Skip to main content Accessibility help
×
Home

Validation of the new Vancouver Chest Pain Rule in Asian chest pain patients presenting at the emergency department

  • Marcus Eng Hock Ong (a1) (a2), Ying Hao (a3), Susan Yap (a1), Pin Pin Pek (a1), Terrance Siang Jin Chua (a4) (a5), Faith Suan Peng Ng (a6) and Swee Han Lim (a1)...

Abstract

Objectives

The new Vancouver Chest Pain (VCP) Rule recommends early discharge for chest pain patients who are at low risk of developing acute coronary syndrome (ACS), and thus can be discharged within 2 hours of arrival at the emergency department (ED). This study aimed to assess the performance of the new VCP Rule for Asian patients presenting with chest pain at the ED.

Methods

This prospective cohort study involved patients attended to at the ED of a large urban centre. Patients of at least 25 years old, presenting with stable chest pain and a non-diagnostic ECG, and with no history of active coronary artery disease were included in the study. The main outcome measures were cardiac events, angioplasty, or coronary artery bypass within 30 days of enrolment.

Results

The study included 1690 patients from 27 August 2000 to 1 May 2002, with 661 patients fulfilling the VCP criteria. Of those for early discharge, 24 had cardiac events and 13 had angioplasty or bypass at 30 days, compared to 91 and 41, respectively, for those unsuitable for discharge. This gave the rule a sensitivity of 78.1% for cardiac events, including angioplasty and bypass. Specificity was 41.0%, and negative predictive value (NPV) was 94.4%.

Conclusion

We found the new VCP Rule to have moderate sensitivity and poor specificity for adverse cardiac events in our population. With an NPV of less than 100%, this means that a small proportion of patients sent home with early discharge would still have adverse cardiac events.

Objectifs

Selon la nouvelle règle de Vancouver sur la douleur thoracique, il est recommandé que les patients qui présentent des douleurs thoraciques mais qui connaissent un faible risque de syndrome coronarien aigu puissent être renvoyés peu de temps après leur arrivée au service des urgences (SU), soit dans les deux heures suivantes. L’étude visait à évaluer la performance de la nouvelle règle de Vancouver chez des patients d’origine asiatique présentant des douleurs thoraciques, au SU.

Méthode

Il s’agit d’une étude de cohorte, prospective, à laquelle ont participé des patients traités dans un SU d’un important centre urbain. Ont été sélectionnés des patients âgés d’au moins 25 ans, qui présentaient une douleur thoracique stable mais chez qui l’ECG s’est révélé non concluant et qui n’avaient pas d’antécédents de coronaropathie active. Les principaux critères d’évaluation consistaient en la survenue d’événements cardiaques ou encore en la réalisation d’une angioplastie ou d’un pontage coronarien dans les 30 jours suivant l’inclusion dans l’étude.

Résultats

Au total, 1690 patients ont participé à l’étude, du 27 août 2000 au 1er mai 2002, dont 661 répondaient aux critères de la nouvelle règle de Vancouver. Parmi ceux qui ont été renvoyés peu de temps après leur arrivée, 24 ont subi un événement cardiaque et 13 autres, une angioplastie ou un pontage coronarien au bout de 30 jours contre 91 et 41 respectivement parmi ceux qui n’étaient pas en état de quitter l’hôpital. Ainsi, la sensibilité de la règle s’est établie à 78,1 % à l’égard des événements cardiaques, y compris de l’angioplastie et du pontage coronarien; la spécificité, à 41,0 % et la valeur prédictive négative (VPN), à 94,4 %.

Conclusions

Les auteurs sont arrivés à la conclusion que la nouvelle règle de Vancouver avait une sensibilité moyenne et une faible spécificité à l’égard des événements cardiaques défavorables dans la population étudiée. Du fait que la VPN est inférieure à 100 %, une faible proportion de patients renvoyés à domicile peu de temps après leur arrivée au SU sont susceptibles de subir des événements cardiaques défavorables.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Validation of the new Vancouver Chest Pain Rule in Asian chest pain patients presenting at the emergency department
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Validation of the new Vancouver Chest Pain Rule in Asian chest pain patients presenting at the emergency department
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Validation of the new Vancouver Chest Pain Rule in Asian chest pain patients presenting at the emergency department
      Available formats
      ×

Copyright

Corresponding author

Correspondence to: Marcus Eng Hock Ong, Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608; Email: marcus.ong.e.h@sgh.com.sg

References

Hide All
1. Amsterdam, EA, Lewis, WR, Yadlapalli, S. Evaluation of low-risk patients with chest pain in the emergency department: value and limitations of recent methods. Cardiol Rev 1999;7:17-26.
2. Pope, JH, Aufderheide, TP, Ruthazer, R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. NEJM 2000;342:1163-1170.
3. McCarthy, BD, Beshansky, JR, D’Agostino, RB, et al. Missed diagnoses of acute myocardial infarction in the emergency department: results from a multicenter study. Ann Emerg Med 1993;22:579-582.
4. Christenson, J, Innes, G, McKnight, D, et al. A clinical prediction rule for early discharge of patients with chest pain. Ann Emerg Med 2006;47:1-10.
5. Greenslade, JH, Cullen, L, Than, M, et al. Validation of the Vancouver Chest Pain Rule using troponin as the only biomarker: a prospective cohort study. Am J Emerg Med 2013;31:1103-1107.
6. Cullen, L, Greenslade, JH, Than, M, et al. The new Vancouver Chest Pain Rule using troponin as the only biomarker: an external validation study. Am J Emerg Med 2014;32:129-134.
7. Scheuermeyer, FX, Wong, H, Yu, E, et al. Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain. CJEM 2014;16:106-119.
8. Than, M, Herbert, M, Flaws, D, et al. What is an acceptable risk of major adverse cardiac event in chest pain patients soon after discharge from the emergency department? A clinical survey. Int J Cardiol 2013;166:752-754.
9. MacGougan, CK, Christenson, JM, Innes, GD, et al. Emergency physicians’ attitudes toward a clinical prediction rule for the identification and early discharge of low risk patients with chest discomfort. CJEM 2001;3:89-94.
10. Kavsak, PA, Worster, A. For a rapid diagnosis of acute myocardial infarction, a sensitive troponin assay is needed in the near-patient testing setting. Expert Rev Cardiovasc Ther 2012;10:309-312.
11. Than, M, Cullen, L, Aldous, S, et al. 2-hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. JACC 2012;59:2091-2098.
12. Lim, SH, Anantharaman, V, Sundram, F, et al. Stress myocardial perfusion imaging for the evaluation and triage of chest pain in the emergency department: a randomized controlled trial. J J Nucl Cardiol 2013;20:1002-1012.
13. Pirrallo, RG, Aufderheide, TP, Provo, TA, et al. Effect of an inspiratory impedance threshold device on hemodynamics during conventional manual cardiopulmonary resuscitation. Resuscitation 2005;66:13-20.
14. Chaturvedi, N. Ethnic differences in cardiovascular disease. Heart 2003;89:681-686.
15. Ellestad, MH, Startt-Selvester, R, Stanton, E, et al. The utility of four biochemical markers in the triage of chest pain patients. Cardiology 2000;93:242-248.
16. Gibler, WB, Lewis, LM, Erb, RE, et al. Early detection of acute myocardial infarction in patients presenting with chest pain and nondiagnostic ecgs: serial CK-MB sampling in the emergency department. Ann Emerg Med 1990;19:1359-1366.
17. Herkner, H, Waldenhofer, U, Laggner, AN, et al. Clinical application of rapid quantitative determination of cardiac troponin-T in an emergency department setting. Resuscitation 2001;49:259-264.
18. Ordonez-Llanos, J, Santalo-Bel, M, Merce-Muntanola, J, et al. Risk stratification of chest pain patients by point-of-care cardiac troponin T and myoglobin measured in the emergency department. Clin Chim Acta 2006;365:93-97.
19. Peacock, WI, Emerman, CL, McErlean, ES, et al. Prediction of short- and long-term outcomes by troponin T levels in low-risk patients evaluated for acute coronary syndromes. Ann Emerg Med 2000;35:213-220.
20. Schaeffer, MW, Brennan, TD, Hughes, JA, et al. Resting radionuclide myocardial perfusion imaging in a chest pain center including an overnight delayed image acquisition protocol. J Nucl Med Technol 2007;35:242-245.
21. Trzeciak, S, Rivers, EP. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J 2003;20:402-405.
22. Goldman, L. Using prediction models and cost-effectiveness analysis to improve clinical decisions: emergency department patients with acute chest pain. Proc Assoc Am Physicians 1995;107:329-333.
23. Bradley, VM. Placing emergency department crowding on the decision agenda. J Emerg Nurs 2005;31:247-258.
24. Dickinson, G. Emergency department overcrowding. CMAJ 1989;140:270-271.
25. Kunz Howard, P. Overcrowding: not just an emergency department issue. J Emerg Nurs 2005;31:227-228.
26. Laskowski-Jones, L. Starling’s curve: a way to conceptualize emergency department overcrowding. J Emerg Nurs 2005;31:229-230.
27. Lynn, SG, Kellermann, AL. Critical decision making: managing the emergency department in an overcrowded hospital. Ann Emerg Med 1991;20:287-292.
28. Walters, SD. Is booming demand dooming emergency department? Mich Hosp 1990;26:4-9.
29. Aroney, CN, Dunlevie, HL, Bett, JH. Use of an accelerated chest pain assessment protocol in patients at intermediate risk of adverse cardiac events. Med J Aust 2003;178:370-374.
30. Grzybowski, M, Zalenski, RJ, Ross, MA, et al. A prediction model for prehospital triage of patients with suspected cardiac ischemia. J Electrocardiol 2000;33(Suppl):253-258.
31. Schillinger, M, Sodeck, G, Meron, G, et al. Acute chest pain--identification of patients at low risk for coronary events. The impact of symptoms, medical history and risk factors. Wien Klin Wochenschr 2004;116:83-89.
32. Selker, HP, Beshansky, JR, Griffith, JL, et al. Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia. A multicenter, controlled clinical trial. Ann Intern Med 1998;129:845-855.
33. Antman, EM, Cohen, M, Bernink, PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000;284:835-842.
34. Backus, BE, Six, AJ, Kelder, JC, et al. A prospective validation of the heart score for chest pain patients at the emergency department. Int J Cardiol 2013;168:2153-2158.

Keywords

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed