CJEM Articles: Erik P. Hess
Displaying 1-4 of 4 results
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September
2010
12
5
Erik P. Hess, George A. Wells, Ian G. Stiell, Jeffrey J. Perry, Lisa A. Calder, Venkatesh Thiruganasambandamoorthy, Veronique L. Roger
Objective: We sought to assess sex differences in clinical presentation, management and outcome in emergency department (ED) patients with chest pain, and to measure the association between female sex and coronary angiography within 30 days.
Methods: We conducted a prospective cohort study in an urban academic ED between Jul. 1, 2007, and Apr. 1, 2008. We enrolled patients over 24 years of age with chest pain and possible acute coronary syndrome (ACS).
Results: Among the 970 included patients, 386 (39.8%) were female. Compared with men, women had a lower prevalence of known coronary artery disease (21.0% v. 34.2%, p < 0.001) and a lower frequency of typical pain (37.1% v. 45.7%, p = 0.01). Clinicians classified a greater proportion of women as having a low (< 10%) pretest probability for ACS (85.0% v. 76.4%, p = 0.001). Despite similar rates of electrocardiography, troponin T and stress testing between sexes, there was a lower rate of acute myocardial infarction (AMI) (4.7% v. 8.4%, p = 0.03) and positive stress test results (4.4% v. 7.9%, p = 0.03) in women. Women were less frequently referred for coronary angiography (9.3% v. 18.9%, p < 0.001). The adjusted association between female sex and coronary angiography was not significant (odds ratio 0.63, 95% confidence interval 0.37–1.10).
Conclusion: Women had a lower rate of AMI and a lower rate of positive stress test results despite similar rates of testing between sexes. Although women were less frequently referred for coronary angiography, these data suggest that sex differences in management were likely appropriate for the probability of disease.
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March
2010
12
2
Erik P. Hess, George A. Wells, Ian G. Stiell, Jeffrey J. Perry, Pam Ladouceur
Objective: We derived a clinical decision rule to determine which emergency department (ED) patients with chest pain and possible acute coronary syndrome (ACS) require chest radiography.
Methods: We prospectively enrolled patients over 24 years of age with a primary complaint of chest pain and possible ACS over a 6 month period. Emergency physicians completed standardized clinical assessments and ordered chest radiographs as appropriate. Two blinded investigators independently classified chest radiographs as "normal," "abnormal not requiring intervention" and "abnormal requiring intervention," based on review of the radiology report and the medical record. The primary outcome was abnormality of chest radiographs requiring acute intervention. Analyses included interrater reliability assessment (with κ statistics), univariate analyses and recursive partitioning.
Results: We enrolled 529 patients during the study period between Jul. 1, 2007, and Dec. 31, 2007. Patients had a mean age of 59.9 years, 60.3% were male, 4.0% had a history of con gestive heart failure and 21.9% had a history of acute myocardial infarction. Only 2.1% (95% confidence interval [CI] 1.1%-3.8%) of patients had radiographic abnormality of the chest requiring acute intervention. The κ statistic for chest radiograph classification was 0.81 (95% CI 0.66-0.95). We derived the following rule: patients can forgo chest radiography if they have no history of congestive heart failure, no history of smoking and no abnormalities on lung auscultation. The rule was 100% sensitive (95% CI 32.0%-40.4%) and 36.1% specific (95% CI 32.0%-40.4%).
Conclusion: This rule has potential to reduce health care costs and enhance ED patient flow. It requires validation in an independent patient population before introduction into clinical practice.
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March
2010
12
2
Erik P. Hess, George A. Wells, Ian G. Stiell, Jeffrey J. Perry, Pam Ladouceur
Objective: We derived a clinical decision rule to determine which emergency department (ED) patients with chest pain and possible acute coronary syndrome (ACS) require chest radiography.
Methods: We prospectively enrolled patients over 24 years of age with a primary complaint of chest pain and possible ACS over a 6 month period. Emergency physicians completed standardized clinical assessments and ordered chest radiographs as appropri ate. Two blinded investigators independently classified chest radi ographs as "normal," "abnormal not requiring intervention" and "abnormal requiring intervention," based on review of the radiol ogy report and the medical record. The primary outcome was abnormality of chest radiographs requiring acute intervention. Analyses included interrater reliability assessment (with κ statistics), univariate analyses and recursive partitioning.
Results: We enrolled 529 patients during the study period between Jul. 1, 2007, and Dec. 31, 2007. Patients had a mean age of 59.9 years, 60.3% were male, 4.0% had a history of con gestive heart failure and 21.9% had a history of acute myocardial infarction. Only 2.1% (95% confidence interval [CI] 1.1%-3.8%) of patients had radiographic abnormality of the chest requiring acute intervention. The κ statistic for chest radiograph classification was 0.81 (95% CI 0.66-0.95). We derived the following rule: patients can forgo chest radiography if they have no history of congestive heart failure, no history of smoking and no abnormalities on lung auscultation. The rule was 100% sensitive (95% CI 32.0%-40.4%) and 36.1% specific (95% CI 32.0%-40.4%). Conclusion: This rule has potential to reduce health care costs and enhance ED patient flow. It requires validation in an independent patient population before introduction into clinical practice.
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July
2008
10
4
Allan S. Jaffe, Erik P. Hess, George A. Wells, Ian G. Stiell, Judd E. Hollander, Patricia Erwin, Venkatesh Thiruganasambandamoorthy, Victor M. Montori
Objective: We sought to determine the diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome (ACS) in the emergency department (ED) setting.
Methods: We searched MEDLINE, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews. We contacted content experts to identify additional articles for review. Reference lists of included studies were hand searched. We selected articles for review based on the following criteria: 1) enrolled consecutive ED patients; 2) incorporated variables from the history or physical examination, electrocardiogram and cardiac biomarkers; 3) did not incorporate cardiac stress testing or coronary angiography into prediction rule; 4) based on original research; 5) prospectively derived or validated; 6) did not require use of a computer; and 7) reported sufficient data to construct a 2 × 2 contingency table. We assessed study quality and extracted data independently and in duplicate using a standardized data extraction form.
Results: Eight studies met inclusion criteria, encompassing 7937 patients. None of the studies verified the prediction rule with a reference standard on all or a random sample of patients. Six studies did not report blinding prediction rule assessors to reference standard results, and vice versa. Three prediction rules were prospectively validated. Sensitivities and specificities ranged from 94% to 100% and 13% to 57%, and positive and negative likelihood ratios from 1.1 to 2.2 and 0.01 to 0.17, respectively.
Conclusion: Current prediction rules for ACS have substantial methodological limitations and have not been successfully implemented in the clinical setting. Future methodologically sound studies are needed to guide clinical practice.
