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          Suspected acute coronary syndrome is the commonest reason for emergency admission to hospital and is a large burden on health-care resources. Strategies to identify low-risk patients suitable for immediate discharge would have major benefits.


          We did a prospective cohort study of 6304 consecutively enrolled patients with suspected acute coronary syndrome presenting to four secondary and tertiary care hospitals in Scotland. We measured plasma troponin concentrations at presentation using a high-sensitivity cardiac troponin I assay. In derivation and validation cohorts, we evaluated the negative predictive value of a range of troponin concentrations for the primary outcome of index myocardial infarction, or subsequent myocardial infarction or cardiac death at 30 days. This trial is registered with ClinicalTrials.gov (number NCT01852123).


          782 (16%) of 4870 patients in the derivation cohort had index myocardial infarction, with a further 32 (1%) re-presenting with myocardial infarction and 75 (2%) cardiac deaths at 30 days. In patients without myocardial infarction at presentation, troponin concentrations were less than 5 ng/L in 2311 (61%) of 3799 patients, with a negative predictive value of 99·6% (95% CI 99·3–99·8) for the primary outcome. The negative predictive value was consistent across groups stratified by age, sex, risk factors, and previous cardiovascular disease. In two independent validation cohorts, troponin concentrations were less than 5 ng/L in 594 (56%) of 1061 patients, with an overall negative predictive value of 99·4% (98·8–99·9). At 1 year, these patients had a lower risk of myocardial infarction and cardiac death than did those with a troponin concentration of 5 ng/L or more (0·6% vs 3·3%; adjusted hazard ratio 0·41, 95% CI 0·21–0·80; p<0·0001).


          Low plasma troponin concentrations identify two-thirds of patients at very low risk of cardiac events who could be discharged from hospital. Implementation of this approach could substantially reduce hospital admissions and have major benefits for both patients and health-care providers.


          British Heart Foundation and Chief Scientist Office (Scotland).

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          Predictors of hospital mortality in the global registry of acute coronary events.

          Management of acute coronary syndromes (ACS) should be guided by an estimate of patient risk. To develop a simple model to assess the risk for in-hospital mortality for the entire spectrum of ACS treated in general clinical practice. A multivariable logistic regression model was developed using 11 389 patients (including 509 in-hospital deaths) with ACS with and without ST-segment elevation enrolled in the Global Registry of Acute Coronary Events (GRACE) from April 1, 1999, through March 31, 2001. Validation data sets included a subsequent cohort of 3972 patients enrolled in GRACE and 12 142 in the Global Use of Strategies to Open Occluded Coronary Arteries IIb (GUSTO-IIb) trial. The following 8 independent risk factors accounted for 89.9% of the prognostic information: age (odds ratio [OR], 1.7 per 10 years), Killip class (OR, 2.0 per class), systolic blood pressure (OR, 1.4 per 20-mm Hg decrease), ST-segment deviation (OR, 2.4), cardiac arrest during presentation (OR, 4.3), serum creatinine level (OR, 1.2 per 1-mg/dL [88.4- micro mol/L] increase), positive initial cardiac enzyme findings (OR, 1.6), and heart rate (OR, 1.3 per 30-beat/min increase). The discrimination ability of the simplified model was excellent with c statistics of 0.83 in the derived database, 0.84 in the confirmation GRACE data set, and 0.79 in the GUSTO-IIb database. Across the entire spectrum of ACS and in general clinical practice, this model provides excellent ability to assess the risk for death and can be used as a simple nomogram to estimate risk in individual patients.
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            National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary.

            This report presents data on U.S. emergency department (ED) visits in 2007, with statistics on hospital, patient, and visit characteristics. Data are from the 2007 National Hospital Ambulatory Medical Care Survey, which uses a national probability sample of visits to emergency departments of nonfederal general and short-stay hospitals in the United States. Sample data were weighted to produce annual national estimates. In 2007, there were about 117 million ED visits in the United States. About 25 percent of visits were covered by Medicaid or the State Children's Health Insurance Program (SCHIP). About one-fifth of ED visits by children younger than 15 years of age were to pediatric EDs. There were 121 ED visits for asthma per 10,000 children under 5 years of age. The leading injury-related cause of ED visits was unintentional falls. Two percent of visits resulted in admission to an observation unit. Electronic medical records were used in 62 percent of EDs.
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              High sensitivity cardiac troponin and the under-diagnosis of myocardial infarction in women: prospective cohort study.

              To evaluate the diagnosis of myocardial infarction using a high sensitivity troponin I assay and sex specific diagnostic thresholds in men and women with suspected acute coronary syndrome.

                Author and article information

                Lancet (London, England)
                19 December 2015
                19 December 2015
                : 386
                : 10012
                : 2481-2488
                [a ]BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
                [b ]Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
                [c ]Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
                [d ]Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
                [e ]Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, UK
                [f ]Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
                [g ]Division of Clinical Sciences, St George's, University of London, London, UK
                [h ]Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
                Author notes
                [* ]Correspondence to: Dr Anoop S V Shah, BHF/University Centre for Cardiovascular Science, SU.305 Chancellor's Building, University of Edinburgh, Edinburgh EH16 4SB, UKCorrespondence to: Dr Anoop S V ShahBHF/University Centre for Cardiovascular ScienceUniversity of EdinburghSU.305 Chancellor's BuildingEdinburghEH16 4SBUK anoop.shah@ 123456ed.ac.uk

                Contributed equally


                Listed at the end of the Article

                © 2015 Shah et al. Open Access article distributed under the terms of CC BY-NC-ND

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).




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