Acute Coronary Syndrome Screening and Diagnostic Practice Variation. (8th May 2017)

• Record Type: Journal Article
• Authors: Yiadom, Maame Yaa A. B.; Liu, Xulei; McWade, Conor M.; Liu, Dandan; Storrow, Alan B.
• Editors: Hiestand, Brian C.
• Other Names: Herdon‐Meadors Patricia investigator.; Shuler Wesley investigator.; Goldlust Eric investigator.; Sawyer Charles investigator.; Wong Andrew investigator.; Tanski Mary investigator.; Patterson Brian investigator.; Wiener Dan investigator.; Baugh Christopher W. investigator.; Carlson Jestin N. investigator.; Strout Tania D. investigator.; Hill Charles D. investigator.; Turturro Michael investigator.; Whitcomb Carlene investigator.; Dunlap Patricia investigator.; McPheeters Rick A. investigator.; Gavin Nicholas investigator.; Hansen Johnathan investigator.; Web Cindy investigator.; Calichman Meghan investigator.; Chen Paul investigator.; Salazar Gilberto investigator.; Shepard Brooke investigator.; Milligan Benjamin investigator.; Rudd Kenneth investigator.; Lee Adrea investigator.; Spiegel Thomas investigator.; Garvey Lee investigator.; Rodi Scott investigator.; Caterino Jeff investigator.; Furlong Brendan investigator.; Dubin Jeff investigator.; Imperato Jason investigator.; Vohra Anju investigator.; Mills Angela investigator.; Hager David investigator.; Podolsky Seth investigator.; Novotny April investigator.; Hartsfield Lisa investigator.; Bosco Samuel investigator.; McDermott David B. investigator.; Pacella Charissa investigator.; Mazzeo Anthony investigator.; Guyette Maria investigator.; McCoy Thomas investigator.; Gronczewski Craig investigator.; Riordan John investigator.; Leahy Joseph investigator.; Hocker Michael investigator.; Mirarchi Ferdinando investigator.; Bhatia Monisha C. investigator.; Paul Cook J. investigator.; Ramanujan Vishnan investigator.; Acquaye Joseph investigator.; Means Tamera investigator.; Strawn Calbert investigator.; Jackson Leigh investigator.; Davis Brook investigator.;
• Is Part Of: Academic emergency medicine. Volume 24:Number 6(2017)
• Page Start: 701
• Page End: 709
• Publication Date: 2017-05-08
• Subjects: Emergency medicine -- Periodicals; 616.02505
• DOI: 10.1111/acem.13184
• Languages: English
• ISSNs: 1069-6563

Abstract

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.