Clinical Trial

. 2023 Jan;25(1):81-89.

doi: 10.1007/s43678-022-00395-w. Epub 2022 Oct 31.

Focused carotid ultrasound to predict major adverse cardiac events among emergency department patients with chest pain

Steven C Brooks^{1

2

3}, Marco L A Sivilotti^{4

5}, Marie-France Hétu⁶, Patrick A Norman⁵, Andrew G Day⁵, Nicole O'Callaghan⁴, Vlad Latiu⁴, Joseph Newbigging⁴, Braeden Hill⁶, Amer M Johri^{6

7}

Affiliations

¹ Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada. steven.brooks@kingstonhsc.ca.
² Department of Public Health Sciences, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada. steven.brooks@kingstonhsc.ca.
³ Kingston General Hospital Research Institute, Kingston Health Sciences Center, Kingston, ON, Canada. steven.brooks@kingstonhsc.ca.
⁴ Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada.
⁵ Kingston General Hospital Research Institute, Kingston Health Sciences Center, Kingston, ON, Canada.
⁶ Department of Medicine, Division of Cardiology, Cardiovascular Imaging Network at Queen's University, Kingston, ON, Canada.
⁷ Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada.

PMID: 36315347
DOI: 10.1007/s43678-022-00395-w

Clinical Trial

Focused carotid ultrasound to predict major adverse cardiac events among emergency department patients with chest pain

Steven C Brooks et al. CJEM. 2023 Jan.

. 2023 Jan;25(1):81-89.

doi: 10.1007/s43678-022-00395-w. Epub 2022 Oct 31.

Authors

Affiliations

¹ Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada. steven.brooks@kingstonhsc.ca.
² Department of Public Health Sciences, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada. steven.brooks@kingstonhsc.ca.
³ Kingston General Hospital Research Institute, Kingston Health Sciences Center, Kingston, ON, Canada. steven.brooks@kingstonhsc.ca.
⁴ Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada.
⁵ Kingston General Hospital Research Institute, Kingston Health Sciences Center, Kingston, ON, Canada.
⁶ Department of Medicine, Division of Cardiology, Cardiovascular Imaging Network at Queen's University, Kingston, ON, Canada.
⁷ Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada.

PMID: 36315347
DOI: 10.1007/s43678-022-00395-w

Abstract
in English, French

Background and objective: Point-of-care focused vascular ultrasound (FOVUS), an assessment of carotid artery plaque, predicts coronary artery disease in outpatients referred for coronary angiography. Our primary objective was to determine the diagnostic accuracy of sonographer-performed FOVUS to predict major adverse cardiac events (MACE) within 30 days among patients with suspected cardiac ischemia in the emergency department (ED).

Methods: We conducted a prospective cohort study of patients with chest pain presenting to a tertiary care ED who had an electrocardiogram and cardiac troponin testing. The primary outcome was a composite of death, acute myocardial infarction, or re-vascularization at 30 days. A sonographer performed FOVUS scans in consenting eligible subjects. Emergency physicians, blinded to the sonographer FOVUS result, performed a second FOVUS on some subjects.

Results: We recruited 326 subjects (age 62.1 ± 13.5 years; 166 (52%) men), 319 of whom completed an FOVUS scan by the sonographer. Of these, 198 (62%) had a positive FOVUS scan and 41 (13%) had a 30-day MACE. The sensitivity was 83% (95% CI 71-94%), specificity 41% (95% CI 36-47%), positive-likelihood ratio 1.41 (95% CI 1.19-1.68), and negative-likelihood ratio 0.41 (95% CI 0.23-0.75). Among 71 subjects also scanned by an emergency physician, the Kappa was 0.50 (95% CI 0.31-0.70), suggesting moderate agreement between sonographer and emergency physician on the determination of significant carotid plaque.

Conclusions: The presence of carotid plaque on sonographer-performed FOVUS is associated with 30-day MACE in ED patients presenting with chest pain. The prognostic performance of FOVUS is not sufficient to support its use as a stand-alone risk stratification tool in the ED. Future work should investigate FOVUS in conjunction with validated clinical decision rules for chest pain and the impact of enhanced training and quality improvement in the conduct of FOVUS by emergency physicians.

Registration: This study was registered at clinicaltrials.gov (NCT02947360).

RéSUMé: CONTEXTE ET OBJECTIF: L'échographie vasculaire focalisée au point de service (FOVUS), une évaluation de la plaque de l'artère carotide, prédit la maladie coronarienne chez les patients externes référés pour une coronarographie. Notre objectif principal était de déterminer la précision diagnostique du FOVUS réalisé par un échographiste pour prédire les événements cardiaques indésirables majeurs (MACE) dans les 30 jours chez les patients présentant une suspicion d'ischémie cardiaque aux urgences. MéTHODES: Nous avons mené une étude de cohorte prospective de patients souffrant de douleurs thoraciques se présentant à un service d'urgence de soins tertiaires et ayant subi un électrocardiogramme et un test de troponine cardiaque. L'issue primaire était un critère composite de décès, d'infarctus aigu du myocarde ou de revascularisation à 30 jours. Un échographiste a effectué des scans FOVUS chez les sujets éligibles consentants. Les médecins urgentistes, aveuglés par le résultat FOVUS de l'échographiste, ont effectué un deuxième FOVUS sur certains sujets. RéSULTATS: Nous avons recruté 326 sujets (âge 62,1 ± 13,5 ans; 166 (52%) hommes), dont 319 ont effectué un examen FOVUS par l'échographiste. Parmi ceux-ci, 198 (62%) avaient un scan FOVUS positif et 41 (13%) avaient un MACE de 30 jours. La sensibilité était de 83% (IC à 95% 71%-94%), la spécificité de 41% (IC à 95% 36%-47%), le rapport de vraisemblance positif de 1,41 (IC à 95% 1,19–1,68) et le rapport de vraisemblance négatif de 0,41 (IC à 95% 0,23–0,75). Parmi les 71 sujets également examinés par un médecin urgentiste, le Kappa était de 0,50 (IC à 95%: 0,31–0,70), ce qui suggère une concordance modérée entre l'échographiste et le médecin urgentiste pour la détermination de la plaque carotide significative. CONCLUSIONS: La présence d'une plaque carotidienne sur un FOVUS effectué par un échographiste est associée à la MACE à 30 jours chez les patients des urgences présentant des douleurs thoraciques. La performance pronostique du FOVUS n'est pas suffisante pour justifier son utilisation comme outil autonome de stratification du risque dans les urgences. Des travaux futurs devraient étudier le FOVUS en conjonction avec des règles de décision clinique validées pour la douleur thoracique et l'impact d'une formation renforcée et d'une amélioration de la qualité dans la conduite du FOVUS par les médecins urgentistes. ENREGISTREMENT: Cette étude a été enregistrée sur clinicaltrials.gov (NCT02947360).

Keywords: Cardiovascular disease; Cardiovascular imaging; Cardiovascular risk; Carotid artery; Carotid ultrasound; Emergency department; POCUS; Peripheral arterial disease; Ultrasound.

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References

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Focused carotid ultrasound to predict major adverse cardiac events among emergency department patients with chest pain

Affiliations

Focused carotid ultrasound to predict major adverse cardiac events among emergency department patients with chest pain

Authors

Affiliations

Abstract
in English, French

References

Publication types

MeSH terms

Associated data

LinkOut - more resources

Full Text Sources

Medical

Abstract in English, French

References

Publication types

MeSH terms

Associated data

LinkOut - more resources

Full Text Sources

Medical

Abstract
in English, French