PMID- 28261908 OWN - NLM STAT- MEDLINE DCOM- 20171017 LR - 20181202 IS - 1553-2712 (Electronic) IS - 1069-6563 (Linking) VI - 24 IP - 6 DP - 2017 Jun TI - Acute Coronary Syndrome Screening and Diagnostic Practice Variation. PG - 701-709 LID - 10.1111/acem.13184 [doi] AB - BACKGROUND: In the absence of the existing acute coronary syndrome (ACS) guidelines directing the clinical practice implementation of emergency department (ED) screening and diagnosis, there is variable screening and diagnostic clinical practice across ED facilities. This practice diversity may be warranted. Understanding the variability may identify opportunities for more consistent practice. METHODS: This is a cross-sectional clinical practice epidemiology study with the ED as the unit of analysis characterizing variability in the ACS evaluation across 62 diverse EDs. We explored three domains of screening and diagnostic practice: 1) variability in criteria used by EDs to identify patients for an early electrocardiogram (ECG) to diagnose ST-elevation myocardial infarction (STEMI), 2) nonuniform troponin biomarker and formalized pre-troponin risk stratification use for the diagnosis of non-ST-elevation myocardial infarction (NSTEMI), and 3) variation in the use of noninvasive testing (NIVT) to identify obstructive coronary artery disease or detect inducible ischemia. RESULTS: We found that 85% of EDs utilize a formal triage protocol to screen patients for an early ECG to diagnose STEMI. Of these, 17% use chest pain as the sole criteria. For the diagnosis of NSTEMI, 58% use intervals >/=4 hours for a second troponin and 34% routinely risk stratify before troponin testing. For the diagnosis of noninfarction ischemia, the median percentage of patients who have NIVT performed during their ED visit is 5%. The median percentage of patients referred for NIVT in hospital (observation or admission) is 61%. Coronary CT angiography is used in 66% of EDs. Exercise treadmill testing is the most frequently reported first-line NIVT (42%). CONCLUSION: Our results suggest highly variable ACS screening and clinical practice. CI - (c) 2017 by the Society for Academic Emergency Medicine. FAU - Yiadom, Maame Yaa A B AU - Yiadom MYAB AD - Department of Emergency Medicine, Vanderbilt University, Nashville, TN. FAU - Liu, Xulei AU - Liu X AD - Department of Biostatistics, Vanderbilt University, Nashville, TN. FAU - McWade, Conor M AU - McWade CM AD - Schools of Medicine and Public Health, Vanderbilt University, Nashville, TN. FAU - Liu, Dandan AU - Liu D AD - Department of Biostatistics, Vanderbilt University, Nashville, TN. FAU - Storrow, Alan B AU - Storrow AB AD - Department of Emergency Medicine, Vanderbilt University, Nashville, TN. CN - ED Operations Study Group 2015 LA - eng GR - K12 HL109019/HL/NHLBI NIH HHS/United States GR - UL1 TR000445/TR/NCATS NIH HHS/United States GR - R01 HL111033/HL/NHLBI NIH HHS/United States PT - Journal Article PT - Multicenter Study DEP - 20170508 PL - United States TA - Acad Emerg Med JT - Academic emergency medicine : official journal of the Society for Academic Emergency Medicine JID - 9418450 RN - 0 (Biomarkers) RN - 0 (Troponin) SB - IM MH - Acute Coronary Syndrome/*diagnosis/epidemiology MH - Aged MH - Biomarkers/blood MH - Chest Pain/diagnosis MH - Coronary Angiography/statistics & numerical data MH - Cross-Sectional Studies MH - Electrocardiography/statistics & numerical data MH - Emergency Service, Hospital/*statistics & numerical data MH - Exercise Test/statistics & numerical data MH - Female MH - Hospitalization/*statistics & numerical data MH - Humans MH - Male MH - Myocardial Infarction/diagnosis MH - Troponin/blood FIR - Herdon-Meadors, Patricia IR - Herdon-Meadors P FIR - Shuler, Wesley IR - Shuler W FIR - Goldlust, Eric IR - Goldlust E FIR - Sawyer, Charles IR - Sawyer C FIR - Wong, Andrew IR - Wong A FIR - Tanski, Mary IR - Tanski M FIR - Patterson, Brian IR - Patterson B FIR - Wiener, Dan IR - Wiener D FIR - Baugh, Christopher W IR - Baugh CW FIR - Carlson, Jestin N IR - Carlson JN FIR - Strout, Tania D IR - Strout TD FIR - Hill, Charles D IR - Hill CD FIR - Turturro, Michael IR - Turturro M FIR - Whitcomb, Carlene IR - Whitcomb C FIR - Dunlap, Patricia IR - Dunlap P FIR - McPheeters, Rick A IR - McPheeters RA FIR - Gavin, Nicholas IR - Gavin N FIR - Hansen, Johnathan IR - Hansen J FIR - Web, Cindy IR - Web C FIR - Calichman, Meghan IR - Calichman M FIR - Chen, Paul IR - Chen P FIR - Salazar, Gilberto IR - Salazar G FIR - Shepard, Brooke IR - Shepard B FIR - Milligan, Benjamin IR - Milligan B FIR - Rudd, Kenneth IR - Rudd K FIR - Lee, Adrea IR - Lee A FIR - Spiegel, Thomas IR - Spiegel T FIR - Garvey, Lee IR - Garvey L FIR - Rodi, Scott IR - Rodi S FIR - Caterino, Jeff IR - Caterino J FIR - Furlong, Brendan IR - Furlong B FIR - Dubin, Jeff IR - Dubin J FIR - Imperato, Jason IR - Imperato J FIR - Vohra, Anju IR - Vohra A FIR - Mills, Angela IR - Mills A FIR - Hager, David IR - Hager D FIR - Podolsky, Seth IR - Podolsky S FIR - Novotny, April IR - Novotny A FIR - Hartsfield, Lisa IR - Hartsfield L FIR - Bosco, Samuel IR - Bosco S FIR - McDermott, David B IR - McDermott DB FIR - Pacella, Charissa IR - Pacella C FIR - Mazzeo, Anthony IR - Mazzeo A FIR - Guyette, Maria IR - Guyette M FIR - McCoy, Thomas IR - McCoy T FIR - Gronczewski, Craig IR - Gronczewski C FIR - Riordan, John IR - Riordan J FIR - Leahy, Joseph IR - Leahy J FIR - Hocker, Michael IR - Hocker M FIR - Mirarchi, Ferdinando IR - Mirarchi F FIR - Bhatia, Monisha C IR - Bhatia MC FIR - Paul Cook, J IR - Paul Cook J FIR - Ramanujan, Vishnan IR - Ramanujan V FIR - Acquaye, Joseph IR - Acquaye J FIR - Means, Tamera IR - Means T FIR - Strawn, Calbert IR - Strawn C FIR - Jackson, Leigh IR - Jackson L FIR - Davis, Brook IR - Davis B EDAT- 2017/03/07 06:00 MHDA- 2017/10/19 06:00 CRDT- 2017/03/07 06:00 PHST- 2017/01/03 00:00 [received] PHST- 2017/02/18 00:00 [revised] PHST- 2017/02/27 00:00 [accepted] PHST- 2017/03/07 06:00 [pubmed] PHST- 2017/10/19 06:00 [medline] PHST- 2017/03/07 06:00 [entrez] AID - 10.1111/acem.13184 [doi] PST - ppublish SO - Acad Emerg Med. 2017 Jun;24(6):701-709. doi: 10.1111/acem.13184. Epub 2017 May 8.