Keara L. Sease

Combining Thrombolysis in Myocardial Infarction risk score and clear-cut alternative diagnosis for chest pain risk stratification

OBJECTIVE The Thrombolysis in Myocardial Infarction (TIMI) risk score is a validated risk stratification tool useful in patients with definite and potential acute coronary syndromes (ACS) but does not identify patients safe for discharge from the emergency department (ED). Likewise, the use of a clear-cut alternative noncardiac diagnosis risk stratifies patients but does not identify a group safe for discharge. We hypothesized that the presence of an alternative diagnosis in patients with a TIMI risk score less than 2 might identify a cohort of patients safe for ED discharge. METHODS In prospective cohort study, we enrolled ED patients with potential ACS. Data included demographics, medical history, components of the TIMI risk score, and whether the treating physician ascribed the condition to an alternative noncardiac diagnosis. Investigators followed the patients through the hospital course, and 30-day follow-up was done. The main outcome was 30-day death, myocardial infarction, or revascularization. RESULTS A total of 3169 patients were enrolled (mean age, 53.6+/-14 years; 45% men; 67% black). There were 991 patients (31%) with an alternative diagnosis, 980 patients with a TIMI risk score of 0, and 828 with a TIMI score of 1. At low levels of TIMI risk (<3), adding in a clinical impression of an alternative diagnosis did not reduce risk; at higher levels of TIMI risk, it did. The incidence of 30-day death, myocardial infarction, or revascularization for patients with a clinical impression of an alternative diagnosis and a TIMI score of 0 was 2.9% (95% confidence interval, 1.6%-5.0%). CONCLUSIONS The TIMI risk score stratifies patients with and without an alternative diagnosis. Unfortunately, patients with both a low TIMI risk score and a clinical impression of an alternative noncardiac diagnosis still have a risk of 30-day adverse events that is not low enough to allow safe discharge from the ED.

TIMI risk score: does it work equally well in both males and females?

Objective: The TIMI (Thrombolysis In Myocardial Infarction) risk score is a seven item risk stratification tool derived from trials of patients with non-ST segment elevation acute coronary syndromes (ACS) that has been validated in emergency department (ED) patients with potential ACS. We hypothesised that it might have different prognostic abilities in male and female patients. Methods: This was a prospective cohort study of ED patients with potential ACS. Data included demographics, medical and cardiac history, and components of the TIMI risk score. Investigators followed the hospital course daily. The main outcome was death, acute myocardial infarction (AMI), or revascularisation within 30 days as stratified by TIMI risk score and compared between genders using χ2 tests. Results: There were 2022 patients enrolled: 1204 (60%) females and 818 (40%) males. The incidence of 30 day death, AMI, revascularisation (n = 168) according to TIMI score is as follows (female vs male): TIMI 0 (n = 670), 1.6% vs 2.0%, p = 0.2; TIMI 1 (n = 525), 4.6% vs 8.5%, p = 0.02; TIMI 2 (n = 378), 6.3% vs 10.4%, p = 0.05; TIMI 3 (n = 234), 6.5% vs 24.6%, p<0.001; TIMI 4 (n = 157), 22.7% vs 24.4%, p = 0.15; TIMI 5 (n = 52), 35.5% vs 39.1%, p = 0. 2; TIMI 6 or 7 (n = 6), 33.3% vs 66.7%, p = 1.0. The relationship between TIMI score and outcome was highly significant (p<0.001) for each gender; however, males tended to have worse outcomes at lower TIMI risk scores. Conclusions: The TIMI risk score successfully risk stratifies both males and females with potential ACS at the time of ED presentation; however, males have worse outcomes at lower TIMI scores than females.

Derivation of a clinical prediction rule for evaluating patients with abdominal pain and diarrhea

OBJECTIVE The objective of the study was to develop a simple prediction rule to reliably identify abdominal pain patients with diarrhea who may require surgical intervention. METHODS We performed a secondary analysis of a prospective cohort study of adults with acute nontraumatic abdominal pain and diarrhea in an urban emergency department (ED). Structured data collection included 109 historical and 28 physical examination items, laboratory and radiographic results, and final diagnosis. The main outcome was operative intervention. RESULTS One thousand patients were enrolled; 174 patients with diarrhea were included in this analysis. Patients had a mean age of 39 +/- 16 years and were likely to be female (64%) and black (60%). Fifteen (9%) patients received a surgical intervention from the ED. Clinical variables associated with the need for surgical intervention using univariate analysis were age older than 40 years, constant pain, and peritonitis on examination. Using recursive partitioning multivariate analysis, the derived prediction rule included 2 variables: age older than 40 years and constant pain. This rule had a sensitivity of 1.0 (95% confidence interval, 0.78-1.0) and specificity of 0.23 (95% confidence interval, 0.16-0.30). CONCLUSION Patients older than 40 years with constant abdominal pain and diarrhea are likely to have a surgical cause of their symptoms.