Risk stratification of patients with chest pain who have an unscheduled revisit to the emergency department

https://doi.org/10.1016/j.ijcard.2023.04.043Get rights and content

Highlights

  • An abnormal hs-cTnT level, with an adjusted cut-off threshold value, is a significant risk factor for the development of acute cardiovascular disease in short-term emergency department revisits.

  • Sequential follow-up of hs-cTnT can predict the short-term development of acute cardiovascular emergencies.

  • Male gender and abnormal electrocardiography rhythms are also significant risk factors for cardiovascular emergencies.

  • The cut-off threshold of hs-cTnT in patients with known coronary artery disease or renal dysfunction should be adjusted accordingly.

Abstract

Aims

Acute cardiovascular (CV) emergencies are critical conditions that require urgent attention in the emergency department (ED). Failure to make a timely diagnosis may result in unscheduled ED revisits and severe outcomes. Therefore, this study aimed to investigate the risk factors associated with potentially missed acute CV emergencies.

Methods and results

This retrospective study enrolled adult patients who presented with chest pain and returned to the ED within 72 h. Demographic information, pre-existing medical conditions, chief complaints, triage level and vital signs, electrocardiography (ECG) reports, and laboratory data were collected from medical charts by independent physicians. The primary outcome was the diagnosis of acute CV diseases, including ACS, pulmonary embolism, unstable arrhythmia, acute decompensated heart failure, and aortic dissection. Multivariable logistic regression was used to analyze the association between variables and acute CV emergencies. A total of 453 eligible patients were included, with 60 (13.2%) patients diagnosed as acute CV emergencies at the ED revisit. Risk factors for acute CV emergencies included male gender (adjusted odds ratio [aOR] = 2.71, 95% confidence interval [CI] = 1.17–6.25), abnormal ECG rhythm (aOR = 10.33, 95% CI = 4.68–22.83), and abnormal changes in high sensitivity Troponin-T (hs-cTnT) during sequential follow-up (aOR = 6.52, 95% CI = 2.19–19.45).

Conclusions

Male gender, abnormal ECG rhythm, and a significant increase in sequential follow-up hs-cTnT levels were identified as significant risk factors for acute CV emergencies. ED physicians should recognize these high-risk patients with chest pain to prevent misdiagnosis and potential severe complications.

Introduction

Chest pain is one of the most common complaints in the emergency department (ED). Acute cardiovascular (CV) emergencies, including acute coronary syndrome (ACS), pulmonary embolism (PE), unstable arrhythmia, acute decompensated heart failure (ADHF), aortic dissection, and fulminant myocarditis, require immediate surgical intervention or intensive hemodynamic monitoring. Additionally, they confer a high risk of mortality with an overall expected disease prevalence of 45–55% [1,2]. Clinical risk stratification tools, such as the Thrombolysis In Myocardial Infarction (TIMI) risk and Global Registry of Acute Coronary Events (GRACE) scores, have been developed to improve proper disposition in patients with confirmed ACS. However, these are not sensitive for ED patients with undifferentiated chest pain [[3], [4], [5]]. The History, Electrocardiogram, Age, Risk factors, Troponin (HEART) score with serial troponin testing (HEART Pathway) has been developed exclusively for patients with undifferentiated chest pain; this has been shown to improve prognosis [6]. However, it has limitations in predicting short-term deterioration of CV disease other than ACS. Moreover, it has not been prospectively validated in populations outside of western Europe and North America. Additionally, cardiac troponin might be falsely elevated in non-acute cardiac conditions, for example the elderly, patients with renal dysfunction, or those with pre-existed myocardial injury. The threshold cut-off value has been investigated but remained undetermined in different populations [1,2,7].

Missing the critical diagnosis of chest pain leads to unscheduled short-term revisits and may cause significant morbidity, mortality, or legal issues. Our study aimed to evaluate patients with chest pain who were at risk of acute cardiac etiology by using a statistical combination of clinical features, personal histories, features of electrocardiography (ECG), and laboratory biomarkers during the index visit. The purpose of this was to predict acute CV emergencies that would develop in short-term revisits to the ED.

Section snippets

Study design and setting

This was a single-center, retrospective cohort study conducted at the ED of National Taiwan University Hospital, Hsin-Chu Branch (NTUH-HCH) between 2019 and 2021. This study was approved by the Institution Review Board of NTUH-HCH (no. 109–003-E). ED physicians reviewed the electronic medical records to recruit eligible patients, collect covariates, interpret results of examination, and define the outcome.

Case selection

Between January 2019 and December 2021, eligible patients were selected based on the

Participant characteristics

Approximately 60,000 patients visit the ED annually; the revisit rate is 4%–5%. During the study period, 7699 patients revisited the ED within 72 h, and 568 patients who presented with chest pain during the index visit were included in this analysis. We excluded 20 non-adult patients who were < 20-years-old. An additional 90 patients failed to receive ECG during the index visit and were excluded. Therefore, 453 patients who matched the inclusion criteria were included in the final analysis; 60

Discussion

The current study found that males, abnormal ECG rhythms, and abnormal hs-cTnT levels—especially a significant elevation at follow-up in the index visit—were high-risk factors associated with the development of acute CV emergencies during short-term revisit. An abnormality in the sequential hs-cTnT trajectory was significantly associated with ACS and non-ACS CV emergencies. Furthermore, the hs-cTnT threshold should be adjusted according to patients' age, creatinine level, and history of CAD.

Conclusion

Being male, arrhythmia, and a significant elevation in sequential follow up hs-cTnT level were significant risk factors associated with the short-term development of acute CV emergencies. Additionally, hs-cTnT levels predicted the outcomes well in the subgroup of younger patients and those with normal renal function alone. The cut-off threshold of hs-cTnT in patients with known CAD or renal dysfunction should be adjusted.

Source of funding

This work was funded by the National Taiwan University Hospital Hsin-Chu Branch (grant number 110-HCH019 and 111-HCH049).

CRediT authorship contribution statement

Yi-Ju Ho: Data curation, Investigation, Methodology, Writing – original draft. Chi-Hsin Chen: Data curation, Investigation, Methodology. Chih-Wei Sung: Investigation, Resources. Cheng-Yi Fan: Investigation, Project administration. Shao-Yung Lin: Investigation. Jiun-Wei Chen: Investigation. Edward Pei-Chuan Huang: Conceptualization, Resources, Supervision, Writing – review & editing.

Declaration of Competing Interest

The authors declare that they have no conflict of interest.

Acknowledgments

We thank Crimson Interactive Inc., an editing brand of Enago, for the English language review.

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