Page 270 - ACCCN's Critical Care Nursing

Case study, Continued
Post-ICD-implantation, her hospital stay was uneventful. Her fluids 5 mg daily, perindopril 5 mg daily, spironolactone 25 mg daily,
were restricted to 1.5 L/day, weighed daily, commenced a beta- co-plavix 100/75 mg daily, spirivia 18mcg daily, seretide 250/25 mg
adrenergic blocking agent and diuretic and provided with educa- BD, lantus 36 units nocte, amiodarone 200 mg BD, gliclazide MR 60
tion concerning heart failure and coronary artery disease. Her mg mane, frusemide 80 mg mane and midi, and GTN spray. She
husband was also included in the education sessions. She was was also referred to a heart failure management program and a
transferred from CCU to the ward and then a few days later dis- cardiac rehabilitation program.
charged home. On discharge her medications were: bisoprolol

Research vignette

Body R, Carley S, Wibberley C, McDowell G, Ferguson J, Mackway- the preceding 24 hours presenting to the ED, excluding other
Jones K. The value of symptoms and signs in the emergent diagnosis primary presenting diagnoses, chest trauma, pregnant women and
of acute coronary syndromes. Resuscitation. 2010; 81(3): 281–6. people with insufficient English to consent. ED doctors used a spe-
Abstract cifically designed yes/no checklist of 21 signs and symptoms on
Objective first assessment and prior to troponin-T testing and were therefore
Patient history and physical examination are widely accepted as blinded to the results. Patients received all usual care and were
cornerstones of diagnosis in modern medicine. This research followed up at 48 hours, 30 days and 6 months, with no patients
aimed to assess the value of individual historical and examination lost to follow-up. Adverse events included death, AMI or the need
findings for diagnosing acute myocardial infarction (AMI) and pre- for urgent revascularisation and AMI was determined by troponin-t
dicting adverse cardiac events in undifferentiated Emergency levels. Interobserver reliability of the checklist was also assessed in
Department (ED) patients with chest pain. 44 cases by two ED doctors and near-perfect agreement occurred
for pain being previously diagnosed as ischaemic, ischaemic ECG
Methods features, sweating observed and rest pain whereas only slight
Patients were prospectively recruited patients presenting to the ED agreement occurred for pain character dull, any radiation, reported
with suspected cardiac chest pain. Clinical features were recorded sweating and paraesthesia.
using a custom-designed report form. All patients were followed-up
for the diagnosis of AMI and the occurrence of adverse events Of the 796 patients eligible and recruited in the study, 18.6% had
(death, AMI or urgent revascularisation) within 6 months. AMI during the index admission and 22.9% went on to have an
adverse event during follow-up. After adjusting for age, gender
Results
AMI was diagnosed in 148 (18.6%) of the 796 patients recruited. and presence of ischaemic ECG changes, the odds of an AMI diag-
Following adjustment for age, sex and ECG changes, the following nosis were increased significantly for central pain, pain duration of
characteristics made AMI more likely (adjusted odds ratio, 95% more than 1 hour, radiates to right and both shoulders/arms,
confidence intervals): pain radiating to the right arm (2.23, 1.24–4), reported vomiting and observed sweating. Importantly, several of
both arms (2.69, 1.36–5.36), vomiting (3.50, 1.81–6.77), central the symptoms identified in the international guidelines, neck and
chest pain (3.29, 1.94–5.61) and sweating observed (5.18, 3.02– arm pain and symptoms occurring at rest, were not useful includ-
8.86). Pain in the left anterior chest made AMI significantly less ing pain radiating to the left side of the chest, which actually
likely (0.25, 0.14–0.46). The presence of rest pain (0.67, 0.41–1.10) reduced the odds of having an AMI diagnosis. Of the significant
or pain radiating to the left arm (1.36, 0.89–2.09) did not signifi- predictors identified above, by far the strongest positive predictors
cantly alter the probability of AMI. of AMI were observed sweating, reported vomiting and hypoten-
sion. In terms of adverse events within 6 months follow-up the
Conclusions results were very similar with the addition of worsening angina and
The results challenge many widely held assertions about the value hypotension as significant predictors with hypotension, reported
of individual symptoms and signs in ED patients with suspected vomiting and pain radiating to both arms the strongest positive
acute coronary syndromes. Several ‘atypical’ symptoms actually predictors.
render AMI more likely, whereas many ‘typical’ symptoms that are
often considered to identify high-risk populations have no diag- Several limitations are relevant to the study including the single
nostic value. site and lack of inclusion of people who were unable to speak
Critique English. The latter may most limit generalisability as the authors
This study investigated the relative importance of the patients’ note that symptoms have been noted to vary between different
history and examination in diagnosing AMI and predicting adverse ethnicities. Furthermore symptoms could only have a yes/no
cardiac events in the following six months in patients presenting response when clinicians may be most influenced by the intensity
to the ED with chest pain. While international guidelines recom- of the individual symptom. Regardless, the results challenge clini-
mend that these factors, in particular the presence of central chest cians to reconsider the value of so-called typical versus atypical
pain radiating to the left side of the chest, neck and arm, or symp- symptoms and that associated symptoms such as vomiting and
toms occurring at rest, are included in determination of diagnosis sweating may be far more important to consider. In this respect as
there has been little recent research to determine their value. nurses are closely involved in triage, history and examination of
patients with chest pain both in ED and other critical care environ-
The study was performed at single hospital in the UK and enrolled ments, nurses must be encouraged to consider an array of symp-
patients over 25 years of age with suspected cardiac chest pain in toms and undertake careful assessments.