Appendix A Article citation in APA format Purpose of study/research questions Design type and methods (sampling method/sample size, description of interventions (if any), and outcomes measured Major findings/findings relevant to project Critique of validity, bias and significance Hess, E.P., Perry, J.J., Calder, L.A., Thiruganasambandamoorthy, V., Roger, V.L., Wells, G.A., & Stiell, I.G. (2010). Sex differences in clinical presentation, management and outcome in emergency department patients with chest pain. CJEM: The Journal of the Canadian Association of Emergency Physicians, 12(5), 405-413. of Evidence: Level IV The purpose of this study is to evaluate the differences between men and women who present to the emergency department with chest pain based on their symptoms, treatment and outcome. This study also measures the association between female sex and cardiac angiography within 30 days. This was a prospective cohort study that took place in an urban teaching hospital’s emergency room. The study was conducted over a 9-month period between July 2008. Patients that were included in the study had to be older than 24 years of age and have a potential diagnosis of ACS. There were 970 patients included in the study with 584 being men. Patients were considered eligible if they presented to the ED with chest pain and were considered to be at a low to moderate risk for ACS. Patient The study showed that women had a significantly lower incidence of CAD. Women were tested for AMI via ECG, troponin T level, and stress tests at the same rate as men, but were still found to have a significantly lower percentage of AMI or positive stress test findings. The findings of this study suggest that on the basis of sex as a tool for disease management was appropriate in the instance of chest pain. Also, women lower frequency of typical chest pain; less referral for cardiac angiography. This study is credible. Patients were assessed on the basis of low to moderate risk. The sample size was 970, which is a significant amount of patients. The study incorporated a 2-month period to further improve their data collection forms and processes. Significance to project: 1.) This study leads to me to ask does there need to be an algorithm for men and one for women when it comes to chest pain?
outcomes were defined as AMI, PCI, cardiac death, 70% stenosis in a major coronary artery and changes in a patient’s nuclear stress test. Steele, R., McNaughton, T., McConahy, M., & Lam, J. (2006).Chest pain in emergency department patients: If the pain is relieved by nitroglycerin, is it more likely to be cardiac chest pain? CJEM: The Journal of the Canadian Association of Emergency Physicians, 8(3), 164-169. of Evidence: Level IV The purpose of this study is to evaluate the use of nitroglycerin as a diagnostic test for determining whether a patient’s chest pain is cardiac or non-cardiac. This is a prospective observational cohort study was conducted over a 9 month period of time. The study took place in an urban emergency room affiliated with an academic institution. Outcome Measures: Patients initial chest pain score was recorded and subsequently after each dose of nitroglycerin. The pain scale used was 1-10 and the visual analog score with happy to sad faces. 270 patients participated in the study. Of those 270 patients, 66% had their chest pain relieved by nitroglycerin. Patients were followed up with via telephone 4 weeks after being in the ED. 257 patients participated in follow- up phone calls. Patients received nitroglycerin based on their presentation at triage of chest pain. It was determined through this study that chest pain relief through nitroglycerin dosing may not be a reliable determining factor of whether a patient’s chest pain is cardiac related or not. There were 177 patients who Weaknesses: 1.) The excluded patients who had a low risk for cardiac issues. 2.) The study took place over a 9-month period. 3.) The study involved only a small patient population. 4.) The ECG was read only by the ED physician. Strengths: 1.) The study used the TIMI score to classify patients. 2.) The patient’s relief from nitroglycerin was measured within 5 minutes of receiving the medication. 3.) The study determined that chest pain relief from nitro is ambivalent to whether the patient is
Primary outcome: ACS, non-fatal AMI Secondary outcomes: CABG, PCI (or combination) 30 days, 1 & 5 chest pain. Only one patient out of 133 that had no CAC found on CT was determined to have chest pain related to a cardiac issue. Through this study CAC levels were analyzed in relation to cardiogenic chest pain and a threshold was derived for testing purposes. A CAC greater than or equal to 37 was identified as a positive marker for chest pain. Sixty-three patients fell into the positive category with this marker and 44% were found to have cardiac chest pain. However, there were 3 patients who fell below the 37 score threshold that were determined to have cardiac chest pain. Patients were followed at 30 days, 1 year and five years. Follow-up at 30 days showed no cardiac events in 99% of the patients, the other study showed the advantages of using CT to assess CAC in patients who present to the ED with chest pain as a diagnostic tool that could increase the number of patients who are shown to need further testing, and those patients who are experiencing noncardiogenic chest pain. Significance to project: 1.) This study could be incorporated into the algorithm for determining a patient’s source of their chest pain. 2.) It causes you to ask the question of why this is not being used in ED now. 3.) This study shows that there could be an increase in patient flow in the ED by using this to rule out cardiac chest pain. 4.) Patient satisfaction rates could increase by using this
1 % is unknown. At 1 year 98% of the patients reported data and only 2% had had cardiac catheterizations with 50% having to have PCI. Five years out only 212 participants provided follow-up data. Of those 212, 9 had had cardiac angiography with the need for interventions. 100% of those patients had a positive CAC score at their initial evaluation. method of testing for chest pain patients. Hess, E.P., Perry, J.J., Ladouceur, P., Wells, G.A., & Stiell, I.G. (2010). Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome. CJEM: The Journal of the Canadian Association of Emergency Physicians, 12(2),128-134. of Evidence: II The purpose of this was to determine which patients that presented to the emergency department with either chest pain or potentially ACS needed chest radiography. This was a study that was part of an ongoing cohort study to determine whether a clinical decision rule regarding chest radiography needed to be in place for patients who present to triage with chest pain. The study was conducted at a Canadian university affiliate hospitals emergency department over a six month period in 2007. Patients were The study found that patients who did not have a history of smoking, CHF or lung abnormalities on assessment did not need a chest x-ray when they presented with chest pain to the ED. Of the 529 patients in the study only 2.1% had a chest x-ray that showed a need for intervention. This study has shown that by using a patient’s medical history and Weaknesses: 1.) The study was only 6 months. 2.) Patients that were eligible were not enrolled due to lack of attention to detail by nurses and registration clerks. 3.) A low number of chest x-rays showed an abnormality needing acute treatment. Strengths: 1.) The study showed that ED could decrease their use
enrolled if they met the criteria of being over the age of 24 years and their primary complaint at triage was chest pain. 529 patients were enrolled in the study and over 60% were males. Also of the 529 patients, 21 had a history of CHF (congestive heart failure) and 116 had a history of AMI (acute myocardial infarction). Patients assessment was performed by the ED physician and chest radiographs were ordered if appropriate. The chest radiographs were read by two blinded emergency department clinicians that categorized the results as normal, abnormal-not requiring intervention, and abnormal-requiring intervention according to the radiology findings and the patient’s assessment. physical assessment a decrease in costs and time can be obtained in the ED when caring for patients who present with chest pain. of chest radiography in patients with chest pain. 2.) ED patient flow could experience an increase if a rule was in place defining which patients with chest pain required a chest x-ray. 3.) Patients would have a decreased exposure to radiation. 4.) Healthcare costs could be decreased. Significance for Project: 1.) The study could be used as a tool in the chest pain diagnosis algorithm. 2.) The information in the study will enhance my PICO question. 3.) Observed a decrease in healthcare costs and an increase in patient flow in the ED. 4.) Showed that patients with a significant cardiac history or specific risk factors need further evaluation.