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Minerva Medica 2010 April;101(2):73-80

language: English

Early stratification of patients with chest pain and suspected acute coronary syndrome in the Emergency Department

Bracco C. 2, Melchio R. 1, Sturlese U. 1, Pomero F. 2, Martini G. 1, Poggi A. 1, Cena P. 2, Severini S. 2, Castagna E. 2, Brignone C. 2, Serraino C. 2, Dutto L. 1, Veglio F. 3, Fenoglio L. 2

1 Department of Emergency Medicine, Santa Croce e Carle Hospital, Cuneo, Italy;
2 Department of Internal Medicine, Santa Croce e Carle Hospital, Cuneo, Italy;
3 Department of Internal Medicine and Experimental Oncology, University of Turin, Turin, Italy


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AIM: The aim of this study was to investigate the accuracy of a critical pathway in the early stratification and management of patients with chest pain and suspected acute coronary syndrome (ACS) in the Emergency Department (ED).
METHODS: An observational study was performed enrolling all patients with non-traumatic chest pain and suspected ACS who presented during a one-year period in the ED, where a critical pathway with five-level risk stratification, based on risk factors, characteristics of pain and ECG, was implemented. Patients were prospectively evaluated for rates of death, unstable angina, myocardial infarction or revascularization procedure occurring during admission or in the 30 days following discharge RESULTS: Overall, 1 813 patients were enrolled: 475 patients (26.1%, 95% CI: 24.0-28.1 ) were admitted and 1 338 (73.8%, 95% CI: 71.7-75.8) were discharged. Main outcomes occurred in 233 (49.9%, 95% CI: 47.5-52.2) of patients admitted and in 6 (0.4%, 95% CI: 0.06-0.7) of those discharged. The risk stratification system showed a good accuracy with an AUC-ROC curve of 0.90 (95% CI: 0.88-0.93). A total of 1541 (85%) patients were managed according to critical pathway. Adverse events were significantly fewer in patients discharged according to pathway criteria than in those who were not (0.27% vs. 1.37%, difference: 1.1% CI 95%: 0.06-2.1), without significant increase of inappropriate admissions.
CONCLUSION: A critical pathway, based on clinical and ECG features, is a safe and accurate tool to stratify and manage the patients with non-traumatic chest pain and suspected ACS in the ED.

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remo.melchio@libero.it