Beyond chest pain: Incremental value of other variables to identify patients for an early ECG

https://doi.org/10.1016/j.ajem.2023.01.054Get rights and content

Highlights

  • The use of additional variables to identify patients for ECGs in the ED can increase the sensitivity of screening for ACS without increasing the number of ECGs that need to be performed in the ED.

  • Screening to obtain an ECG in 100% of ACS patients in the ED is challenging without introducing more complex risk calculation into clinical care.

  • The use of predictive modeling to identify those with high risk for ACS, as well as the subset with STEMI, can improve emergency cardiovascular care delivery.

Abstract

Background

Chest pain (CP) is the hallmark symptom for acute coronary syndrome (ACS) but is not reported in 20–30% of patients, especially women, elderly, non-white patients, presenting to the emergency department (ED) with an ST-segment elevation myocardial infarction (STEMI).

Methods

We used a retrospective 5-year adult ED sample of 279,132 patients to explore using CP alone to predict ACS, then we incrementally added other ACS chief complaints, age, and sex in a series of multivariable logistic regression models. We evaluated each model's identification of ACS and STEMI.

Results

Using CP alone would recommend ECGs for 8% of patients (sensitivity, 61%; specificity, 92%) but missed 28.4% of STEMIs. The model with all variables identified ECGs for 22% of patients (sensitivity, 82%; specificity, 78%) but missed 14.7% of STEMIs. The model with CP and other ACS chief complaints had the highest sensitivity (93%) and specificity (55%), identified 45.1% of patients for ECG, and only missed 4.4% of STEMIs.

Conclusion

CP alone had highest specificity but lacked sensitivity. Adding other ACS chief complaints increased sensitivity but identified 2.2-fold more patients for ECGs. Achieving an ECG in 10 min for patients with ACS to identify all STEMIs will be challenging without introducing more complex risk calculation into clinical care.

Introduction

Mortality from STEMI rises 7.5% for every 30-min delay in care [1]. The American Heart Association, American College of Cardiology, American College of Emergency Physicians and European College of Cardiology endorse acquiring an electrocardiogram (ECG) within 10 min of a patient's arrival in an Emergency Department (ED) if symptoms suggest myocardial ischemia [2,3,4]. Thus, even before physician evaluation, EDs screen for patients with a potential STEMI who should be prioritized to jump queue for an ECG [5,6,7]. This early ECG is then interpreted by a physician [5,6,7]. Identifying STEMI patients as quickly as possible helps get them the immediate care they need. Furthermore, it helps rule out STEMI for those with other ACS conditions (i.e. non-ST elevation myocardial infarction (NSTEMI) and unstable angina (UA)) which assures they can safely progress along their urgent but less emergent diagnostic pathways.

Few studies have described strategies to screen all arriving ED patients for symptoms that suggest myocardial ischemia [2,3]. Consequently, the criteria EDs use to screen for ACS varies across institutions, and 15% of EDs have no set screening criteria [8]. Approximately 14% of EDs reported using “chest pain” as the only criterion [8], yet previous studies found 20–30% of ACS patients never reported chest pain [9,10,11]. This suggests that considering other ACS chief complaints might facilitate identifying those with an atypical or non-chest pain presentation [9]. Furthermore, since ACS affects primarily older adults, age might help predict the likelihood of an acute event [[12], [13], [14]]. Sex has also been associated with variation in ACS presentation, where ACS is more prevalent among men, but more likely to have a delayed diagnosis and present with non-chest pain symptoms in women.” [[15], [16], [17]].

Although chest pain can identify the majority of patients with ACS (most common symptom) [[1], [2], [3]], screening for ACS is challenging because while the diagnosis is often considered, it is relatively rare [18]. Indeed, most patients with concerning symptoms will have an alternative condition as their final diagnosis [19]. Currently, it is unclear whether inclusion of non-chest pain ACS symptoms would improve early ACS identification, or the degree to which more sensitive screening reduces specificity or increases the number of ECGs performed. These trade-offs must be quantified to inform optimal ACS screening practice and policy to more accurately direct care to cardiologists.

We sought to evaluate the incremental value of adding other ACS chief complaints, age, and sex to chest pain as screening criteria to identify potential ACS patients in need of an early ECG to diagnose STEMI.

Section snippets

Study design

This proof-of-concept study used a 5-year retrospective ED cohort to investigate the gains/trade-offs for a range of ED arrival practices to screen arriving patient for ACS to identify those needing an early ECG. We calculate risk using a series of logistic regression models with the underlying assumption that high ACS risk drives the need for an early ECG. We were specifically interested in the added value and trade-offs of adding other ACS chief complaints, age, and sex to the report of chest

Results

Our 5-year sample included 279,132 patients. We observed an ACS rate of 0.5% (1397), of which 16.1% (225) were STEMIs, 70.0% (978) were NSTEMI, and 13.9% (194) were UA. ACS patients were substantially older than those without ACS (mean age: 68.1 vs 50.3 years, SMD 0.97) and the rest of included ED population (mean age: 50.4 years). Less than 1% (6) of ACS patients were under 30 years old, while more than half were >50 years (1224) and 26% (360) were >80 years. ACS patients also included more

Discussion

Adding other ACS chief complaints, age, and sex to screening can help identify patients with ACS and STEMI, as evidenced by sensitivity and the AUC, over the use of chest pain as the sole screening criteria and observed ED care. Including more criteria to the decision-making processes used in the early phases of care may improve EDs' abilities to appropriately screen patients for ECGs. Nevertheless, this comes with clinical practice trade-offs that suggest achieving an ECG within 10 min for all

Limitations

There are limitations to consider when interpreting our findings. We used final hospital diagnosis ICD codes, which may capture in-hospital events that were not active in the ED. We examined all admitted patient cases where the first ECG was acquired in-hospital. None represented missed ACS diagnoses. All reflected an evolution of illness towards an ACS event. Although this captured ACS events that were identified after the ED care, we determined it was favorable to acquire an ECG early for

Conclusion

Chest pain had the highest specificity but was insufficiently sensitive to be the only ACS screening criterion. Incorporating other ACS chief complaints dramatically improved sensitivity and missed the fewest STEMI patients, but it would result in 2.2-fold more ECGs compared to observed care. This proof-of-concept analysis can inform balancing risk tolerance with the potential burden of increased early ECG testing from ED intake. Nevertheless, achieving ECGs within 10 min will require more

CRediT authorship contribution statement

Gabrielle Bunney: Writing – review & editing, Investigation. Vandana Sundaram: Writing – original draft, Visualization, Validation, Methodology, Investigation, Formal analysis, Data curation. Anna Graber-Naidich: Writing – original draft, Software, Investigation, Data curation. Ian Brown: Writing – review & editing, Data curation. Allison B. McCoy: Writing – review & editing, Methodology, Data curation, Conceptualization. Brian Freeze: Writing – review & editing. David Berger: Writing – review

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

Research reported in this publication was supported by the Emergency Department Benchmarking Alliance (EDBA), National Institutes of Health's (NIH) National Heart Lung and Blood Institute's (NHLBI) award number K23HL133477, National Institutes of Health's (NIH) National Center for Advancing Translational Sciences (NCATS) award numbers UL1TR000445 and UL1TR002243, which include the Vanderbilt Institute for Clinical and Translational Research Learning Healthcare System Platform. The content is

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