RESUMO
OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a preestablished process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74% of these had a final diagnosis of acute myocardial infarction [AMI]). Of the 660 patients that remained in the emergency room under observation, 77 (12%) had AMI without ST segment elevation and 202 (31%) had unstable angina (UA). In route 2 (high probability of ACS) 17% of patients had AMI and 43% had UA, whereas in route 3 (low probability) 2% had AMI and 7% had UA. The admission ECG has been confirmed as a poor sensitivity test for the diagnosis of AMI (49%), with a positive predictive value considered only satisfactory (79%). CONCLUSION: A systematic diagnostic strategy, as used in this study, is essential in managing patients with chest pain in the emergency room in order to obtain high diagnostic accuracy, lower cost, and optimization of the use of coronary care unit beds.
Assuntos
Baixo Débito Cardíaco/diagnóstico , Dor no Peito/diagnóstico , Serviço Hospitalar de Emergência , Idoso , Angina Instável/diagnóstico , Dor no Peito/fisiopatologia , Custos e Análise de Custo , Diagnóstico Diferencial , Ecocardiografia , Eletrocardiografia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Valor Preditivo dos Testes , Sensibilidade e EspecificidadeRESUMO
PURPOSE: To evaluate the efficacy of a systematic model of care for patients with chest pain and no ST segment elevation in the emergency room. METHODS: From 1003 patients submitted to an algorithm diagnostic investigation by probability of acute ischemic syndrome. We analyzed 600 ones with no elevation of ST segment, then enrolled to diagnostic routes of median (route 2) and low probability (route 3) to ischemic syndrome. RESULTS: In route 2 we found 17% acute myocardial infarction and 43% unstable angina, whereas in route 3 the rates were 2% and 7%, respectively. Patients with normal/non-specific ECG had 6% probability of AMI whereas in those with negative first CKMB it was 7%; the association of the 2 data only reduced it to 4%. In patients in route 2 the diagnosis of AMI could only be ruled out with serial CKMB measurement up to 9 hours, while in route 3 it could be done in up to 3 hours. Thus, sensitivity and negative predictive value of admission CKMB for AMI were 52% and 93%, respectively. About one-half of patients with unstable angina did not disclose objective ischemic changes on admission. CONCLUSION: The use of a systematic model of care in patients with chest pain offers the opportunity of hindering inappropriate release of patients with ACI and reduces unnecessary admissions. However some patients even with normal ECG should not be released based on a negative first CKMB. Serial measurement of CKMB up to 9 hours is necessary in patients with medium probability of AMI.
Assuntos
Angina Instável/diagnóstico , Dor no Peito/etiologia , Infarto do Miocárdio/diagnóstico , Algoritmos , Dor no Peito/diagnóstico , Eletrocardiografia , Serviços Médicos de Emergência , Humanos , Valor Preditivo dos Testes , Estudos Prospectivos , Sensibilidade e Especificidade , TriagemRESUMO
OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a pre-established process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74% of these had a final diagnosis of acute myocardial infarction [AMI]). Of the 660 patients that remained in the emergency room under observation, 77 (12%) had AMI without ST segment elevation and 202 (31%) had unstable angina (UA). In route 2 (high probability of ACS) 17% of patients had AMI and 43% had UA, whereas in route 3 (low probability) 2% had AMI and 7 % had UA. The admission ECG has been confirmed as a poor sensitivity test for the diagnosis of AMI ( 49%), with a positive predictive value considered only satisfactory (79%). CONCLUSION: A systematic diagnostic strategy, as used in this study, is essential in managing patients with chest pain in the emergency room in order to obtain high diagnostic accuracy, lower cost, and optimization of the use of coronary care unit beds.
RESUMO
OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a pre-established process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74% of these had a final diagnosis of acute myocardial infarction [AMI]). Of the 660 patients that remained in the emergency room under observation, 77 (12%) had AMI without ST segment elevation and 202 (31%) had unstable angina (UA). In route 2 (high probability of ACS) 17% of patients had AMI and 43% had UA, whereas in route 3 (low probability) 2% had AMI and 7% had UA. The admission ECG has been confirmed as a poor sensitivity test for the diagnosis of AMI (49%), with a positive predictive value considered only satisfactory (79%). CONCLUSION: A systematic diagnostic strategy, as used in this study, is essential in managing patients with chest pain in the emergency room in order to obtain high diagnostic accuracy, lower cost, and optimization of the use of coronary care unit beds.
RESUMO
PURPOSE: To evaluate the in-hospital (IH) outcome and the short-term follow-up of predominantly elderly patients presenting to an emergency room (ER) with congestive heart failure (CHF). METHODS: In an 11 month period, 57 patients presenting to the ER with CHF were included. Mean age was 69 +/- 15 years (27 to 94) and 39 (68.4%) were male. CHF diagnosis was based on the Boston criteria. We evaluated IH outcome and prognosis in a mean follow-up of 5.7 +/- 2.7 months (1 to 12). In addition, some mortality predictors and mechanisms of death according on the ACME system were identified. RESULTS: Eight patients (14%) died in the IH period. Modes of death were circulatory failure (CF) in 7, and peri-operative (PO) in one (aortic valve replacement). During follow-up 9 deaths occurred. Five were due to CF, 2 were sudden and 2 were PO (mitral valve replacement and ventriculectomy). Six-months and 1-year survival rates of the patients who were discharged were 82% and 66%, respectively. Sodium lower than 135 mEq/l (p = 0.004) and female gender (p = 0.038) were independent predictors of mortality. CONCLUSION: Elderly patients with CHF admitted to the ER have high in-hospital and short-term follow up mortalities. The majority die from CF due to worsening heart failure.
Assuntos
Insuficiência Cardíaca/terapia , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência , Feminino , Seguimentos , Insuficiência Cardíaca/mortalidade , Humanos , Masculino , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJETIVO - Conhecer a evoluçäo intra-hospitalar (IH) e pós-alta (PA) de uma populaçäo predominantemente idosa, com insuficiência cardíaca congestiva (ICC) na unidade de emergência (UE). MÉTODOS - Durante 11 meses, foram selecionados 57 pacientes consecutivos com ICC, atendidos em UE, com idade média de 69ñ15 (27 a 94) anos, sendo 39 (68,4 por cento) homens. O diagnóstico de ICC baseou-se nos critérios de Boston. Avaliou-se a evoluçäo IH e PA num período médio de 5,7ñ2,7 (1 A 12) meses, procurando-se identificar variáveis que se correlacionassem com a mortalidade e o mecanismo de morte, avaliado pelo sistema ACME. RESULTADOS - Oito (14 por cento) pacientes faleceram na fase IH, sendo 7 por falência circulatória (FC), e 1 em pós-operatório (PO). Durante o seguimento ocorreram 9 (18,4 por cento) óbitos, sendo 5 por FC, 2 mortes súbitas e 2 em (troca valvar mitral e ventriculectomia). A sobrevida dos pacientes...
Assuntos
Humanos , Idoso , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Emergências , Insuficiência Cardíaca/terapia , Prognóstico , Idoso de 80 Anos ou maisRESUMO
We describe four patients with sympathotonic orthostatic hypotension, a syndrome in which the decrease in blood pressure associated with standing is accompanied by tachycardia. The patients in this series had experienced either a viral infection or rapid weight loss prior to the onset of their orthostatic intolerance. Vasomotor reflexes and norepinephrine production were normal, and analysis of palmar autonomic surface potentials indicated that the sympathetic innervation of the upper extremities was intact. The amplitudes of the plantar autonomic surface potentials, however, were decreased although still within the normal range. The latencies of plantar autonomic surface potentials were slightly prolonged. Although most autonomic function tests are normal in sympathotonic orthostatic hypotension, mild abnormalities in the plantar autonomic surface potentials may indicate a neuropathy that primarily affects low thoracic or lumbar sympathetic neurons.