study. Median age was 69 years and 55% of the participants were male. A MACEoccurred in 57 patients (18%). Rates of MACE according to TIMI risk scorewere: TIMI 0, 3/37 (8%); TIMI 1, 4/79 (5%); TIMI 2, 12/77 (16%); TIMI 3,15/67 (22%); TIMI 4 13/36 (36%); TIMI 5, 5/14 (36%); TIMI 6, 5/5 (100%);TIMI 7 0/0 (p�0.005).

Conclusion: Increasing TIMI risk score is strongly associated with risk of MACEin chest pain patients. The TIMI risk score is sensitive enough to identify Chinesepatients at high risk of an adverse event but not specific enough to identify patientssuitable for early discharge.

97 A Prospective Investigation of the Prognostic Value of“TIMI” and “Front Door TIMI” in Chinese PatientsPresenting to the Emergency Department WithUndifferentiated Chest Pain

Graham CA, Chan JW, Rotheray KR, Rainer TH/Chinese University of Hong Kong,Shatin, Hong Kong; University of Melbourne, Melbourne, Australia

Study Objective: Chest pain is a common complaint among emergencydepartment (ED) patients. The Thrombolysis in Myocardial Infarction risk score(TIMI-RS) and front door Thrombolysis in Myocardial Infarction risk score(FDTIMI-RS) have been proven to be useful to risk stratify chest pain patients inmany Western countries, but it has not been validated in Asian countries. Wehypothesised that the TIMI-RS would be a valid tool in the Hong Kong Chinesepopulation. The aim of this study was to establish the relationship between TIMI-RSand FDTIMI-RS and the 30-day rate of major adverse cardiac outcomes (MACE) ofpatients with chest pain.

Methods Design: Single center prospective observational cohort study.Participants: Consecutive ED patients presenting with chest pain were enrolled fromJuly 2009 until March 2010. Data collection: patient characteristics, TIMI-RS itemsand past medical and medication history. Primary outcome: MACE within 30 days ofED presentation. MACE is defined as a composite outcome which is fulfilled if any ofthe following occurs: death (all causes), readmission with myocardial infarction (MI),acute coronary syndrome not diagnosed at initial ED presentation, and percutaneouscoronary intervention.

Results: 1000 patients were recruited and 30-day follow-up was completed on allpatients. Patients had a mean age of 66.7�14 years and 54% were male. 169 (17%)patients had a MACE within 30 days of ED presentation. The incidence of MACE ineach TIMI-RS group is as follows: TIMI-RS 0, 1/145, (0.7%); TIMI-RS 1, 21/249(8.4%); TIMI-RS 2, 44/239, (18.4%); TIMI-RS 3, 40/179, (22.3%); TIMI-RS 4,42/122, (34.4%), TIMI-RS 5, 14/52, (26.9%), TIMI-RS 6/7, 7/14, (50%). Therewas an excellent correlation between TIMI-RS and MACE (��0.964, p �0.001).Increasing FDTIMI-RS was also associated with increased risk of MACE within 30days (�� 1, p�0.01).

Conclusion: The TIMI-RS and FDTIMI-RS may be useful tools for riskstratification of ED patients with undifferentiated chest pain. However, patients inthe low risk group still had a risk of having MACE (0.7% for TIMI-RS�0 and 1.3%for FDTIMI-RS�0). Therefore, while the scores can guide patient disposition fromthe ED, they cannot fully replace clinical judgement.

98 Communication and Perceptions of Risk AmongPhysicians and Patients With Potential Acute CoronarySyndromes

Newman DH, Shah KH, Ackernam BE, Kraushar ML, Lederhandler MH, MasriAC, Starikov A, Tsao D/Mt. Sinai School of Medicine, New York, NY; StonyBrook University Medical Center, Stony Brook, NY; Columbia University, NewYork City, NY

Study Objectives: Patients admitted for possible acute coronary syndrome canbe risk stratified by robust predictive models. We aimed to characterize theperception and contemporaneous communication of these risks in the emergencydepartment (ED) and the degree to which these factors inform dispositiondecisions.

Methods: We conducted an observational, matched-pairs survey study in our 2academic, inner city EDs with a combined annual census of approximately 185000.Inclusion criterion was “patient being admitted primarily for acute coronarysyndrome” per treating physicians. Exclusions were non-English speaking, non-literate, EKG or troponin values diagnostic for acute coronary syndrome, prisoners,and acute distress. Trained research assistants staffed EDs on a university calendarfrom 8am to midnight and monitored for potential coronary complaints. Research

assistants approached patients whom physicians agreed would be admitted “primarilyfor acute coronary syndrome.” Immediately after their discussion regarding finaldisposition, the patient and physician completed paired surveys regardingcommunication content, which included current risk and prognosis estimates,perceived potential benefits of admission, and perceived primary purpose ofadmission. Descriptive statistics including 95% confidence intervals were calculatedfor all measures. Kappa was calculated for agreement between physician and patientwith regard to rationale for admission.

Results: During the 18-month study period, 849 surveys were completed. Allpatients (n�425) had primary or secondary complaints of chest pain. Patients’mean age was 58 (range 23-91). 53% were male, 34% black, 24% Hispanic, 23%white, and 19% other or unreported. Education level was 39% “some high schoolor graduated,” 25% “some college or Associate’s,” 14% Bachelor’s, and 15%graduate/professional degree. Post-hoc application of cohort characteristicssuggested a mean risk �5% for death, MI or revascularization within 30 days.Physicians’ (n�424) mean estimate of risk was 15% (95%CI: 13-17); patients’estimate was 33% (95%CI: 30-36). For 62% of patients, their estimate of riskremained the same or increased after speaking with the physician. Roughly 1-third (31%, 95%CI: 27-36) of patients and half (48%, 95%CI: 43-53) ofphysicians reported that the primary motivation for admission (coronary risk) wasnot discussed. Among physicians who reported discussing rationale for admission,the Kappa agreement value in rationale for admission was 0.38 (“fair”).Physicians reported medico-legal concern as 1 of the reasons for their dispositiondecision in 11% (95%CI: 8-14) of cases and that they would not stay overnight ifthey were the patient in 27% (95%CI: 23-32) of cases.

Conclusion: Communications surrounding admission for acute coronarysyndrome often did not address risk of acute coronary syndrome. Risk wasoverestimated and communications did not typically align risk estimates or clarifyrationale for admission. A significant proportion of admissions were affected bylegal concerns and physicians commonly would not have chosen admission forthemselves.

99 Bedside Carotid Ultrasonography to Risk Stratify PatientsWith Chest Pain in the Emergency Department

Datta A, Bharati A, Pearl-Davis M, Perry K, Gupta S, Garg N, Sison C, Chun LemaP/New York Hospital Queens, Flushing, NY; North Shore-LIJ, Manhasset, NY

Study Objectives: The purpose of this study was to determine the role of bedsideultrasound carotid intima-media thickness measurements as an additional diagnostic testto risk stratify patients presenting with chest pain in the emergency department (ED).Assessment of patients with subclinical acute coronary syndrome is challenging inthe acute setting. Outpatient studies have demonstrated a correlation betweencarotid intima-media thickness on ultrasound and cardiovascular disease. Wehypothesize that carotid intima-media thickness is a predictor of cardiovascularevents and carotid ultrasonography can serve as a noninvasive tool to assess thepatients’ risk of acute coronary syndrome in the acute setting. Our goal is toidentify patients at risk for acute coronary syndrome despite normal cardiacenzymes and electrocardiogram. There are no known published studies thatinvestigate the role of carotid intima-media thickness in the emergencydepartment using cardiac computed tomography (CT) or percutaneous cardiacintervention as a gold standard.

Methods: This is a prospective study of a convenience sample of adult patientsgreater than 21 years of age who presented to the emergency department with chestpain. The study location is an urban academic emergency department with a censusof 120,000 annual visits and 24-hour cardiac catheterization capabilities. Patientswho did not have a gold standard study (CT or percutaneous coronaryintervention), had previous carotid surgery, or were unable to provide informedconsent were excluded from the study. Ultrasound (Zonare, Mountain View, CA)IMT measurements of the right and left common carotid arteries were acquiredwith a 10MHz linear transducer. Three images of the near and far vessel wallwere obtained from anterior, medial, and posterior views (a total of 12 carotidintima-media thickness segments). Images were stored and analyzed by CarotidAnalyzer 5 (Mailing Imaging Application LLC, Coralville, Iowa). Association ofeach of the v measurements with percent of atherosclerosis on cardiac CT orpercutaneous coronary intervention, sex, race, age (�55 years) and medicalhistory was assessed using either the Mann-Whitney test or Kruskal-Wallis test asappropriate.

Results: Ninety-one patients (56% males) were included in the study fromJanuary 2009 to January 2011. Mean age was 56�13 years (range: 30-89) and

Research Forum Abstracts

S210 Annals of Emergency Medicine Volume , . : October