The Validity of Heart Score and Life Style Factors of Evaluation for Patient with Chest Pain in Emergency Department

Walla Taleb Oumran, Safaa Jawad kadhem, Hadeel Fadil Farhood
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Keywords : Chest pain, Percutaneous, ACS
Medical Journal of Babylon  14:3 , 2018 doi:1812-156X-14-3
Published :05 January 2018

Abstract

Chest pain is one of most common reasons for attended patients to emergency department. The risk of chest pain in the emergency department is critical. An acute coronary syndrome needs to be distinguished from a variety of other cardiac and non-cardiac diseases that cause chest pain and the rate of hospitalization in high-cost units. Risk for chest pain patients at the emergency department is recommended in several guidelines. The history, ECG, age, risk factors, and troponin So we can diagnose the patients with chest pain at the emergency department and identify both low and high risk patients for an acute coronary syndrome (ACS) by using HEART score and life style. Distribution all patient attended to ED with chest pain in Heart score, application of Heart score to patient with chest pain to evaluate the critical cases and to decrease the intervention with not critical. The study is prospectively cohort study. Clinical data from 282 patient present with chest pain in emergency department were analyzed and who had a major adverse cardiac event within 6 weeks (Acute Myocardial Infarction, Coronary Artery Bypass Graft, Percutaneous Coronary Intervention) from (1/10/2016) to (16/2/2017). In Marjan city of medicine, we analyzed 282/940 patient were 78 (27.3%) discharge home and 204 (72.7%) admitted to hospital. Patient with absent of risk factor 116 p (41.1%), 166 (58.9) presented of risk factor were all suffer from chest pain, age, risk factor, past medical, serum troponin, electrocardiogram, distributed with heart score low, medium high. There was a relation between score element its higher with troponin level (43.64) and lower with one RF (5.77). 136 patient reached to the end point and 146 patients did not reached to the end point were all highly significant. Chest pain is most common cause that lead patient attended to ED and that pain is duo to many causes some are life threaten and some not for decrease the cost, and good diagnosis and decrease uses of coronary care unit bed so that need do the necessary management to patient that complain of chest pain.

Introduction

Chest pain is commonest cause that lead Patient attended to Emergency Department as it account for approximately 5 to 20 % of all ED cases [1]. Its 2nd cause that lead patient attended to Emergency Department in United States [2]. in the United States about 12% of emergency department visits is Chest pain and has a mortality of about 5%.in one year [3]. The percentage of patient that attended to Emergency Department that complain of chest pain will be increase from 2006 to 2011 in United States [4]. 55- 85% of the patients with chest pain presenting to the emergency department do not have a cardiac cause for their symptoms [5]. There are percentage of patient that attended to Emergency Department for chest pain are sixty [6]. The development of coronary heart disease (CHD) is due to Cardiac risk factors which are Diabetes Mellitus, Smoking, Cholesterol Level, Obesity, Hypertension, Physical inactivity and stress all of them that effect on Morbidity and Mortality [7, 8]. Good Life –Style that affect in perfect way on Coronary artery atherosclerosis [9]. Chest pain has multiple causes which consist of serious conditions such as musculoskeletal; Lumbosacrale, Respira-tory cause Lung, the pleura or the trachea, Cardiac including the pericardium, Aaorta, Esophagus, Diaphragm, Pain that referral from the abdominal cavity & its organs like the Stomach, Gallbladder and Pancreas; and Neurological and Anxiety/ emotion. The approach to patients with chest pain represent difficult task in the emergency department (ED) [2]. It is the duty of the emergency department doctor to recognize an acute coronary syndrome (ACS) and differentiate it from a variety of other cardiac and non-cardiac diseases that may cause chest pain. In some patients, it is a relatively easy task, in particular in cases of ST segment elevation acute myocardial infarction (STEMI). However, the number of patients with STEMI of patient that complain of chest pain will found in Emergency Department is relatively small [12]. Considering the high mortality of acute myocardial infarction (AMI) and notable improvement in prognosis following timely interventions, early diagnosis of AMI and ACS is critical [13]. The first line of investigation to patient that attended to Emergency Department are electrocardiography ECG and the Serum Troponin [14,15]. Due to lack of standardization and inter-personnel variations, many risk strati?cation scores have been tried over time. And these scores were recommended by the international cardiac guidelines to be used for risk strati?cation [16,17]. One of these scores is The HEART score was recently developed.

Materials and methods

Statistical analysis was carried out using SPSS version 20. Categorical variables were presented as frequencies and percentages. Pearson’s chi square (X2) was used to find the association between categorical variables. A p-value of ? 0.05 was considered as significant.
Ethical approval:
1- The acceptance of ethical committee of Marjan teaching hospital in Babylon province was taken to conduct this study and official agreement Was obtained from Babylon Health Director.
2- Acceptance of scientific committee in the department of medicine in Babylon medical college Babylon University .
3- The participant verbal consents the objective of the study.
4-study protocol was approved by the ethical committee in Babylon Medical college.
Limitation:
1-limited time for data collection.
2-not all responders gave their consent to the questionnaire.
3-some data are based on self reports of the patient leading to under or over answering. but information bias cannot be excluded.




Results

The mean age of all patient (54.87 ± 17.83). mean BMI (kg/m2) (26.31±3.0), mean of troponin level (2.53±1.96)mean of heart score (4.86±2.67). 3.1. The Distribution of Patients According to Socio-demographic Characteristics Table 3.1 shows distribution of patients according to socio-demographic characteristics including (age, gender, residence, occupation and level of education, physical activity, ECG findings, troponin level, past medical history and presence of risk factors). The Distribution of Patients According to Type of Risk Factor and Past Medical History, Table 2 shows distribution of patients according to type of risk factors and past medical history. The Association between Heart score and Study Variables, Table3 shows the association between heart score and study variables Including (gender, residence, occupation, level of education and physical activity). There was significant association between heart score and all study variables. The Association between Heart score and Score Elements, Table 4 shows the association between heart score and score elements including (age, ECG changes, troponin level, presence of the risk factors and past medical history). There was significant association between heart score and all study variable . The Association between Heart score and Final Result, Table 5 shows the association between heart score and final results after6 weeks of follow up including (Acute myocardial infarction, death, Percutaneous coronary intervention or continue medical treatment and continue normal life).

Discussions

The patient who attended to ED that complain of chest pain doubt to treated by physicians. The decision is with less confidence to discharge patient without intervention. These discharge without or less intervention lead to bad prognosis, the attended to hospital which was not needed that lead to reverse result and a lot of money. The patient that attended to ED most of them male with young and middle Age group which are live in urban area &unemployed with mild physical Activity when we do S. troponin we found who had high level titer is critical one as we mention in result. When ECG done, we found that patients with normal ECG most of them with low risk for ACS. and can safety discharge them. Cohort study Heart Score in our people that indicate to strong influence. That use to identify Risk of MACE in few minute .And we show that the Heart Score was divided in 2 group that one of them reach to End Point and the other not reach. The end point are Death, PCI, AMI that after fallow up for six week. Heart Score average ± SD of 2 group was 6.56 ± 1.8 that for who reach to end point, and 3.28 ± 2.36 to not reach. In compare to other study, its 6.51± 1.84 without 3.71± 1.83 [16], the other study 7.2± 1.7And without 3.8± 1.9 [17],The last one 6.54± 1.7 without 3.96 ± 2[17]The heart score put the patients in three group low (0-3), medium (4-6)And high (7-10). For clinically important irreversible adverse cardiac events (MACE). In comparison with other study .the low heart score (0 -3) was (33%) of total patient and had (3.2%). When do comparison with other study for group who reach to endpoint 2.5% [16], 0.99 [17] and 1.7% [24]. Based on our results. The medium heart score (4-6) was (37.6%) of total patients and had (60.4%) for reaching to end point MACE with comparison with other study, 20.3% [16], 11.6% [17] and 16.6% [234The high heart score (7-10) was (29.4 %) of total patient and had (83.1%) for reaching to end point to compare with other study 72% [16] 65.2% [17] and 50.1% [24] these findings have important practical importance. The ED evaluation of low risk patient with suspected ACS is characterized by high frequency, costs, and care variation [25]. Good prognosis value for low Heart Score (0-3) was 100% in compression to other study 94% [26] and 98% [27]. We found most patient with chest pain had risk factor more than one and Hypertension is in top of the list as we mention in result .And about past medical history the top is the MI. In this study we compare between heart score element and it show that it’s Higher with s. Troponin the odd ratio is (43.64) and lower with risk factor (5.77). There was a significant positive linear correlation between heart score and pack year and positive linear correlation between heart score and body mass index. There was a risk result to patient who smoke pack in day for long time &and who had high BMI. Several scores was develop to help ED Physician in identifying patient complain of chest pain with a high risk of MACE who warrant more aggressive diagnostic and treatment strategies and those with low risk, who can be safely discharged. For this reason, the Heart score has been found to be a hopeful tool, outperforming more conventional risk scores, especially in low–intermediate risk population [17, 24]. In ED the 1sr line of diagnosed patient with chest pain is ECG but it take time to done to patient with chest pain more than ten minute. so an effort to decrease this time, that to identify serious cases in ED and To decrease time that needed for PCI especially in STEMI. after 6 week fallow up of patient with chest pain . patient with high score (7-10) reach to endpoint more than low score (0-3). where most patient with low score (0-3) live with normal life The end result of study of good investigation of patients with chest pain that attended to ED was effective. A significant reduction in the number of cases of AMI, which would not have been diagnosed by the usual investigation model, has been one of the most important results obtained [28, 29].

Conclusions

Chest pain is most common cause that lead patient attended to ED and that pain is duo to many causes some are life threaten and some not .for decrease the cost, and good diagnosis and decrease uses of coronary care unit CCU bed so that need do the necessary management to patient that complain of chest pain. S. Troponin level should be done as fast as possible and it help for Heart Score detection The good confidence decision will done with Heart Score in ED and not need Invasive intervention The Heart Score is so simple, fast and dependable judgment for prognosis to patient with chest pain and could be used in triage HAERT score is help both patient and doctor in ED by this score we will try to improve the low Score 0-3 could be discharge with no or less complication and It will decrease staining of patient in ER &decrease intervention with patient.

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