Journal Club Summary
Methodology Score: 3.5/5
Usefulness Score: 2.5/5
Scheuermeyer FX, Innes G, Grafstein E, Kiess M, Boychuk B, Yu E, Kalla D, Christenson J.
Ann Emerg Med. 2012 Apr;59(4):256-264.e3.
This prospective single-centre Canadian cohort study of an ED chest pain algorithm (observation, serial troponins, EKGs, and provocative testing within 48 hours) had 82.5% (99/120) ACS cases diagnosed on the index ED visit, and 21/120 (17.5%) diagnosed on outpatient stress testing with none being defined as missed ACS. Our JC group agreed that obtaining provocative testing within 48 hours was better for patient care but would prove difficult in many settings; additionally we felt that the small number of outpatient diagnosed ACS and older generation troponin use limits its utility and generalizability.
By: Dr. Michael Thomson
(Presented May 2014)
Epi Lesson:
Screening Tests in the ED
Diagnostic tests in the ED are often used to screen many patients for the possibility of severe illness, e.g. ACS in chest pain, SAH in headache, dementia in the elderly. We typically wish to rule-out a condition and such testing must be highly sensitive (SnOut) but will have false positives, e.g Troponin, CT Head, Ottawa-3DY. In contrast, specialty services may be more interested in ruling in a condition definitively using tests that are highly specific (SpIn), e.g. coronary angiography, CT angiography of the brain, a battery of cognitive tests.
Diagnostic tests in the ED are often used to screen many patients for the possibility of severe illness, e.g. ACS in chest pain, SAH in headache, dementia in the elderly. We typically wish to rule-out a condition and such testing must be highly sensitive (SnOut) but will have false positives, e.g Troponin, CT Head, Ottawa-3DY. In contrast, specialty services may be more interested in ruling in a condition definitively using tests that are highly specific (SpIn), e.g. coronary angiography, CT angiography of the brain, a battery of cognitive tests.
By: Dr. Ian Stiell
