ABSTRACT
BACKGROUND: The aim of this study was to evaluate whether pretest probability (PTP) assessment using the Diamond-Forrester Model (DFM) combined with coronary calcium scoring (CCS) can safely rule out obstructive coronary artery disease (CAD) and 30-day major adverse cardiovascular events (MACE) in acute chest pain patients. METHODS: We retrospectively evaluated consecutive patients, age ≥18 years, with no known CAD, negative initial electrocardiogram, and troponin level. All patients had coronary computed tomographic angiography (CCTA) with CCS, and our final cohort consisted of 1988 patients. Obstructive CAD was defined as luminal narrowing of ≥50% in 1 or more vessels by CCTA. Patients were classified according to PTP as low (<10%), intermediate (10%-90%), or high (>90%). RESULTS: The DFM classified 293 (14.7%), 1445 (72.7%), and 250 (12.6%) of patients as low, intermediate, and high risk, respectively, with corresponding 30-day MACE rates of 0.0%, 2.35%, and 14.8%. For patients with intermediate PTP and CCS ≤10, the negative predictive value was 99.2% (95% confidence interval: 98.7-99.8) for 30-day MACE while it was 92.62% (95% confidence interval: 87.9-97.3) for patients with high PTP. Among patients with a high PTP and CCS of zero, the prevalence of 30-day MACE and obstructive CAD remained high (7.07% and 10.1%, respectively). CONCLUSIONS: In acute chest pain patients without evidence of ischemia on initial electrocardiogram and cardiac troponin, low PTP by DFM or the combination of intermediate PTP and CCS ≤10 had excellent negative predictive values to rule out 30-day MACE. CCS is not sufficient to exclude obstructive CAD and 30-day MACE in patients with high PTP.
Subject(s)
Calcium/metabolism , Chest Pain/diagnosis , Computed Tomography Angiography/methods , Coronary Angiography/methods , Coronary Occlusion/diagnosis , Coronary Vessels/diagnostic imaging , Vascular Calcification/diagnosis , Acute Disease , Cause of Death/trends , Chest Pain/epidemiology , Chest Pain/etiology , Coronary Occlusion/complications , Electrocardiography , Female , Follow-Up Studies , Humans , Incidence , Male , Middle Aged , Predictive Value of Tests , Prognosis , Retrospective Studies , Risk Factors , Severity of Illness Index , Time Factors , United States/epidemiology , Vascular Calcification/complications , Vascular Calcification/metabolismSubject(s)
Anticoagulants/administration & dosage , Chest Pain/diagnosis , Dyspnea/diagnosis , Echocardiography/methods , Point-of-Care Testing , Pulmonary Embolism , Thrombolytic Therapy/methods , Chest Pain/etiology , Diagnosis, Differential , Dyspnea/etiology , Endometrial Neoplasms/complications , Female , Humans , Lower Extremity/blood supply , Lower Extremity/diagnostic imaging , Middle Aged , Patient Care Management/methods , Pulmonary Artery/diagnostic imaging , Pulmonary Embolism/diagnosis , Pulmonary Embolism/etiology , Pulmonary Embolism/physiopathology , Pulmonary Embolism/therapy , Venous Thrombosis/complications , Venous Thrombosis/diagnosis , Venous Thrombosis/physiopathologyABSTRACT
Although the majority of acute chest pain patients are diagnosed with noncardiac chest pain after noninvasive testing, identifying these low-risk patients before testing is challenging. The objective of this study was to validate the coronary artery disease (CAD) consortium models for predicting obstructive CAD and 30-day major adverse cardiovascular events (MACE) in acute chest pain patients considered for coronary computed tomography angiogram, as well as to determine the pretest probability threshold that identifies low-risk patients with <1% MACE. We studied 1,981 patients with no known CAD and negative initial troponin and electrocardiogram. We evaluated CAD consortium models (basic: age, sex, and chest pain type; clinical: basicâ¯+â¯diabetes, hypertension, dyslipidemia, and smoking; and clinicalâ¯+â¯coronary calcium score [CAC] models) for prediction of obstructive CAD (≥50% stenosis on coronary CT angiogram) and 30-day MACE (Acute Myocardial Infarction, revascularization, and mortality). The C-statistic for predicting obstructive CAD was 0.77 (95% confidence interval [CI] 0.73 to 0.77) for the basic, 0.80 (95% CI 0.77 to 0.80) for the clinical, and 0.88 (95% CI 0.85 to 0.88) for the clinicalâ¯+â¯CAC models. The C-statistic for predicting 30-day MACE was 0.82 (95% CI 0.77 to 0.87) for the basic, 0.84 (95% CI 0.79 to 0.88) for the clinical, and 0.87 (95% CI 0.83 to 0.91) for the clinicalâ¯+â¯CAC models. In 47.3% of patients for whom the clinical model predicted ≤5% probability for obstructive CAD, the observed 30-day MACE was 0.53% (95% CI 0.07% to 0.999%); in the 66.9% of patients for whom the clinicalâ¯+â¯CAC model predicted ≤5% probability, the 30-day MACE was 0.75% (95% CI 0.29% to 1.22%). We propose a chest pain evaluation algorithm based on these models that classify 63.3% of patients as low risk with 0.56% (95% CI 0.15% to 0.97%) 30-day MACE. In conclusion, CAD consortium models have excellent diagnostic and prognostic value for acute chest pain patients and can safely identify a significant proportion of low-risk patients by achieving <1% missed 30-day MACE.
Subject(s)
Chest Pain/diagnostic imaging , Computed Tomography Angiography , Coronary Angiography , Coronary Artery Disease/diagnostic imaging , Age Factors , Biomarkers/blood , Chest Pain/epidemiology , Comorbidity , Coronary Artery Disease/epidemiology , Diagnosis, Differential , Electrocardiography , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Prevalence , Risk Assessment , Risk Factors , Sex FactorsABSTRACT
We surveyed volunteers from 8 hospices in the Delaware Valley regarding training, perceived needs, and role satisfaction. Results were consistent with previous studies: satisfaction with preservice training and with volunteering was very high; respondents reported feeling very prepared and confident about doing hospice work as a result of their volunteer training. In addition, longer volunteer preservice training was associated with higher levels of overall satisfaction with training; levels of volunteer satisfaction and fulfillment tended to be lower during the first year of volunteering; and participation in volunteer support teams was associated with finding volunteer work rewarding and with feeling a part of the hospice team. Implications for preservice training and ongoing support and education of hospice volunteers are discussed.
