Gestalt for shock and mortality in the emergency department: A prospective study.

OBJECTIVE: The diagnosis of shock in patients presenting to the emergency department (ED) is often challenging. We aimed to compare the accuracy of experienced emergency physician gestalt against Li's pragmatic shock (LiPS) tool for predicting the likelihood of shock in the emergency department, using 30-day mortality as an objective standard. METHOD: In a prospective observational study conducted in an urban, academic ED in Hong Kong, adult patients aged 18years or older admitted to the resuscitation room or high dependency unit were recruited. Eligible patients had a standard ED workup for shock. The emergency physician treating the patient was asked whether he or she considered shock to be probable, and this was compared with LiPS. The proxy 'gold' or reference standard was 30-day mortality. The area under the receiver operating curve (AUROC) was used to predict prognosis. The primary outcome measure was 30-day mortality. RESULTS: A total of 220 patients fulfilled the inclusion criteria and were included in the analysis. The AUROC for LiPS (0.722; sensitivity=0.733, specificity=0.711, P<0.0001) was greater than emergency physician gestalt (0.620, sensitivity=0.467, specificity=0.774, P=0.0137) for diagnosing shock using 30-day mortality as a proxy (difference P=0.0229). LiPS shock patients were 6.750 times (95%CI=2.834-16.076, P<0.0001) more likely to die within 30-days compared with non-shock patients. Patients diagnosed by emergency physicians were 2.991 times (95%CI=1.353-6.615, P=0.007) more likely to die compared with the same reference. CONCLUSIONS: LiPS has a higher diagnostic accuracy than emergency physician gestalt for shock when compared against an outcome of 30-day mortality.

Prognostic values of 4 risk scores in Chinese patients with chest pain: Prospective 2-centre cohort study.

Four risk scores for stratifying patients with chest pain presenting to emergency departments (EDs) (namely Thrombolysis in myocardial infarction [TIMI], Global registry for acute coronary events [GRACE], Banach and HEART) have been developed in Western settings but have never been compared and validated in Chinese patients. We aimed to find out to the number of MACE within 7 days, 30 days, and 6 months after initial ED presentation, and also to compare the prognostic performance of these scores in Chinese patients with suspected cardiac chest pain (CCP) to predict 7-day, 30-day, and 6-month major adverse cardiac events (MACE).A prospective 2-center observational cohort study of consecutive patients presenting with chest pain to the EDs of 2 university hospitals in Guangdong and Hong Kong from 17 March 2012 to 14 August 2013 was conducted. Patients aged ≥18 years with suspected CCP but without ST-segment elevation myocardial infarction (STEMI) were recruited.Of 833 enrolled patients (mean age 65.1 years, SD14.5; 55.6% males), 121 (14.5%) experienced MACE within 6 months (4.8% with safety outcomes and 10.3% with effectiveness outcomes). The HEART score had the largest area under the receiver operating characteristic (ROC) curve for predicting MACE at 7-day, 30-day, and 6-month follow-up [area under curve (AUC) = 0.731, 0.726, and 0.747, respectively. The HEART score also had the largest AUC for predicting effectiveness outcome (AUC = 0.715, 0.704, and 0.721, respectively). However, there was no significant difference in AUC between HEART and TIMI scores. Banach had the largest AUC for predicting safety outcome (AUC = 0.856, 0.837, and 0.850, respectively).The HEART score performed better than the GRACE and Banach scores to predict total MACE and effectiveness outcome in Chinese patients with suspected CCP, whereas the Banach score best predicted safety outcomes.