Ninety-minute accelerated critical pathway for chest pain evaluation

doi:10.1016/S0002-9149(01)01801-X

The American Journal of Cardiology

Volume 88, Issue 6, 15 September 2001, Pages 611-617

https://doi.org/10.1016/S0002-9149(01)01801-X Get rights and content

Abstract

Rapid, efficient, and accurate evaluation of chest pain patients in the emergency department optimizes patient care from public health, economic, and liability perspectives. To evaluate the performance of an accelerated critical pathway for patients with suspected coronary ischemia that utilizes clinical history, electrocardiographic findings, and triple cardiac marker testing (cardiac troponin I [cTnI], myoglobin, and creatine kinase-MB [CK-MB]), we performed an observational study of a chest pain critical pathway in the setting of a large Emergency Department at the Veterans Affairs Medical Center in 1,285 consecutive patients with signs and symptoms of cardiac ischemia. The accelerated critical pathway for chest pain evaluation was analyzed for: (1) accuracy in triaging of patients within 90 minutes of presentation, (2) sensitivity, specificity, positive predictive value, and negative predictive value of cTnI, myoglobin, and CK-MB in diagnosing acute myocardial infarction (MI) within 90 minutes, and (3) impact on Coronary Care Unit (CCU) admissions. All MIs were diagnosed within 90 minutes of presentation (sensitivity 100%, specificity 94%, positive predictive value 47%, negative predictive value 100%). CCU admissions decreased by 40%. Ninety percent of patients with negative cardiac markers and a negative electrocardiogram at 90 minutes were discharged home with 1 patient returning with an MI (0.2%) within the next 30 days. Thus, a simple, inexpensive, yet aggressive critical pathway that utilizes high-risk features from clinical history, electrocardiographic changes, and rapid point-of-care testing of 3 cardiac markers allows for accurate triaging of chest pain patients within 90 minutes of presenting to the emergency department.

Section snippets

Methods

Preliminary studies with cTnI were approved by the University of California, San Diego, Committee on Human Subjects. From this initial research, a critical pathway utilizing a cardiac marker algorithm was established as the standard of care and implemented at the San Diego Veterans’ Affairs Hospital. During a 9-month period from July 1998 to April 1999, we analyzed the diagnoses, triage patterns, and medical outcome of 1,285 consecutive patients who presented to the emergency department with

Patient characteristics

The clinical characteristics of the 1,285 patients enrolled in this study are shown in Table 1. Patients without a subsequent diagnosis of MI or unstable angina more commonly waited >6 hours before presenting to the emergency department. Patients diagnosed with MI or unstable angina were likely to have new onset of chest pain at rest as well as a history of MI. In the 66 patients with acute MI confirmed by elevated CK-MB, the electrocardiogram was diagnostic (ST-segment elevation) in only 17%

Discussion

Using the critical pathway in this study, all patients who “ruled in” with an acute MI were identified within a 90-minute time period. The negative predictive value of early repetitive cardiac marker testing in this setting was 100% using a combination of 3 markers. Although not all patients were discharged at 90 minutes, the results of this study indicates that rapid triage of all patients, including high- and low-risk patients is possible within 90 minutes of presentation. This critical

Acknowledgements

The investigators thank our laboratory technicians for carefully running the markers and the CCU nurses for aiding in collection of samples and and adherence to the critical pathway.

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Ninety-minute accelerated critical pathway for chest pain evaluation

Abstract

Section snippets

Methods

Patient characteristics

Discussion

Acknowledgements

Am J Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

Am J Cardiol

Ann Emerg Med

Evaluation of the patient with acute chest pain

N Engl J Med

Physicians’ estimate of the probability of myocardial infarction in emergency room patients with chest pain

Med Dec Making

Emergency department triage strategies for acute chest pain using creatine kinase-MB and troponin I assaysa cost-effectiveness analysis

Ann Intern Med

A clinical trial of a chest-pain observation unit for patients with unstable angina. Chest Pain Evaluation in the Emergency Room (CHEER) Investigators

N Engl J Med