RESUMEN
BACKGROUND: The aim of this study was to evaluate whether pretest probability (PTP) assessment using the Diamond-Forrester Model (DFM) combined with coronary calcium scoring (CCS) can safely rule out obstructive coronary artery disease (CAD) and 30-day major adverse cardiovascular events (MACE) in acute chest pain patients. METHODS: We retrospectively evaluated consecutive patients, age ≥18 years, with no known CAD, negative initial electrocardiogram, and troponin level. All patients had coronary computed tomographic angiography (CCTA) with CCS, and our final cohort consisted of 1988 patients. Obstructive CAD was defined as luminal narrowing of ≥50% in 1 or more vessels by CCTA. Patients were classified according to PTP as low (<10%), intermediate (10%-90%), or high (>90%). RESULTS: The DFM classified 293 (14.7%), 1445 (72.7%), and 250 (12.6%) of patients as low, intermediate, and high risk, respectively, with corresponding 30-day MACE rates of 0.0%, 2.35%, and 14.8%. For patients with intermediate PTP and CCS ≤10, the negative predictive value was 99.2% (95% confidence interval: 98.7-99.8) for 30-day MACE while it was 92.62% (95% confidence interval: 87.9-97.3) for patients with high PTP. Among patients with a high PTP and CCS of zero, the prevalence of 30-day MACE and obstructive CAD remained high (7.07% and 10.1%, respectively). CONCLUSIONS: In acute chest pain patients without evidence of ischemia on initial electrocardiogram and cardiac troponin, low PTP by DFM or the combination of intermediate PTP and CCS ≤10 had excellent negative predictive values to rule out 30-day MACE. CCS is not sufficient to exclude obstructive CAD and 30-day MACE in patients with high PTP.
Asunto(s)
Calcio/metabolismo , Dolor en el Pecho/diagnóstico , Angiografía por Tomografía Computarizada/métodos , Angiografía Coronaria/métodos , Oclusión Coronaria/diagnóstico , Vasos Coronarios/diagnóstico por imagen , Calcificación Vascular/diagnóstico , Enfermedad Aguda , Causas de Muerte/tendencias , Dolor en el Pecho/epidemiología , Dolor en el Pecho/etiología , Oclusión Coronaria/complicaciones , Electrocardiografía , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Estados Unidos/epidemiología , Calcificación Vascular/complicaciones , Calcificación Vascular/metabolismoRESUMEN
Although the majority of acute chest pain patients are diagnosed with noncardiac chest pain after noninvasive testing, identifying these low-risk patients before testing is challenging. The objective of this study was to validate the coronary artery disease (CAD) consortium models for predicting obstructive CAD and 30-day major adverse cardiovascular events (MACE) in acute chest pain patients considered for coronary computed tomography angiogram, as well as to determine the pretest probability threshold that identifies low-risk patients with <1% MACE. We studied 1,981 patients with no known CAD and negative initial troponin and electrocardiogram. We evaluated CAD consortium models (basic: age, sex, and chest pain type; clinical: basicâ¯+â¯diabetes, hypertension, dyslipidemia, and smoking; and clinicalâ¯+â¯coronary calcium score [CAC] models) for prediction of obstructive CAD (≥50% stenosis on coronary CT angiogram) and 30-day MACE (Acute Myocardial Infarction, revascularization, and mortality). The C-statistic for predicting obstructive CAD was 0.77 (95% confidence interval [CI] 0.73 to 0.77) for the basic, 0.80 (95% CI 0.77 to 0.80) for the clinical, and 0.88 (95% CI 0.85 to 0.88) for the clinicalâ¯+â¯CAC models. The C-statistic for predicting 30-day MACE was 0.82 (95% CI 0.77 to 0.87) for the basic, 0.84 (95% CI 0.79 to 0.88) for the clinical, and 0.87 (95% CI 0.83 to 0.91) for the clinicalâ¯+â¯CAC models. In 47.3% of patients for whom the clinical model predicted ≤5% probability for obstructive CAD, the observed 30-day MACE was 0.53% (95% CI 0.07% to 0.999%); in the 66.9% of patients for whom the clinicalâ¯+â¯CAC model predicted ≤5% probability, the 30-day MACE was 0.75% (95% CI 0.29% to 1.22%). We propose a chest pain evaluation algorithm based on these models that classify 63.3% of patients as low risk with 0.56% (95% CI 0.15% to 0.97%) 30-day MACE. In conclusion, CAD consortium models have excellent diagnostic and prognostic value for acute chest pain patients and can safely identify a significant proportion of low-risk patients by achieving <1% missed 30-day MACE.
Asunto(s)
Dolor en el Pecho/diagnóstico por imagen , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Factores de Edad , Biomarcadores/sangre , Dolor en el Pecho/epidemiología , Comorbilidad , Enfermedad de la Arteria Coronaria/epidemiología , Diagnóstico Diferencial , Electrocardiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Prevalencia , Medición de Riesgo , Factores de Riesgo , Factores SexualesAsunto(s)
Anticoagulantes/administración & dosificación , Dolor en el Pecho/diagnóstico , Disnea/diagnóstico , Ecocardiografía/métodos , Pruebas en el Punto de Atención , Embolia Pulmonar , Terapia Trombolítica/métodos , Dolor en el Pecho/etiología , Diagnóstico Diferencial , Disnea/etiología , Neoplasias Endometriales/complicaciones , Femenino , Humanos , Extremidad Inferior/irrigación sanguínea , Extremidad Inferior/diagnóstico por imagen , Persona de Mediana Edad , Manejo de Atención al Paciente/métodos , Arteria Pulmonar/diagnóstico por imagen , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/etiología , Embolia Pulmonar/fisiopatología , Embolia Pulmonar/terapia , Trombosis de la Vena/complicaciones , Trombosis de la Vena/diagnóstico , Trombosis de la Vena/fisiopatologíaRESUMEN
We surveyed volunteers from 8 hospices in the Delaware Valley regarding training, perceived needs, and role satisfaction. Results were consistent with previous studies: satisfaction with preservice training and with volunteering was very high; respondents reported feeling very prepared and confident about doing hospice work as a result of their volunteer training. In addition, longer volunteer preservice training was associated with higher levels of overall satisfaction with training; levels of volunteer satisfaction and fulfillment tended to be lower during the first year of volunteering; and participation in volunteer support teams was associated with finding volunteer work rewarding and with feeling a part of the hospice team. Implications for preservice training and ongoing support and education of hospice volunteers are discussed.