1pTDNAnQKmAOqe2GGhsqRCjffFDrQqklIX-kScMvcAiHmRPxQnWYVQZRnsxPjBM1Mrx3V2NrTeDtJPnQ1u8fPE8S4v3si9XTxNC8t9mHlPsXZDwyqdXejrHPzPyLcsh_mHDJ6vZbNK4sU2g-dvsfT7jd0ciB-JB50dmB7fnmfiy-XF5_N3ydXHt-_PX18lLlf1kuQ6B93oCusMtKO61bah1qpOaeuoAQdNoUvXda0usc2VhRoclbauOh2XUmfi-VE3Nvz9EJsxo2dHw2Anmg9ssCqxqHSWVxH67A60nw9hit0ZrCHL67hhRGVHlIsOcKDO7IMfbVgNgtnCML3ZwjBbGAbQxDAi6emt9KEZqf1L-eN-BLw8Aih6ceMpGHbRaEetD9Fl087-__qv7tDd4Cfv7HBNK_G_fxjODJhP2zhs04BaQeRr9QucibDB</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>1902499021</pqid></control><display><type>article</type><title>Missed myocardial infarctions in ED patients prospectively categorized as low risk by established risk scores</title><source>MEDLINE</source><source>Elsevier ScienceDirect Journals Complete</source><creator>Singer, A.J ; Than, M.P ; Smith, S ; McCullough, P ; Barrett, T.W ; Birkhahn, R ; Reed, M ; Thode, H.C ; Arnold, W.D ; Daniels, L.B ; de Filippi, C ; Headden, G ; Peacock, W.F</creator><creatorcontrib>Singer, A.J ; Than, M.P ; Smith, S ; McCullough, P ; Barrett, T.W ; Birkhahn, R ; Reed, M ; Thode, H.C ; Arnold, W.D ; Daniels, L.B ; de Filippi, C ; Headden, G ; Peacock, W.F</creatorcontrib><description>Abstract Study
o
bjectives Few studies have prospectively compared multiple cardiac risk prediction scores. We compared the rate of missed acute myocardial infarction (AMI) in chest pain patients prospectively categorized as low risk by unstructured clinical impression, and by HEART, TIMI, GRACE, and EDACS scores, in combination with two negative contemporary cardiac troponins (cTn) available in the U.S. Methods We enrolled 434 patients with chest pain presenting to one of seven emergency departments (ED). Risk scores were prospectively calculated and included the first two cTn. Low risk was defined for each score as HEART ≤ 3, TIMI ≤ 0, GRACE ≤ 50, and EDACS ≤ 15. AMI incidence was calculated for low risk patients and compared across scores using Χ2 tests and C statistics. Results The patients
'
median age was 57, 58% were male, 60% white, and 80 (18%) had AMI. The missed AMI rate in low risk patients for each of the scores when combined with 2 cTn were HEART 3.6
%, TIMI 0%, GRACE 6.3%, EDACS 0.9%, and unstructured clinical impression 0%. The C-statistic was greatest for the EDACS score, 0.94 (95% CI, 0.92
–
0.97). Conclusions Using their recommended cutpoints and non high sensitivity cTn, TIMI and unstructured clinical impression were the only scores with no missed cases of AMI. Using lower cutpoints (GRACE ≤ 48, TIMI = 0, EDACS ≤ 11, HEART ≤ 2) missed no case of AMI, but classified less patients as low-risk.</description><identifier>ISSN: 0735-6757</identifier><identifier>EISSN: 1532-8171</identifier><identifier>DOI: 10.1016/j.ajem.2017.01.003</identifier><identifier>PMID: 28108220</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>Accuracy ; Acute coronary syndromes ; Angina pectoris ; Chest ; Chest Pain - blood ; Chest Pain - diagnosis ; Clinical medicine ; Decision Support Techniques ; Electrocardiography ; Electrocardiography - statistics & numerical data ; Emergency ; Emergency medical care ; Emergency medical services ; Emergency Service, Hospital ; Female ; Finland ; Health risks ; Heart attacks ; Heart diseases ; Humans ; Incidence ; Ischemia ; Male ; Medical imaging ; Middle Aged ; Myocardial infarction ; Myocardial Infarction - blood ; Myocardial Infarction - diagnosis ; Pain ; Patients ; Physicians ; Population ; Predictive Value of Tests ; Prospective Studies ; Risk Assessment ; Risk groups ; Troponin - blood</subject><ispartof>The American journal of emergency medicine, 2017-05, Vol.35 (5), p.704-709</ispartof><rights>2017 Elsevier Inc.</rights><rights>Copyright © 2017 Elsevier Inc. All rights reserved.</rights><rights>Copyright Elsevier Limited 2017</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c439t-47407b7819207ce9d7abeda3f37aceb0c0b576cffd761d43a090ce6a98f777733</citedby><cites>FETCH-LOGICAL-c439t-47407b7819207ce9d7abeda3f37aceb0c0b576cffd761d43a090ce6a98f777733</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://www.sciencedirect.com/science/article/pii/S0735675717300037$$EHTML$$P50$$Gelsevier$$H</linktohtml><link.rule.ids>314,776,780,3537,27901,27902,65306</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/28108220$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Singer, A.J</creatorcontrib><creatorcontrib>Than, M.P</creatorcontrib><creatorcontrib>Smith, S</creatorcontrib><creatorcontrib>McCullough, P</creatorcontrib><creatorcontrib>Barrett, T.W</creatorcontrib><creatorcontrib>Birkhahn, R</creatorcontrib><creatorcontrib>Reed, M</creatorcontrib><creatorcontrib>Thode, H.C</creatorcontrib><creatorcontrib>Arnold, W.D</creatorcontrib><creatorcontrib>Daniels, L.B</creatorcontrib><creatorcontrib>de Filippi, C</creatorcontrib><creatorcontrib>Headden, G</creatorcontrib><creatorcontrib>Peacock, W.F</creatorcontrib><title>Missed myocardial infarctions in ED patients prospectively categorized as low risk by established risk scores</title><title>The American journal of emergency medicine</title><addtitle>Am J Emerg Med</addtitle><description>Abstract Study
o
bjectives Few studies have prospectively compared multiple cardiac risk prediction scores. We compared the rate of missed acute myocardial infarction (AMI) in chest pain patients prospectively categorized as low risk by unstructured clinical impression, and by HEART, TIMI, GRACE, and EDACS scores, in combination with two negative contemporary cardiac troponins (cTn) available in the U.S. Methods We enrolled 434 patients with chest pain presenting to one of seven emergency departments (ED). Risk scores were prospectively calculated and included the first two cTn. Low risk was defined for each score as HEART ≤ 3, TIMI ≤ 0, GRACE ≤ 50, and EDACS ≤ 15. AMI incidence was calculated for low risk patients and compared across scores using Χ2 tests and C statistics. Results The patients
'
median age was 57, 58% were male, 60% white, and 80 (18%) had AMI. The missed AMI rate in low risk patients for each of the scores when combined with 2 cTn were HEART 3.6
%, TIMI 0%, GRACE 6.3%, EDACS 0.9%, and unstructured clinical impression 0%. The C-statistic was greatest for the EDACS score, 0.94 (95% CI, 0.92
–
0.97). Conclusions Using their recommended cutpoints and non high sensitivity cTn, TIMI and unstructured clinical impression were the only scores with no missed cases of AMI. Using lower cutpoints (GRACE ≤ 48, TIMI = 0, EDACS ≤ 11, HEART ≤ 2) missed no case of AMI, but classified less patients as low-risk.</description><subject>Accuracy</subject><subject>Acute coronary syndromes</subject><subject>Angina pectoris</subject><subject>Chest</subject><subject>Chest Pain - blood</subject><subject>Chest Pain - diagnosis</subject><subject>Clinical medicine</subject><subject>Decision Support Techniques</subject><subject>Electrocardiography</subject><subject>Electrocardiography - statistics & numerical data</subject><subject>Emergency</subject><subject>Emergency medical care</subject><subject>Emergency medical services</subject><subject>Emergency Service, Hospital</subject><subject>Female</subject><subject>Finland</subject><subject>Health risks</subject><subject>Heart attacks</subject><subject>Heart diseases</subject><subject>Humans</subject><subject>Incidence</subject><subject>Ischemia</subject><subject>Male</subject><subject>Medical imaging</subject><subject>Middle Aged</subject><subject>Myocardial infarction</subject><subject>Myocardial Infarction - blood</subject><subject>Myocardial Infarction - diagnosis</subject><subject>Pain</subject><subject>Patients</subject><subject>Physicians</subject><subject>Population</subject><subject>Predictive Value of Tests</subject><subject>Prospective Studies</subject><subject>Risk Assessment</subject><subject>Risk groups</subject><subject>Troponin - blood</subject><issn>0735-6757</issn><issn>1532-8171</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2017</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>8G5</sourceid><sourceid>BENPR</sourceid><sourceid>GUQSH</sourceid><sourceid>M2O</sourceid><recordid>eNp9Uk1v1TAQtBCIvhb-AAdkiQuXhN04iRMJIaHSAlIRB-BsOc4GnObj4c0rCr8eh1dA6gEfbMs7M1rPrBBPEFIELF_0qe1pTDNAnQKmAOqe2GGhsqRCjffFDrQqklIX-kScMvcAiHmRPxQnWYVQZRnsxPjBM1Mrx3V2NrTeDtJPnQ1u8fPE8S4v3si9XTxNC8t9mHlPsXZDwyqdXejrHPzPyLcsh_mHDJ6vZbNK4sU2g-dvsfT7jd0ciB-JB50dmB7fnmfiy-XF5_N3ydXHt-_PX18lLlf1kuQ6B93oCusMtKO61bah1qpOaeuoAQdNoUvXda0usc2VhRoclbauOh2XUmfi-VE3Nvz9EJsxo2dHw2Anmg9ssCqxqHSWVxH67A60nw9hit0ZrCHL67hhRGVHlIsOcKDO7IMfbVgNgtnCML3ZwjBbGAbQxDAi6emt9KEZqf1L-eN-BLw8Aih6ceMpGHbRaEetD9Fl087-__qv7tDd4Cfv7HBNK_G_fxjODJhP2zhs04BaQeRr9QucibDB</recordid><startdate>20170501</startdate><enddate>20170501</enddate><creator>Singer, A.J</creator><creator>Than, M.P</creator><creator>Smith, S</creator><creator>McCullough, P</creator><creator>Barrett, T.W</creator><creator>Birkhahn, R</creator><creator>Reed, M</creator><creator>Thode, H.C</creator><creator>Arnold, W.D</creator><creator>Daniels, L.B</creator><creator>de Filippi, C</creator><creator>Headden, G</creator><creator>Peacock, W.F</creator><general>Elsevier Inc</general><general>Elsevier Limited</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7RV</scope><scope>7T5</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>8G5</scope><scope>ABUWG</scope><scope>AEUYN</scope><scope>AFKRA</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>GUQSH</scope><scope>H94</scope><scope>K9.</scope><scope>KB0</scope><scope>M0S</scope><scope>M1P</scope><scope>M2O</scope><scope>MBDVC</scope><scope>NAPCQ</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>Q9U</scope><scope>7X8</scope></search><sort><creationdate>20170501</creationdate><title>Missed myocardial infarctions in ED patients prospectively categorized as low risk by established risk scores</title><author>Singer, A.J ; Than, M.P ; Smith, S ; McCullough, P ; Barrett, T.W ; Birkhahn, R ; Reed, M ; Thode, H.C ; Arnold, W.D ; Daniels, L.B ; de Filippi, C ; Headden, G ; Peacock, W.F</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c439t-47407b7819207ce9d7abeda3f37aceb0c0b576cffd761d43a090ce6a98f777733</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2017</creationdate><topic>Accuracy</topic><topic>Acute coronary syndromes</topic><topic>Angina pectoris</topic><topic>Chest</topic><topic>Chest Pain - blood</topic><topic>Chest Pain - diagnosis</topic><topic>Clinical medicine</topic><topic>Decision Support Techniques</topic><topic>Electrocardiography</topic><topic>Electrocardiography - statistics & numerical data</topic><topic>Emergency</topic><topic>Emergency medical care</topic><topic>Emergency medical services</topic><topic>Emergency Service, Hospital</topic><topic>Female</topic><topic>Finland</topic><topic>Health risks</topic><topic>Heart attacks</topic><topic>Heart diseases</topic><topic>Humans</topic><topic>Incidence</topic><topic>Ischemia</topic><topic>Male</topic><topic>Medical imaging</topic><topic>Middle Aged</topic><topic>Myocardial infarction</topic><topic>Myocardial Infarction - blood</topic><topic>Myocardial Infarction - diagnosis</topic><topic>Pain</topic><topic>Patients</topic><topic>Physicians</topic><topic>Population</topic><topic>Predictive Value of Tests</topic><topic>Prospective Studies</topic><topic>Risk Assessment</topic><topic>Risk groups</topic><topic>Troponin - blood</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Singer, A.J</creatorcontrib><creatorcontrib>Than, M.P</creatorcontrib><creatorcontrib>Smith, S</creatorcontrib><creatorcontrib>McCullough, P</creatorcontrib><creatorcontrib>Barrett, T.W</creatorcontrib><creatorcontrib>Birkhahn, R</creatorcontrib><creatorcontrib>Reed, M</creatorcontrib><creatorcontrib>Thode, H.C</creatorcontrib><creatorcontrib>Arnold, W.D</creatorcontrib><creatorcontrib>Daniels, L.B</creatorcontrib><creatorcontrib>de Filippi, C</creatorcontrib><creatorcontrib>Headden, G</creatorcontrib><creatorcontrib>Peacock, W.F</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Nursing & Allied Health Database</collection><collection>Immunology Abstracts</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>Research Library (Alumni Edition)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest One Sustainability</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>Research Library Prep</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Research Library</collection><collection>Research Library (Corporate)</collection><collection>Nursing & Allied Health Premium</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central Basic</collection><collection>MEDLINE - Academic</collection><jtitle>The American journal of emergency medicine</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Singer, A.J</au><au>Than, M.P</au><au>Smith, S</au><au>McCullough, P</au><au>Barrett, T.W</au><au>Birkhahn, R</au><au>Reed, M</au><au>Thode, H.C</au><au>Arnold, W.D</au><au>Daniels, L.B</au><au>de Filippi, C</au><au>Headden, G</au><au>Peacock, W.F</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Missed myocardial infarctions in ED patients prospectively categorized as low risk by established risk scores</atitle><jtitle>The American journal of emergency medicine</jtitle><addtitle>Am J Emerg Med</addtitle><date>2017-05-01</date><risdate>2017</risdate><volume>35</volume><issue>5</issue><spage>704</spage><epage>709</epage><pages>704-709</pages><issn>0735-6757</issn><eissn>1532-8171</eissn><abstract>Abstract Study
o
bjectives Few studies have prospectively compared multiple cardiac risk prediction scores. We compared the rate of missed acute myocardial infarction (AMI) in chest pain patients prospectively categorized as low risk by unstructured clinical impression, and by HEART, TIMI, GRACE, and EDACS scores, in combination with two negative contemporary cardiac troponins (cTn) available in the U.S. Methods We enrolled 434 patients with chest pain presenting to one of seven emergency departments (ED). Risk scores were prospectively calculated and included the first two cTn. Low risk was defined for each score as HEART ≤ 3, TIMI ≤ 0, GRACE ≤ 50, and EDACS ≤ 15. AMI incidence was calculated for low risk patients and compared across scores using Χ2 tests and C statistics. Results The patients
'
median age was 57, 58% were male, 60% white, and 80 (18%) had AMI. The missed AMI rate in low risk patients for each of the scores when combined with 2 cTn were HEART 3.6
%, TIMI 0%, GRACE 6.3%, EDACS 0.9%, and unstructured clinical impression 0%. The C-statistic was greatest for the EDACS score, 0.94 (95% CI, 0.92
–
0.97). Conclusions Using their recommended cutpoints and non high sensitivity cTn, TIMI and unstructured clinical impression were the only scores with no missed cases of AMI. Using lower cutpoints (GRACE ≤ 48, TIMI = 0, EDACS ≤ 11, HEART ≤ 2) missed no case of AMI, but classified less patients as low-risk.</abstract><cop>United States</cop><pub>Elsevier Inc</pub><pmid>28108220</pmid><doi>10.1016/j.ajem.2017.01.003</doi><tpages>6</tpages></addata></record> |
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| subjects | Accuracy Acute coronary syndromes Angina pectoris Chest Chest Pain - blood Chest Pain - diagnosis Clinical medicine Decision Support Techniques Electrocardiography Electrocardiography - statistics & numerical data Emergency Emergency medical care Emergency medical services Emergency Service, Hospital Female Finland Health risks Heart attacks Heart diseases Humans Incidence Ischemia Male Medical imaging Middle Aged Myocardial infarction Myocardial Infarction - blood Myocardial Infarction - diagnosis Pain Patients Physicians Population Predictive Value of Tests Prospective Studies Risk Assessment Risk groups Troponin - blood |
| title | Missed myocardial infarctions in ED patients prospectively categorized as low risk by established risk scores |
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