39 Value of 2D-Echocardiography in Patients With ChestPain and Suspected Acute Coronary Syndromes

Lascala TF, Pazin-Filho A, Dias Romano MM, Almeida Filho OC, Schmidt A, MarinNeto J, Maciel BC/Medical School of Ribeirao Preto - University of Sao Paulo,Ribeirao Preto, Brazil

Study Objective: Chest pain is a major reason for admission to the emergencydepartment (ED). Traditional risk stratification strategy still results in a proportion ofpatients being inadequately evaluated and discharged. Echocardiogram is a potentialtool to optimize this evaluation. We sought to evaluate the impact ofechocardiography on the outcome of patients with suspected acute coronarysyndromes.

Methods: We prospectively studied 735 chest pain patients referred to ED withsuspected acute coronary syndrome. Of those, 409 patients (Group I) had anechocardiogram performed at presentation with regional and global left ventricularfunction (VF) information provided to the attending physician. Those without anecho composed Group II. Patients were followed for 12-months regarding survivaland percutaneous coronary intervention. Information on traditional risk stratificationfactors was available for all.

Results: Echocardiogram was performed at presentation in 55.7% of patients.Group I (2.9/10.0; 95%CI 2.0;3.9) had lower unadjusted mortality rate than GroupII (4.9/10.0;95%CI 3.6;6.4) (logrank test p�0.01). The difference persistedsignificant after adjustment for a wide range of covariates (HR 0.50 - 95%CI 0.31;0.82). Having an echo implied greater odds for percutaneous coronary interventionamong patients without ST elevation (2.57-95%CI 1.23; 5.37). Information aboutglobal VF was associated with lower HR for death even after adjustment (0.78-95%CI 0.65; 0.92). Global VF had an incremental value over traditional riskstratification (24.0 � 31.1global chi-square; p�0.05).

Conclusions: Echocardiogram at presentation of patients with suspected acutecoronary syndrome has shown an incremental value over traditional risk stratificationand was significantly associated with increased survival. It is likely that the additionalinformation prompts the physicians to a more aggressive therapeutic approach.

40 Prospective Evaluation of the Use of the Thrombolysis inMyocardial Infarction (TIMI) Score as a RiskStratification Tool for Chest Pain Patients Admitted to anEmergency Department Observation Unit

Holly J, Hamilton D, Mallin M, Black K, Robbins R, Davis V, Barton E, MadsenT/University of Utah, Salt Lake City, UT

Study Objectives: Several studies have demonstrated the utility of theThrombolysis in Myocardial Infarction (TIMI) score in predicting both 30-day and1-year outcomes among emergency department (ED) patients with potential acutecoronary syndrome. The utility of the TIMI score as a risk stratification tool amongpatients selected for placement in an ED observation unit, however, has not beenevaluated. Accurate risk stratification in this group could potentially identify patientsat higher risk for significant cardiac events who may be more appropriate for inpatientadmission, rather than ED observation unit admission. Our goal was to evaluate theuse of the TIMI score as a risk stratification tool for chest pain patients admitted toan ED observation unit and to compare outcomes and inpatient admission rates forpatients stratified by the TIMI score.

Methods: We performed a prospective observational study with 30-day telephonefollow-up for all chest pain patients admitted to our ED observation unit for the 12-month period from June 1, 2009, to May 31, 2010. Our chest pain protocol includespatients who report a history of coronary disease, but excludes patients with positivebiomarkers in the ED or significant EKG changes. Baseline data, outcomes related toED observation unit stay (positive troponin, provocative testing, cardiaccatheterization, death), inpatient admission, and 30-day outcomes were recorded.TIMI scores were calculated based on baseline risk factors and clinical characteristicsas well as provider interpretation of EKG, as confirmed by review by the principalinvestigator. TIMI score was not utilized in the decision to admit to the ECU andwas calculated with blinding to the patient outcomes.

Results: 552 total chest patients were evaluated. Mean age was 54.1 years (range19-80 years) and 46% were male. We evaluated the composite outcome ofmyocardial infarction, revascularization (stent/CABG), or death either during the EDobservation unit stay, inpatient admission, or the 30-day follow-up period. 18patients experienced the composite outcome: stent (12 patients), CABG (1 patients),

MI and stent (2 patients), and MI and CABG (1 patient). Distribution of patients byTIMI score was as follows: 0 (102 patients), 1 (196), 2 (142), 3 (72), 4 (27), and 5(5). Risk of the composite outcome generally increased by TIMI score: 0 (1%), 1(2.6%), 2 (2.1%), 3 (6.9%), 4 (11.1%), and 5 (20%). We established a thresholdscore of 3 or higher as a potential predictor of moderate-risk ED observation unitchest pain patients. Those who were moderate risk (score 3-5) were significantly morelikely to experience MI, stent, or CABG than the low-risk group (score 0-2) [9/104moderate-risk patients (8.7%) had the composite outcome vs. 9/448 low risk patients(2%, p�0.002)]. Those moderate-risk by TIMI score were also more likely to requireadmission to an inpatient unit from the ED observation unit (15.4% vs. 9.8%,p�0.048).

Conclusion: In addition to its utility in predicting events in ED patients, theTIMI risk score may also serve as an effective risk stratification tool among ED chestpain patients selected for ED observation unit placement. Those who are moderate-risk by TIMI (score of 3 or greater) may be considered for either inpatient admissionor more aggressive evaluation, treatment, and consultation while in observation.

41 Prospective Evaluation of Outcomes in Geriatric ChestPain Patients Admitted to an Emergency DepartmentObservation Unit

Johnson E, Holly J, Hamilton D, Black K, Robbins R, Davis V, Barton E,Madsen T/University of Utah Health Sciences, Salt Lake City, UT

Study Objectives: Emergency department (ED) observation units are an important toolto help emergency physicians safely and efficiently evaluate and risk-stratify patients with chestpain. However, due to concerns of high admission rates and adverse events in geriatric patients(age 65 years or older), these patients are often excluded from ED observation unit chest painprotocols based on age alone. Our goal was to evaluate characteristics and outcomes of geriatricchest pain patients treated in our ED observation unit.

Methods: We performed a prospective, observational analysis for all chest painpatients admitted to our ED observation unit during the 12-month period from June1, 2009, to May 31, 2010. Information regarding presentation, baselinedemographics, and risk factors was obtained at the time of admission. Outcomesrelated to ED observation unit stay [positive troponin, provocative testing,revascularization procedures including stent and coronary artery bypass graft(CABG), and death] and inpatient admission were recorded. A 30-day follow-up wasperformed by telephone and review of the electronic medical record for outcomes(MI, stent, CABG, death) occurring in the period following ED observation unitplacement. Geriatric patients were defined as age 65 or older.

Results: 552 patients were evaluated for chest pain in our ED observation unitduring the study period, including 113 (20.5%) geriatric and 439 (79.5%) non-geriatric patients. Mean age was 54.1 years (range 19-80 years). Geriatric and non-geriatric groups were similar in sex (percent male: 38.9% vs. 47.8%, p�0.091) andhistory of diabetes (21.2% vs. 19.6%, p�0.696), while geriatric patients were morelikely to report a history of coronary disease (31.9% vs. 14.6%, p�0.001). Weevaluated the composite outcome of myocardial infarction, revascularization (stent/CABG), or death either during the ED observation unit stay, inpatient admission, orthe 30-day follow-up period. 18 total patients (3.2%) experienced the compositeoutcome: 12 patients had stent placement, 3 CABG, 2 with MI and stent, 1 with MIand CABG, and no deaths. 3.5% of geriatric patients experienced the compositeoutcome, compared to 3.2% of non-geriatric patients (p�0.772). Admission ratesfrom the ED observation unit (observation failure rates) were also similar between the2 groups, with 13.3% of geriatric patients requiring inpatient admission compared to9.3% of non-geriatric patient (p�0.223).

Conclusion: Despite a higher proportion of patients reporting a history of CAD,geriatric chest pain patients had similar rates of significant cardiac events andinpatient admission from the ED observation unit when compared to non-geriatricpatients. When screened appropriately, geriatric patients may receive safe andeffective evaluation and risk stratification in an ED observation unit.

42 Acquisition and Retention of Knowledge and Skills inBasic Life Support Among Emergency Medicine Residents

Gloria FK/St. Luke’s Medical Center, Quezon City, Philippines

Study Objectives: Survival of patients in cardiac arrest depends more on effectivebasic life support rather than advanced treatment. Unfortunately, previous studieshave shown that acquisition and retention of basic life support knowledge and skills is

Research Forum Abstracts

Volume , . : October Annals of Emergency Medicine S191