148 Questions
What can decrease the specificity of a stress test?
Underlying electrocardiographic abnormalities
Which condition may result in a false-positive stress test outcome?
Aortic stenosis
Who may have a higher rate of false-positive stress test results?
Women
What is the negative predictive value of stress testing for the diagnosis of ACS or cardiac event within 30 days in low-risk ED patients?
98.7%
When is it recommended to perform exercise testing according to current guidelines?
When patients are free of active ischemic or heart failure symptoms for a minimum of 8 to 12 hours
What is one potential consequence of performing provocative testing in a low-risk population?
Further downstream testing and intervention without significant reductions in future rates of infarction
What diagnostic methods appear to be effective for detecting symptomatic CAD in low-to moderate-risk patients according to the text?
An abbreviated ED-based, so-called rule-out MI protocol, followed by mandatory stress testing
Which condition may lead to a false-positive stress test outcome?
Aortic stenosis
What can decrease the specificity of a stress test?
Medication-induced electrocardiographic abnormalities
Who may have a higher rate of false-positive stress test results?
Women
What is the negative predictive value of stress testing for the diagnosis of ACS or cardiac event within 30 days in low-risk ED patients?
98.7%
When is it recommended to perform exercise testing according to current guidelines?
When patients are free of active ischemic or heart failure symptoms for a minimum of 8 to 12 hours
What is one potential consequence of performing provocative testing in a low-risk population?
Further downstream testing and intervention without significant reductions in future rates of infarction
What diagnostic methods appear to be effective for detecting symptomatic CAD in low-to moderate-risk patients according to the text?
Mandatory stress testing following an abbreviated ED-based rule-out MI protocol
What is the positive predictive accuracy of regional systolic wall motion abnormalities in a patient without known CAD as an indicator of AMI or infarction?
50%
What does paradoxical wall motion and decreased ejection fraction observed during systole after AMI indicate?
Subsequent loss of muscle tone from necrosis
What does resting echocardiography provide an assessment of in patients with ACS?
Global and regional function
What is the significance of the absence of segmental abnormalities in echocardiography for cases of suspected MI?
High negative predictive value
What is stress echocardiography superior to for CAD detection in women?
Conventional treadmill testing
What technique uses microbubble ultrasonic contrast agents to assess microvascular perfusion and regional function with echocardiography?
Myocardial contrast echocardiography (MCE)
What is a potential limitation for the use of two-dimensional echocardiography in the ED?
Inability to distinguish among ischemia, AMI, or old infarction
What can stress echocardiography detect early after an AMI?
CAD and assess cardiac function
What is a vital tool to assess various complications of AMI?
Echocardiography
What can help evaluate other causes of clinical presentations mimicking ACS?
Echocardiography
What restricts the use of echocardiography in the ED?
Technical limitations
What kind of test has been suggested for patients with nondiagnostic ECGs, negative markers, and negative rest echocardiography after a period of observation?
Emergency pharmacologic stress echocardiography
What is the positive predictive accuracy of regional systolic wall motion abnormalities in a patient without known CAD as an indicator of AMI or infarction?
50%
What does resting echocardiography provide an assessment of in patients with ACS?
Global and regional function
What is the negative predictive value of stress testing for the diagnosis of ACS or cardiac event within 30 days in low-risk ED patients?
As high as 98%
What can be detected in up to 90% of patients with ACS when echocardiography is performed shortly after ED arrival, during an episode of chest pain?
Wall motion abnormalities
What is a potential technical limitation for the use of echocardiography in the ED?
Limited expertise of the operator and reader interpreting the study
What does stress echocardiography detect early after an AMI?
Myocardial viability and ventricular function
What is the superior diagnostic method for CAD detection in women?
Stress echocardiography
What diagnostic method has been suggested for patients with nondiagnostic ECGs, negative markers, and negative rest echocardiography after a period of observation?
Pharmacologic stress echocardiography
What is the primary purpose of myocardial scintigraphy with radionuclide tracer injection and imaging?
Assessment of myocardial perfusion and function in real-time
What does the redistribution pattern in subsequent myocardial scintigraphy imaging indicate?
Active coronary ischemia
In patients with a normal initial study, what is the likelihood of acute coronary syndrome (ACS)?
Extremely low
What is the potential consequence of performing immediate myocardial scintigraphy in low to moderate-risk patients with atypical chest pain?
Detection of ACS and risk assessment for cardiac events
What is the primary purpose of myocardial scintigraphy with radionuclide tracer injection and imaging?
Assessment of myocardial perfusion and function in real-time
What does the redistribution pattern in subsequent myocardial scintigraphy imaging indicate?
Active coronary ischemia
In patients with a normal initial study, what is the likelihood of acute coronary syndrome (ACS)?
Extremely low
What diagnostic method has promising positive and negative predictive values for cardiac events, with high sensitivity and good specificity for CAD?
Myocardial scintigraphy
What is the primary purpose of Coronary Computed Tomography Angiography (CCTA)?
To assess coronary artery disease in patients who have been ruled out for AMI and other active forms of ACS
What does Coronary Computed Tomography Angiography (CCTA) accurately detect in symptomatic stable patients with low to intermediate pretest probability of CAD?
Significant coronary artery obstructive lesions
What is one predictive capability of Coronary Computed Tomography Angiography (CCTA) in addition to detecting significant coronary obstructive lesions?
Predictive of outcome
In which type of patients may Coronary Computed Tomography Angiography (CCTA) be an appropriate imaging study?
Symptomatic stable patients with low to intermediate pretest probability of CAD
What is the primary purpose of Coronary Computed Tomography Angiography (CCTA)?
To detect significant coronary obstructive lesions in symptomatic stable patients with low to intermediate pretest probability of CAD
What can be detected by Coronary Computed Tomography Angiography (CCTA) in symptomatic stable patients with low to intermediate pretest probability of CAD?
Coronary artery obstructive lesions
What is a potential consequence of performing provocative testing in a low-risk population?
Increased false-positive stress test results
What is one predictive capability of Coronary Computed Tomography Angiography (CCTA) in addition to detecting significant coronary obstructive lesions?
Predictive of outcome
Which risk stratification tool is designed for identifying low-risk individuals with a low short-term MACE rate eligible for discharge from the emergency department?
EDACS
What clinical data are used in the EDACS-ADP risk calculation?
Serum troponin testing and ECG results
Which of the following is NOT a descriptor used in calculating the EDACS score?
Pain worsened with inspiration
What is the primary purpose of the GRACE risk model and TIMI risk score?
Evaluating individuals with undifferentiated chest pain
What is the primary purpose of the HEART Score?
To identify low-risk patients for safe discharge after a limited evaluation in the emergency department (ED)
What scoring range indicates high-risk patients according to the HEART Score?
$7$ to $10$
What does the HEART Pathway combine with the HEART Score to improve diagnostic accuracy?
Additional troponin obtained at 3 hours
What is the MACE rate for short-term risk of myocardial infarction, need for PCI or CABG, and death within 6 weeks for low-risk patients according to the HEART Score?
$1.7%$
What is a key consideration for using the HEART Score outside of the ED population?
It should not be used outside of the ED population
What does the HEART Pathway offer compared to the HEART Score alone?
Higher sensitivity and greater negative predictive value for MACE
What does intermediate-risk patients' (scored 4 to 6) MACE rate suggest according to the text?
Approximately 12% to 17%
What is required for improving diagnostic accuracy according to the text?
Clear understanding of five variable components in the HEART Score
What is noted as a valuable aspect of the HEART Score according to the text?
Easily calculated using information obtained from a standard ED evaluation
What does application of decision tools like EDACS-ADP and HEART Score in the ED aim to improve?
Resource utilization
What are clinical decision making still guided by, according to the text?
Patient’s condition, local resource availability, and physician assessment.
What is the primary purpose of the Emergency Department Assessment of Chest Pain Score (EDACS)?
To identify patients who may safely be discharged from the ED
Which clinical data are used in the EDACS-ADP risk calculation?
Patient's age, sex, history of CAD or CAD risk factors, and chest pain descriptors
What is one feature used in the EDACS score calculation to indicate higher risk?
Pain radiation to shoulder, jaw, neck or arm
What distinguishes recent developments like EDACS and HEART Score from earlier risk stratification tools like GRACE and TIMI?
They provide ED-appropriate, easily performed, accurate clinical decision tools for use in the ED
Which statement about the HEART Score is accurate?
It uses five variables: patient history of chest pain (H), 12-lead ECG (E), patient age (A), risk factor burden (R), and a single serum troponin determination (T).
What is the primary purpose of the HEART Pathway?
To combine the HEART Score with an additional troponin obtained at 3 hours to improve diagnostic accuracy.
What does the MACE rate of approximately 12% to 17% for intermediate-risk patients (scored 4 to 6) suggest?
They require ED observation and additional risk stratification testing or cardiology consultation.
What is the significance of the absence of new ischemic changes in an ECG according to the EDACS-ADP model?
It is one of the criteria for identifying low-risk patients along with two negative serum troponin values at 0 and 2 hours.
What does application of decision tools like EDACS-ADP and HEART Score in the ED aim to improve?
Resource utilization in the emergency department.
50% to 65% MACE rate for high-risk patients (scores 7 to 10) suggests:
50% to 65% chance of requiring consideration of coronary intervention and hospital admission.
What does the HEART Score offer in terms of decision making in the ED?
Easily calculated risk stratification using information obtained from a standard ED evaluation.
Which statement accurately describes the validation and usage scope of the HEART Score?
It has been validated in various studies but should not be used outside of the ED population.
What does the HEART Pathway offer compared to the HEART Score alone?
Improved diagnostic accuracy with higher sensitivity and greater negative predictive value for major adverse cardiac events (MACE).
GRACE risk model and TIMI risk score were designed to identify patients who may safely be discharged from the ED
False
EDACS is a clinical aid for identifying low-risk individuals with a low short-term MACE rate eligible for discharge from the emergency department
True
EDACS-ADP includes serum troponin testing and ECG results in the patient evaluation
True
Presence of diaphoresis is a higher risk descriptor used in calculating the EDACS score
True
EDACS-ADP uses three negative serum troponin values at 0, 2, and 4 hours to identify low-risk patients for safe discharge after a limited evaluation.
False
HEART Score is a tool developed in the United States for rapid risk stratification of patients with chest pain suspected of acute myocardial infarction (AMI) in the ED.
False
The scoring range for low-risk patients according to the HEART Score is 3 to 5.
False
High-risk patients according to the HEART Score have a MACE rate of approximately 30% to 40%.
False
The HEART Score alone is more valuable for decision making in the ED compared to the HEART Pathway.
False
The HEART Pathway offers a higher sensitivity and greater negative predictive value for MACE compared to the HEART Score alone.
True
Application of decision tools like EDACS-ADP and HEART Score in the ED has no impact on resource utilization.
False
Clinical decision making in the ED is solely guided by the patient’s condition and physician assessment, and local resource availability has no influence.
False
The HEART Score has been validated in various studies and can be used outside of the ED population without any limitations.
False
To improve diagnostic accuracy, the HEART Pathway combines the HEART Score with an additional troponin obtained at 3 hours.
True
The HEART Pathway is noted to have a lower sensitivity and lesser negative predictive value for MACE compared to the HEART Score alone.
False
The HEART Score has a scoring range from 0 to 10 for rapid risk stratification of patients with chest pain suspected of acute myocardial infarction (AMI) in the ED.
True
GRACE risk model and TIMI risk score were designed to identify patients who may safely be discharged from the ED.
False
EDACS is a clinical aid for identifying low-risk individuals with a low short-term MACE rate eligible for discharge from the emergency department.
True
The HEART Score has been validated in various studies and can be used outside of the ED population without any limitations.
False
EDACS-ADP uses three negative serum troponin values at 0, 2, and 4 hours to identify low-risk patients for safe discharge after a limited evaluation.
True
HEART Score ranges from 0 to 10 for rapid risk stratification of patients with chest pain suspected of acute myocardial infarction (AMI) in the ED
True
The HEART Score is easily calculated using information obtained from a standard ED evaluation
True
EDACS-ADP uses two negative serum troponin values at 0 and 2 hours to identify low-risk patients for safe discharge after a limited evaluation
False
HEART Score identifies low-risk patients with two negative serum troponin values at 0 and 2 hours and an ECG without new ischemic changes
False
Intermediate-risk patients, according to the HEART Score, have a MACE rate of approximately 12% to 17%
True
HEART Pathway combines the HEART Score with an additional troponin obtained at 3 hours to improve diagnostic accuracy
True
HEART Pathway has a lower sensitivity and negative predictive value for MACE compared to the HEART Score alone
False
The primary purpose of the Emergency Department Assessment of Chest Pain Score (EDACS) is to identify low-risk patients for safe discharge after a limited evaluation
True
The HEART Score has been validated in various studies and can be used outside of the ED population
False
Application of decision tools like EDACS-ADP and HEART Score in the ED has no impact on resource utilization
False
HEART Score is a tool developed in the Netherlands for rapid risk stratification of patients with chest pain suspected of acute myocardial infarction (AMI) in the ED
True
The HEART Pathway offers a higher sensitivity and greater negative predictive value for MACE compared to the HEART Score alone
True
What is the approximate range of expedited ED evaluations without hospital admissions compared to usual inpatient costs?
20% to 50%
What is the typical range of time for the final evaluation phase based on the chosen serum marker determination strategy?
1 hour to approximately 12 hours
What percentage of patients with chest pain can be safely evaluated in the ED or observation unit with ultimate discharge to home?
75% to 80%
What is the primary diagnostic consideration during the first phase of ED evaluation for a patient with suspected ACS?
Recognition of evolving STEMI
What occurs during the second phase of ED evaluation if a patient does not present with STEMI or other significant ACS?
Serial ECGs and serum marker determinations
What follows if a patient 'rules in' for NSTEMI or other significant ACS presentation during ED evaluation?
Inpatient admission or transfer
What is the average duration of the first phase focused on STEMI recognition during ED evaluation?
$ ext{< 10 minutes}$
What is the primary diagnostic consideration during the first phase of ED evaluation for a patient with suspected ACS?
Recognition of evolving STEMI
What is the average duration of the first phase focused on STEMI recognition during ED evaluation?
Less than 10 minutes
What occurs during the second phase of ED evaluation if a patient does not present with STEMI or other significant ACS?
Traditional rule-out MI approach
During which phase of ED evaluation are alternative diagnoses established and risk assessment occurs?
Second phase
What percentage of patients with chest pain can be safely evaluated in the ED or observation unit with ultimate discharge to home?
Approximately 75% to 80%
What is the typical range of charges and actual costs for expedited ED evaluations without hospital admissions compared to the usual inpatient costs?
20% to 50% of the usual inpatient costs
What is the range of time for the final evaluation phase based on the chosen serum marker determination strategy?
6 hours to 12 hours
What is a key factor influencing the appropriate pathway for patients with suspected obstructive CAD?
Patient presentation features
Which disposition extends the ED or hospital stay by hours or longer?
Continued additional ED or observation unit evaluation with or without cardiology consultation
What is used for patient risk stratification during the first and second phases of the evaluation?
Physician judgment and clinical decision rules
Which tool is used for patient risk stratification during the first and second phases of the evaluation?
HEART Score
What is the primary purpose of the HEART Score?
To rapidly risk-stratify patients with chest pain suspected of AMI in the ED
What is the significance of the absence of segmental abnormalities in echocardiography for cases of suspected MI?
It indicates a low risk for adverse cardiac events
When is it recommended to perform exercise testing according to current guidelines?
In specific instances after initial evaluation in the ED or observation unit
What does paradoxical wall motion and decreased ejection fraction observed during systole after AMI indicate?
A high likelihood of subsequent adverse cardiac events
What does application of decision tools like EDACS-ADP and HEART Score in the ED aim to improve?
Resource utilization and hospital admissions
What kind of test has been suggested for patients with nondiagnostic ECGs, negative markers, and negative rest echocardiography after a period of observation?
Coronary CT angiography (CCTA)
What distinguishes recent developments like EDACS and HEART Score from earlier risk stratification tools like GRACE and TIMI?
Incorporation of patient gestalt and clinical decision rules
What is required for improving diagnostic accuracy according to the text?
Integration of qualitative and quantitative risk assessment methods
Which disposition extends the ED or hospital stay by hours or longer?
Continued additional ED or observation unit evaluation with or without cardiology consultation
What tool is used for patient risk stratification during the first and second phases of the evaluation?
HEART Score
What is one potential consequence of performing provocative testing in a low-risk population?
Decreased sensitivity of test results
What clinical data are used in the EDACS-ADP risk calculation?
Serum troponin values at 0, 2, and 4 hours
What is the primary purpose of the HEART Pathway?
To offer a higher sensitivity and greater negative predictive value for MACE compared to the HEART Score alone
What is the typical management approach for intermediate-risk patients in the hospital setting?
Further evaluation in the emergency department
What is the primary purpose of the observation unit strategy for chest pain–accelerated diagnostic protocol?
To reduce hospital admissions with no increase in adverse events
What is the main purpose of employing further ACS evaluation with stress testing, echocardiography, or coronary CT angiography before disposition?
To rule out MI and ensure appropriate management
What is the typical management approach for low-risk patients identified by qualitative and quantitative methods?
Immediate discharge to outpatient care
What is the primary purpose of employing a chest pain–accelerated diagnostic protocol for intermediate-risk patients?
To expedite inpatient admission for further evaluation
What is the significance of identifying intermediate risk patients by physician gestalt, diagnostic study results, ED course, or clinical decision rules?
Further evaluation in the emergency department
What is one potential consequence of managing low-risk patients identified by qualitative and quantitative methods as inpatients?
Increased risk of adverse events due to unnecessary hospitalization
Study Notes
-
The text discusses two prediction models, EDACS-ADP and HEART Score, used in emergency departments (ED) to identify low-risk patients for safe discharge after a limited evaluation.
-
EDACS-ADP identifies low-risk patients with two negative serum troponin values at 0 and 2 hours and an ECG without new ischemic changes.
-
HEART Score is a tool developed in the Netherlands for rapid risk stratification of patients with chest pain suspected of acute myocardial infarction (AMI) in the ED.
-
It uses five variables: patient history of chest pain (H), 12-lead ECG (E), patient age (A), risk factor burden (R), and a single serum troponin determination (T).
-
Scoring ranges from 0 to 10, with low-risk patients (a score of 3 or less) having a MACE rate of 1.7% for short-term risk of myocardial infarction, need for PCI or CABG, and death within 6 weeks.
-
Intermediate-risk patients (scored 4 to 6) have a MACE rate of approximately 12% to 17%, suggesting ED observation and additional risk stratification testing or cardiology consultation.
-
High-risk patients (scores 7 to 10) have a MACE rate of approximately 50% to 65% and require consideration of coronary intervention and hospital admission.
-
The HEART Score is easily calculated using information obtained from a standard ED evaluation, making it valuable for decision making in the ED.
-
The HEART Score has been validated in various studies, but should not be used outside of the ED population and requires a clear understanding of the five variable components.
-
To improve diagnostic accuracy, the HEART Pathway combines the HEART Score with an additional troponin obtained at 3 hours.
-
The HEART Pathway is noted to have a higher sensitivity and greater negative predictive value for MACE compared to the HEART Score alone.
-
Application of these decision tools in the ED can improve resource utilization.
-
Clinical decision making is still guided by the patient’s condition, local resource availability, and physician assessment.
-
The text discusses two prediction models, EDACS-ADP and HEART Score, used in emergency departments (ED) to identify low-risk patients for safe discharge after a limited evaluation.
-
EDACS-ADP identifies low-risk patients with two negative serum troponin values at 0 and 2 hours and an ECG without new ischemic changes.
-
HEART Score is a tool developed in the Netherlands for rapid risk stratification of patients with chest pain suspected of acute myocardial infarction (AMI) in the ED.
-
It uses five variables: patient history of chest pain (H), 12-lead ECG (E), patient age (A), risk factor burden (R), and a single serum troponin determination (T).
-
Scoring ranges from 0 to 10, with low-risk patients (a score of 3 or less) having a MACE rate of 1.7% for short-term risk of myocardial infarction, need for PCI or CABG, and death within 6 weeks.
-
Intermediate-risk patients (scored 4 to 6) have a MACE rate of approximately 12% to 17%, suggesting ED observation and additional risk stratification testing or cardiology consultation.
-
High-risk patients (scores 7 to 10) have a MACE rate of approximately 50% to 65% and require consideration of coronary intervention and hospital admission.
-
The HEART Score is easily calculated using information obtained from a standard ED evaluation, making it valuable for decision making in the ED.
-
The HEART Score has been validated in various studies, but should not be used outside of the ED population and requires a clear understanding of the five variable components.
-
To improve diagnostic accuracy, the HEART Pathway combines the HEART Score with an additional troponin obtained at 3 hours.
-
The HEART Pathway is noted to have a higher sensitivity and greater negative predictive value for MACE compared to the HEART Score alone.
-
Application of these decision tools in the ED can improve resource utilization.
-
Clinical decision making is still guided by the patient’s condition, local resource availability, and physician assessment.
-
The text discusses two prediction models, EDACS-ADP and HEART Score, used in emergency departments (ED) to identify low-risk patients for safe discharge after a limited evaluation.
-
EDACS-ADP identifies low-risk patients with two negative serum troponin values at 0 and 2 hours and an ECG without new ischemic changes.
-
HEART Score is a tool developed in the Netherlands for rapid risk stratification of patients with chest pain suspected of acute myocardial infarction (AMI) in the ED.
-
It uses five variables: patient history of chest pain (H), 12-lead ECG (E), patient age (A), risk factor burden (R), and a single serum troponin determination (T).
-
Scoring ranges from 0 to 10, with low-risk patients (a score of 3 or less) having a MACE rate of 1.7% for short-term risk of myocardial infarction, need for PCI or CABG, and death within 6 weeks.
-
Intermediate-risk patients (scored 4 to 6) have a MACE rate of approximately 12% to 17%, suggesting ED observation and additional risk stratification testing or cardiology consultation.
-
High-risk patients (scores 7 to 10) have a MACE rate of approximately 50% to 65% and require consideration of coronary intervention and hospital admission.
-
The HEART Score is easily calculated using information obtained from a standard ED evaluation, making it valuable for decision making in the ED.
-
The HEART Score has been validated in various studies, but should not be used outside of the ED population and requires a clear understanding of the five variable components.
-
To improve diagnostic accuracy, the HEART Pathway combines the HEART Score with an additional troponin obtained at 3 hours.
-
The HEART Pathway is noted to have a higher sensitivity and greater negative predictive value for MACE compared to the HEART Score alone.
-
Application of these decision tools in the ED can improve resource utilization.
-
Clinical decision making is still guided by the patient’s condition, local resource availability, and physician assessment.
-
The text discusses two prediction models, EDACS-ADP and HEART Score, used in emergency departments (ED) to identify low-risk patients for safe discharge after a limited evaluation.
-
EDACS-ADP identifies low-risk patients with two negative serum troponin values at 0 and 2 hours and an ECG without new ischemic changes.
-
HEART Score is a tool developed in the Netherlands for rapid risk stratification of patients with chest pain suspected of acute myocardial infarction (AMI) in the ED.
-
It uses five variables: patient history of chest pain (H), 12-lead ECG (E), patient age (A), risk factor burden (R), and a single serum troponin determination (T).
-
Scoring ranges from 0 to 10, with low-risk patients (a score of 3 or less) having a MACE rate of 1.7% for short-term risk of myocardial infarction, need for PCI or CABG, and death within 6 weeks.
-
Intermediate-risk patients (scored 4 to 6) have a MACE rate of approximately 12% to 17%, suggesting ED observation and additional risk stratification testing or cardiology consultation.
-
High-risk patients (scores 7 to 10) have a MACE rate of approximately 50% to 65% and require consideration of coronary intervention and hospital admission.
-
The HEART Score is easily calculated using information obtained from a standard ED evaluation, making it valuable for decision making in the ED.
-
The HEART Score has been validated in various studies, but should not be used outside of the ED population and requires a clear understanding of the five variable components.
-
To improve diagnostic accuracy, the HEART Pathway combines the HEART Score with an additional troponin obtained at 3 hours.
-
The HEART Pathway is noted to have a higher sensitivity and greater negative predictive value for MACE compared to the HEART Score alone.
-
Application of these decision tools in the ED can improve resource utilization.
-
Clinical decision making is still guided by the patient’s condition, local resource availability, and physician assessment.
Learn about the feasibility of exercise stress testing for ED patients and the appropriate use of provocative testing for those with resolved symptoms and low to moderate suspicion of ACS. Understand the current guidelines for undergoing provocative testing, myocardial perfusion imaging, or coronary CT angiography prior to discharge or within 72 hours of discharge.
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