title: Emergency physician high pretest probability for acute coronary syndrome correlates with adverse cardiovascular outcomes.
abstract: OBJECTIVE
  The value of unstructured physician estimate of risk for disease processes, other than acute coronary syndrome (ACS), has been demonstrated. The authors sought to evaluate the predictive value of unstructured physician estimate of risk for ACS in emergency department (ED) patients without obvious initial evidence of a cardiac event.
  
  
  METHODS
  This was a post hoc secondary analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospectively collected multicenter data registry of patients over the age of 18 years presenting to the ED with symptoms of ACS between 1999 and 2001. In this registry, following patient history, physical exam, and electrocardiogram (ECG), the unstructured treating physician estimate of risk was recorded. A 30-day follow-up and a medical record review were used to determine rates of adverse cardiac events, death, myocardial infarction (MI), or revascularization procedure. The analysis included all patients with nondiagnostic ECG changes, normal initial biomarkers, and a non-MI initial impression from the registry and excluded those without complete data or who were lost to follow-up. Data were stratified by unstructured physician risk estimate: noncardiac, low risk, high risk, or unstable angina.
  
  
  RESULTS
  Of 15,608 unique patients in the registry, 10,145 met inclusion/exclusion criteria. Patients were defined as having unstable angina in 6.0% of cases; high risk, 23.5% of cases; low risk, 44.2%; and noncardiac, 26.3% of cases. Adverse cardiac event rates had an inverse relationship, decreasing from 22.0% (95% confidence interval [CI] = 18.8% to 25.6%) for unstable angina, 10.2% (95% CI = 9.0% to 11.5%) for those stratified as high risk, 2.2% (95% CI = 1.8% to 2.6%) for low risk, and to 1.8% (95% CI = 1.4% to 2.4%) for noncardiac. The relative risk (RR) of an adverse cardiac event for those with an initial label of unstable angina compared to those with a low-risk designation was 10.2 (95% CI = 8.0 to 13.0). The RR of an event for those with a high-risk initial impression compared to those with a low-risk initial impression was 4.7 (95% CI = 3.8 to 5.9). The risk of an event among those with a low-risk initial impression was the same as for those with a noncardiac initial impression (RR = 0.83, 95% CI = 0.6 to 1.2).
  
  
  CONCLUSIONS
  In ED patients without obvious initial evidence of a cardiac event, unstructured emergency physician (EP) estimate of risk correlates with adverse cardiac outcomes.
authors: Division of Emergency Medicine, Duke University Medical Center, Durham, NC, USA. chand018@mc.duke.edu
authors: Abhinav
authors: A
authors: Chandra
authors: Christopher J
authors: CJ
authors: Lindsell
authors: Alexander
authors: A
authors: Limkakeng
authors: Deborah B
authors: DB
authors: Diercks
authors: James W
authors: JW
authors: Hoekstra
authors: Judd E
authors: JE
authors: Hollander
authors: J Douglas
authors: JD
authors: Kirk
authors: W Frank
authors: WF
authors: Peacock
authors: W Brian
authors: WB
authors: Gibler
authors: Charles V
authors: CV
authors: Pollack
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis*; D002637:Chest Pain / Q000175:diagnosis; D016009:Chi-Square Distribution; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D012042:Registries; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors