The Challenge of Triaging Chest Pain Patients: The Bernese University Hospital Experience

Accurate diagnosis of the causes of chest pain and dyspnea remain challenging. In this preliminary observational study with a 5-year follow-up, we attempted to find a simplified approach to selecting patients with chest pain needing immediate care based on the initial evaluation in ED. During a 24-month period were randomly selected 301 patients and a conditional inference tree (CIT) was used as the basis of the prognostic rule. Common diagnoses were musculoskeletal chest pain (27%), ACS (19%) and panic attack (12%). Using variables of ACS symptoms we estimated the likelihood of ACS based on a CIT to be high at 91% (32), low at 4% (198) and intermediate at 20.5–40% in (71) patients. Coronary catheterization was performed within 24 hours in 91% of the patients with ACS. A culprit lesion was found in 79%. Follow-up (median 4.2 years) information was available for 70% of the patients. Of the 164 patients without ACS who were followed up, 5 were treated with revascularization for stable angina pectoris, 2 were treated with revascularization for myocardial infarction, and 25 died. Although a simple triage decision tree could theoretically help to efficient select patients needing immediate care we need also to be vigilant for those presenting with atypical symptoms.

[1]  Massimo Gallerani,et al.  Seasonal and weekly patterns of hospital admissions for nonfatal and fatal myocardial infarction. , 2009, The American journal of emergency medicine.

[2]  M. Klinkman,et al.  Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network. , 1994, The Journal of family practice.

[3]  J. Ornato,et al.  ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patie , 2007, Journal of the American College of Cardiology.

[4]  Achim Zeileis,et al.  Bias in random forest variable importance measures: Illustrations, sources and a solution , 2007, BMC Bioinformatics.

[5]  Maureen Chase,et al.  Prospective validation of the Thrombolysis in Myocardial Infarction Risk Score in the emergency department chest pain population. , 2006, Annals of emergency medicine.

[6]  E. Antman,et al.  The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. , 2000, JAMA.

[7]  S. Z. Abildstrøm,et al.  Women with acute coronary syndrome are less invasively examined and subsequently less treated than men. , 2010, European heart journal.

[8]  E. Antman,et al.  Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) 11B trial. , 1999, Circulation.

[9]  E. Antman,et al.  Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial , 2009, The Lancet.

[10]  D. Levy,et al.  Prediction of coronary heart disease using risk factor categories. , 1998, Circulation.

[11]  A. Conway Morris,et al.  TIMI risk score accurately risk stratifies patients with undifferentiated chest pain presenting to an emergency department , 2006, Heart.

[12]  K. Hornik,et al.  Unbiased Recursive Partitioning: A Conditional Inference Framework , 2006 .

[13]  R. Bassan,et al.  Accuracy of a neural diagnostic tree for the identification of acute coronary syndrome in patients with chest pain and no ST-segment elevation. , 2004, Critical pathways in cardiology.

[14]  R. Califf,et al.  A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. , 1997 .

[15]  J. Hollander,et al.  Evaluation of a clinical decision rule for young adult patients with chest pain. , 2005, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[16]  G. Dupuis,et al.  Angina symptoms in men and women with stable coronary artery disease and evidence of exercise-induced myocardial perfusion defects. , 2006, American heart journal.

[17]  L. P. D. Isla,et al.  Estratificación de riesgo en pacientes con dolor torácico sin ascenso persistente del segmento ST basado en variables clínicas, ECG y bioquímicas. ¿Cuánto tiempo debemos esperar? , 2003 .

[18]  Robert Califf,et al.  Value of the History and Physical in Identifying Patients at Increased Risk for Coronary Artery Disease , 1993, Annals of Internal Medicine.

[19]  L. Pérez de Isla,et al.  [Risk stratification using combined ECG, clinical, and biochemical assessment in patients with chest pain without ST-segment elevation. How long should we wait? ]. , 2003, Revista espanola de cardiologia.

[20]  T. Fearn,et al.  Classification and Regression Trees (CART) , 2020, Statistical Learning from a Regression Perspective.

[21]  M. Teghtsoonian,et al.  Distinguishable sensations of breathlessness induced in normal volunteers. , 1989, The American review of respiratory disease.

[22]  M. Mcclellan,et al.  Trends in treatment and outcomes for acute myocardial infarction: 1975-1995. , 2001, The American journal of medicine.

[23]  J. Ornato,et al.  2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST‐Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update) , 2009, Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions.

[24]  A. Exadaktylos,et al.  Referral practice among Swiss and non-Swiss walk-in patients in an urban surgical emergency department. , 2010, Swiss medical weekly.

[25]  S. Kaul,et al.  Myocardial contrast echocardiography versus Thrombolysis In Myocardial Infarction score in patients presenting to the emergency department with chest pain and a nondiagnostic electrocardiogram. , 2005, Journal of the American College of Cardiology.

[26]  D. Caesar,et al.  Chest pain presenting to the Emergency Department--to stratify risk with GRACE or TIMI? , 2007, Resuscitation.

[27]  J. Maindonald.  Statistical Learning from a Regression Perspective , 2008 .

[28]  Eugenia Yu,et al.  A clinical prediction rule for early discharge of patients with chest pain. , 2006, Annals of emergency medicine.

[29]  S Capewell,et al.  The health care burden of acute chest pain , 2005, Heart.

[30]  Panic disorder in emergency ward patients with chest pain. , 1997, The Journal of nervous and mental disease.

[31]  E. Roupie,et al.  Prediction of myocardial infarction risk in older patients with acute coronary syndrome. , 2009, The American journal of emergency medicine.

[32]  A. Timmis,et al.  Assessment of recent onset chest pain or discomfort of suspected cardiac origin: summary of NICE guidance , 2010, BMJ : British Medical Journal.

[33]  Oscar Miró,et al.  Triage flowchart to rule out acute coronary syndrome. , 2007, The American journal of emergency medicine.

[34]  Fred S Apple,et al.  Universal definition of myocardial infarction. , 2007, Journal of the American College of Cardiology.