Monday, March 28, 2011


The March 23rd issue of Lancet, carried a simple piece of work by the group from New Zealand on the evaluation of chest pains in the emergency department, in the Asian Pacific region. The study is called ASPECT - Asia Pacific Evaluation of Chest Pain Trial.
Sorting out chest pains in the ER ( emergency room ), can be quite a challenge. If you are too strict in your criteria, you may either discharge too many home ( and run the risk of deaths and AMIs at home ) with the attendant risk of patient complaints and law suits, or if you are too lax, you end up admitting too many chest pains and clog up all your hospital beds.
The group of workers from Christchurch, New Zealand, led by Dr Martin Than actually involved cases from 14 ER across the Asian Pacific regions, including hospitals in Hong Kong, Taiwan, Indonesia, Singapore, and Australia. This gives us the Asian flavour. They studied 3582 patients, age 18 and above who presented with chest pains of more then 5 mins duration. They categorised them into TIMI risk scores from 0-7, their ECG on presentation ( see if there are any ischemic changes ), and the stat Trop T, CK and Myoglobin, and 2 hours later. The primary endpoint was cardiac events at 30 days. They found that using these simple criteria, they could achieve a sensitivity of 99.3% ( they were not insensitive ), and they had a negative predictive value of 99.1%. that if the protocol predicts that the patient does not have cardiac chest pains, they were right 99.1% of the time. That is good, especially since the protocol cost is fairly cheap. In the USA, you may have to use the MSCT to exclude cardiac disease with chest pains, in those in the low and intermediate risk group.
I usually use a combination of what they do. In patients with chest pains, I think the history is very important and the associated cardiac risk ( TIMI risk score) factors. A good history of anginal type chest pains, and the presence of 1 or 2 cardiac risk factors, will make me very wary of sending that patient home. A good look at the ECG for ischemic changes, and a Trop T at point of care. Usually, this allows me to make up my mind whether to admit or not. I suppose the saying is true. If at the of all this, you are still unable to discriminate between cardiac or non cardiac pains ( and this can happen, especially in females with diabetes ), then admitting may be the better patient care option. Better to be over cautious then to risk a death at home.

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