The impact of the HEART score on the prevalence of cardiac testing and patient outcomes in a rural emergency department.

INTRODUCTION: This study was conducted to examine the use of the HEART score for risk stratification of chest pain patients presenting to rural Ontario emergency departments (EDs), assessing both its validity in a rural context and its utility in health-care resource management. METHODS: This study was a retrospective chart review of adult patients presenting to the ED with chest pain. The HEART score was assessed for its ability to risk-stratify patients (high, moderate and low) in terms of the likelihood of a major adverse cardiac event (MACE) within 6 weeks. The prevalence of follow-up testing for each risk category of patients was then determined such that the potential impact on health resource management was estimated based on the number of tests ordered in low-risk patients. RESULTS: Of the 215 charts included, 24 (11.2%) patients experienced a MACE within 6 weeks. None of the patients with a low HEART score experienced a MACE. In comparison, the incidence of MACE in moderate- and high-risk groups was calculated to be 13.9% (95% confidence interval [CI] [5.91% and 21.89%, respectively]) and 66.7% (95% CI [46.54% and 86.86%, respectively]). Eighteen percent of the low-risk patients received follow-up testing with no positive results suggestive of acute coronary syndrome. CONCLUSION: Our results provide external validation of the predictive value of the HEART score in determining the risk of MACE in patients presenting to a rural ED with chest pain. Our results also suggest that rates of follow-up testing in low-risk patients may be reduced in communities with limited access to resources.

Résumé Introduction: Examiner le recours au score HEART pour stratifier le risque lié à la douleur thoracique chez les patients qui se présentent aux services d'urgence des régions rurales de l'Ontario, en en évaluant la validité dans un contexte rural et l'utilité dans la gestion des ressources de santé. Méthodologie: Examen rétrospectif des dossiers de patients adultes s'étant présentés à l'urgence pour une douleur thoracique. Le score HEART a été évalué pour sa capacité de stratifier les patients en fonction du risque (élevé, modéré, faible) d'événement cardiaque indésirable majeur (ÉCIM) dans les 6 semaines suivantes. La prévalence des tests de suivi pour chaque catégorie de risque a ensuite été déterminée afin d'estimer l'impact potentiel sur la gestion des ressources de santé selon le nombre de tests demandés chez les patients à faible risque. Résultats: Sur les 215 dossiers inclus, 24 (11,2 %) patients ont subi un ÉCIM dans les 6 semaines suivantes. Aucun des patients ayant obtenu un faible score HEART n'a subi un ÉCIM. Par ailleurs, l'incidence d'ÉCIM dans les groupes à risque modéré et élevé s'est élevée à respectivement 13,9 % (IC à 95 % [5,91; 21,89 %]) et 66,7 % (IC à 95 % [46,54; 86,86 %]). Dix-huit pour cent des patients à faible risque ont subi un test de suivi sans résultat évoquant un syndrome coronarien aigu. Conclusion: Nos résultats ont validé de façon externe la valeur prédictive du score HEART dans la détermination du risque d'ÉCIM chez les patients qui se présentent à l'urgence rurale pour une douleur thoracique. Nos résultats laissent également croire que le taux de tests de suivi chez les patients à faible risque serait réduit dans les communautés dont l'accès aux ressources est limité. Mots-clés: médecine rurale, médecine d'urgence, maladie cardiaque ischémique, score HEART.

Canadian Association of Emergency Physicians position statement on acute ischemic stroke.

The CAEP Stroke Practice Committee was convened in the spring of 2013 to revisit the 2001 policy statement on the use of thrombolytic therapy in acute ischemic stroke. The terms of reference of the panel were developed to include national representation from urban academic centres as well as community and rural centres from all regions of the country. Membership was determined by attracting recognized stroke leaders from across the country who agreed to volunteer their time towards the development of revised guidance on the topic. The guideline panel elected to adopt the GRADE language to communicate guidance after review of existing systematic reviews and international clinical practice guidelines. Stroke neurologists from across Canada were engaged to work alongside panel members to develop guidance as a dyad-based consensus when possible. There was no unique systematic review performed to support this guidance, rather existing efficacy data was relied upon. After a series of teleconferences and face to face meetings, a draft guideline was developed and presented to the CAEP board in June of 2014. The panel noted the development of significant new evidence to inform a number of clinical questions related to acute stroke management. In general terms the recommendations issued by the CAEP Stroke Practice Committee are supportive of the use of thrombolytic therapy when treatment can be administered within 3 hours of symptom onset. The committee is also supportive of system-level changes including pre-hospital interventions, the transport of patients to dedicated stroke centers when possible and tele-health measures to support thrombolytic therapy in a timely window. Of note, after careful deliberation, the panel elected to issue a conditional recommendation against the use of thrombolytic therapy in the 3­4.5 hour window. The view of the committee was that as a result of a narrow risk benefit balance, one that is considerably narrower than the same considerations under 3 hours, a significant number of informed patients and families would opt against the risk of early intracranial hemorrhage and the possibility of increased 90-day mortality that is not seen for more timely treatment. Furthermore, the frequently impaired nature of patients suffering an acute stroke and the difficulties in asking families to make life and death decisions in a highly time-sensitive context led the panel to restrict a strong endorsement of thrombolytic to the 3 hour outermost limit. The committee noted as well that Health Canada has not approved a thrombolytic agent beyond a three hour window in acute ischemic stroke.