Acute Coronary Syndrome Screening and Diagnostic Practice Variation

and the ED Operations Study Group 2015

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

Background: In the absence of the existing acute coronary syndrome (ACS) guidelines directing the clinical practice implementation of emergency department (ED) screening and diagnosis, there is variable screening and diagnostic clinical practice across ED facilities. This practice diversity may be warranted. Understanding the variability may identify opportunities for more consistent practice. Methods: This is a cross-sectional clinical practice epidemiology study with the ED as the unit of analysis characterizing variability in the ACS evaluation across 62 diverse EDs. We explored three domains of screening and diagnostic practice: 1) variability in criteria used by EDs to identify patients for an early electrocardiogram (ECG) to diagnose ST-elevation myocardial infarction (STEMI), 2) nonuniform troponin biomarker and formalized pre-troponin risk stratification use for the diagnosis of non-ST-elevation myocardial infarction (NSTEMI), and 3) variation in the use of noninvasive testing (NIVT) to identify obstructive coronary artery disease or detect inducible ischemia. Results: We found that 85% of EDs utilize a formal triage protocol to screen patients for an early ECG to diagnose STEMI. Of these, 17% use chest pain as the sole criteria. For the diagnosis of NSTEMI, 58% use intervals ≥4 hours for a second troponin and 34% routinely risk stratify before troponin testing. For the diagnosis of noninfarction ischemia, the median percentage of patients who have NIVT performed during their ED visit is 5%. The median percentage of patients referred for NIVT in hospital (observation or admission) is 61%. Coronary CT angiography is used in 66% of EDs. Exercise treadmill testing is the most frequently reported first-line NIVT (42%). Conclusion: Our results suggest highly variable ACS screening and clinical practice.

Original languageEnglish (US)
Pages (from-to)701-709
Number of pages9
JournalAcademic Emergency Medicine
Volume24
Issue number6
DOIs
StatePublished - Jun 1 2017
Externally publishedYes

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Acute Coronary Syndrome
Troponin
Hospital Emergency Service
Electrocardiography
Ischemia
Triage
Coronary Angiography
Chest Pain
Coronary Artery Disease
Epidemiology
Biomarkers
Observation
Guidelines
Exercise

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Acute Coronary Syndrome Screening and Diagnostic Practice Variation. / and the ED Operations Study Group 2015.

In: Academic Emergency Medicine, Vol. 24, No. 6, 01.06.2017, p. 701-709.

Research output: Contribution to journalArticle

and the ED Operations Study Group 2015. / Acute Coronary Syndrome Screening and Diagnostic Practice Variation. In: Academic Emergency Medicine. 2017 ; Vol. 24, No. 6. pp. 701-709.
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title = "Acute Coronary Syndrome Screening and Diagnostic Practice Variation",
abstract = "Background: In the absence of the existing acute coronary syndrome (ACS) guidelines directing the clinical practice implementation of emergency department (ED) screening and diagnosis, there is variable screening and diagnostic clinical practice across ED facilities. This practice diversity may be warranted. Understanding the variability may identify opportunities for more consistent practice. Methods: This is a cross-sectional clinical practice epidemiology study with the ED as the unit of analysis characterizing variability in the ACS evaluation across 62 diverse EDs. We explored three domains of screening and diagnostic practice: 1) variability in criteria used by EDs to identify patients for an early electrocardiogram (ECG) to diagnose ST-elevation myocardial infarction (STEMI), 2) nonuniform troponin biomarker and formalized pre-troponin risk stratification use for the diagnosis of non-ST-elevation myocardial infarction (NSTEMI), and 3) variation in the use of noninvasive testing (NIVT) to identify obstructive coronary artery disease or detect inducible ischemia. Results: We found that 85{\%} of EDs utilize a formal triage protocol to screen patients for an early ECG to diagnose STEMI. Of these, 17{\%} use chest pain as the sole criteria. For the diagnosis of NSTEMI, 58{\%} use intervals ≥4 hours for a second troponin and 34{\%} routinely risk stratify before troponin testing. For the diagnosis of noninfarction ischemia, the median percentage of patients who have NIVT performed during their ED visit is 5{\%}. The median percentage of patients referred for NIVT in hospital (observation or admission) is 61{\%}. Coronary CT angiography is used in 66{\%} of EDs. Exercise treadmill testing is the most frequently reported first-line NIVT (42{\%}). Conclusion: Our results suggest highly variable ACS screening and clinical practice.",
author = "{and the ED Operations Study Group 2015} and Yiadom, {Maame Yaa A.B.} and Xulei Liu and McWade, {Conor M.} and Dandan Liu and Storrow, {Alan B.} and Patricia Herdon-Meadors and Wesley Shuler and Eric Goldlust and Charles Sawyer and Andrew Wong and Andrew Wong and Brian Patterson and Dan Wiener and Baugh, {Christopher W.} and Carlson, {Jestin N.} and Strout, {Tania D.} and Hill, {Charles D.} and Michael Turturro and Carlene Whitcomb and Patricia Dunlap and McPheeters, {Rick A.} and Nicholas Gavin and Johnathan Hansen and Cindy Web and Meghan Calichman and Paul Chen and Gilberto Salazar and Brooke Shepard and Benjamin Milligan and Kenneth Rudd and Adrea Lee and Thomas Spiegel and Lee Garvey and Scott Rodi and Jeff Caterino and Brendan Furlong and Jeff Dubin and Jason Imperato and Anju Vohra and Angela Mills and David Hager and Seth Podolsky and April Novotny and Lisa Hartsfield and Samuel Bosco and McDermott, {David B.} and Charissa Pacella and Anthony Mazzeo and Maria Guyette and Thomas McCoy",
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T1 - Acute Coronary Syndrome Screening and Diagnostic Practice Variation

AU - and the ED Operations Study Group 2015

AU - Yiadom, Maame Yaa A.B.

AU - Liu, Xulei

AU - McWade, Conor M.

AU - Liu, Dandan

AU - Storrow, Alan B.

AU - Herdon-Meadors, Patricia

AU - Shuler, Wesley

AU - Goldlust, Eric

AU - Sawyer, Charles

AU - Wong, Andrew

AU - Wong, Andrew

AU - Patterson, Brian

AU - Wiener, Dan

AU - Baugh, Christopher W.

AU - Carlson, Jestin N.

AU - Strout, Tania D.

AU - Hill, Charles D.

AU - Turturro, Michael

AU - Whitcomb, Carlene

AU - Dunlap, Patricia

AU - McPheeters, Rick A.

AU - Gavin, Nicholas

AU - Hansen, Johnathan

AU - Web, Cindy

AU - Calichman, Meghan

AU - Chen, Paul

AU - Salazar, Gilberto

AU - Shepard, Brooke

AU - Milligan, Benjamin

AU - Rudd, Kenneth

AU - Lee, Adrea

AU - Spiegel, Thomas

AU - Garvey, Lee

AU - Rodi, Scott

AU - Caterino, Jeff

AU - Furlong, Brendan

AU - Dubin, Jeff

AU - Imperato, Jason

AU - Vohra, Anju

AU - Mills, Angela

AU - Hager, David

AU - Podolsky, Seth

AU - Novotny, April

AU - Hartsfield, Lisa

AU - Bosco, Samuel

AU - McDermott, David B.

AU - Pacella, Charissa

AU - Mazzeo, Anthony

AU - Guyette, Maria

AU - McCoy, Thomas

PY - 2017/6/1

Y1 - 2017/6/1

N2 - Background: In the absence of the existing acute coronary syndrome (ACS) guidelines directing the clinical practice implementation of emergency department (ED) screening and diagnosis, there is variable screening and diagnostic clinical practice across ED facilities. This practice diversity may be warranted. Understanding the variability may identify opportunities for more consistent practice. Methods: This is a cross-sectional clinical practice epidemiology study with the ED as the unit of analysis characterizing variability in the ACS evaluation across 62 diverse EDs. We explored three domains of screening and diagnostic practice: 1) variability in criteria used by EDs to identify patients for an early electrocardiogram (ECG) to diagnose ST-elevation myocardial infarction (STEMI), 2) nonuniform troponin biomarker and formalized pre-troponin risk stratification use for the diagnosis of non-ST-elevation myocardial infarction (NSTEMI), and 3) variation in the use of noninvasive testing (NIVT) to identify obstructive coronary artery disease or detect inducible ischemia. Results: We found that 85% of EDs utilize a formal triage protocol to screen patients for an early ECG to diagnose STEMI. Of these, 17% use chest pain as the sole criteria. For the diagnosis of NSTEMI, 58% use intervals ≥4 hours for a second troponin and 34% routinely risk stratify before troponin testing. For the diagnosis of noninfarction ischemia, the median percentage of patients who have NIVT performed during their ED visit is 5%. The median percentage of patients referred for NIVT in hospital (observation or admission) is 61%. Coronary CT angiography is used in 66% of EDs. Exercise treadmill testing is the most frequently reported first-line NIVT (42%). Conclusion: Our results suggest highly variable ACS screening and clinical practice.

AB - Background: In the absence of the existing acute coronary syndrome (ACS) guidelines directing the clinical practice implementation of emergency department (ED) screening and diagnosis, there is variable screening and diagnostic clinical practice across ED facilities. This practice diversity may be warranted. Understanding the variability may identify opportunities for more consistent practice. Methods: This is a cross-sectional clinical practice epidemiology study with the ED as the unit of analysis characterizing variability in the ACS evaluation across 62 diverse EDs. We explored three domains of screening and diagnostic practice: 1) variability in criteria used by EDs to identify patients for an early electrocardiogram (ECG) to diagnose ST-elevation myocardial infarction (STEMI), 2) nonuniform troponin biomarker and formalized pre-troponin risk stratification use for the diagnosis of non-ST-elevation myocardial infarction (NSTEMI), and 3) variation in the use of noninvasive testing (NIVT) to identify obstructive coronary artery disease or detect inducible ischemia. Results: We found that 85% of EDs utilize a formal triage protocol to screen patients for an early ECG to diagnose STEMI. Of these, 17% use chest pain as the sole criteria. For the diagnosis of NSTEMI, 58% use intervals ≥4 hours for a second troponin and 34% routinely risk stratify before troponin testing. For the diagnosis of noninfarction ischemia, the median percentage of patients who have NIVT performed during their ED visit is 5%. The median percentage of patients referred for NIVT in hospital (observation or admission) is 61%. Coronary CT angiography is used in 66% of EDs. Exercise treadmill testing is the most frequently reported first-line NIVT (42%). Conclusion: Our results suggest highly variable ACS screening and clinical practice.

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DO - 10.1111/acem.13184

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EP - 709

JO - Academic Emergency Medicine

JF - Academic Emergency Medicine

SN - 1069-6563

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