Prediction of myocardial infarction risk in older patients with acute coronary syndrome.

PURPOSES: To identify bedside variables that aid in diagnosis of acute coronary syndrome (ACS) and might facilitate rapid triage of patients aged > or = 65 years. BASIC PROCEDURES: Prospective, observational study of consecutive patients aged > or = 65 years with suspicion of ACS presenting to our emergency department (ED). Patients' medical characteristics were collected at baseline and during a 1-month follow-up period. We identified variables independently associated with ACS by multivariate analyses and bootstrapping techniques. MAIN FINDINGS: Among 399 patients, 124 (31.1%) received a diagnosis of ACS (61 acute myocardial infarction, 63 unstable angina). We surveyed multiple clinical and ECG variables to develop a predictive model which included the following variables: male sex, history of coronary artery disease, typical chest pain, dyspnea, epigastric pain, pathological Q-wave, ST-segment elevation (area under the receiver operating characteristic curve (AUC) 0.79, 95% confidence interval 0.71 to 0.82). With the addition of cardiac troponin I to the model the AUC increased to 0.83 (0.79 to 0.88). We used these findings to create the Heart Attack Risk for aged Patient (HARP) scale. Our data suggest that patients with a low HARP score might be safely managed without further testing. PRINCIPAL CONCLUSIONS: A model based on variables easily available at ED presentation from history, physical examination, and electrocardiography, can help ED physicians to identify seniors at very low risk of ACS.

Impact of point-of-care testing in the emergency department evaluation and treatment of patients with suspected acute coronary syndromes.

OBJECTIVES: To assess the impact of point-of-care testing (POCT) for troponin I (cTnI) measurement on the time to anti-ischemic therapy (TAIT) for patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) presenting to the emergency department (ED). METHODS: This was an open-label, randomized, single-center trial conducted in a university-affiliated hospital. cTnI measurement of patients with suspicion of NSTE-ACS coming to the ED was randomly allocated to POCT or central hospital laboratory testing (CHLT). The authors compared patients' baseline characteristics, time to anti-ischemic therapy, and medical outcomes between the randomized groups, in all study participants and in high-risk NSTE-ACS (cTnI level >or= 0.10 microg/mL), and in those with low suspicion ACS (no chest pain and no ST deviation). RESULTS: Of the 860 patients enrolled, 113 were high-risk NSTE-ACS patients, including 53 (46.9%) allocated to POCT and 60 (53.1%) to CHLT. POCT was associated with decreased time to anti-ischemic therapy of about three-quarters of an hour, which was due to a shorter time to physician notification of cTnI level, in both all and subgroup participants. In contrast, neither ED length of stay nor medical outcomes differed between study groups. CONCLUSIONS: Point-of-care testing for cTnI measurement might be clinically relevant for ED patients with a suspicion of NSTE-ACS, particularly for high-risk patients with a low suspicion of ACS.