We compared the sensitivity of three commonly used cardiac markers between two subpopulations, those who came to the Emergency Department (ED) late (6-24 h) after their symptoms began, and those who arrived earlier (<6 h), in a prospective comparative trial. Among all adult patients who presented to our ED with symptoms suggestive of acute myocardial infarction (MI), we drew serum for myoglobin, CK-MB, and troponin I upon arrival (time 0) and 2 h later. Outcomes, including acute MI, were determined. Sensitivities for all three markers between the subpopulations who arrived fewer than 6 h from symptom onset were compared to those who arrived later (6-24 h). We enrolled 346 eligible subjects, 36% of whom described cardiac symptoms as beginning 6 or more hours earlier; 14% suffered acute MIs. For time 0, the sensitivity of all three markers for acute MI was significantly higher among those subjects with symptoms of 6 or more hours' duration as compared to those with less. For troponin I, the increase in sensitivity between these two subpopulations approached 300%. At the time of the 2-h sample, the differences in sensitivities were much less and were not statistically significant. We conclude that cardiac marker values obtained at time 0 among Emergency Department patients who arrive 6 or more hours after cardiac symptom onset provide significantly higher sensitivities as compared to those obtained in patients who arrive earlier. For troponin I, the increase in sensitivity approaches threefold.

Adult↗

PubMed2005

Multisystem organ failure.

Explore the source record for details and available documents.

Colonic Neoplasms↗

PubMed2005

Pleuritic chest pain and exertional dyspnea.

Explore the source record for details and available documents.

Adult↗

PubMed2005

Disagreement between formal and medical record criteria for the diagnosis of acute coronary syndrome.

OBJECTIVES: To measure agreement between formal and medical record criteria for the diagnosis of acute coronary syndrome (ACS) among patients undergoing an emergency department evaluation for potential acute coronary symptoms. METHODS: Cases of ACS were determined by both formal (World Health Organization 1984 criteria for acute myocardial infarction [AMI], Braunwald criteria for unstable angina pectoris [UAP]) and medical record criteria. In the latter, a diagnosis was made if providers indicated AMI or UAP anywhere in the medical record. All information included in formal criteria was available to clinicians establishing the medical record diagnosis. The two criteria for diagnosis were compared, and a kappa value was recorded. Two blinded observers adjudicated discordant cases, with a kappa value recorded. Disagreements between these two coinvestigators were resolved by a Delphi technique. RESULTS: A total of 375 eligible subjects were enrolled, of whom 65 (17%; 45 AMI, 20 UAP) had ACS by both sets of criteria. Formal and medical record criteria disagreed in 32 subjects. This represented 9% (95% confidence interval = 6% to 12%) of the overall study population but 33% (95% confidence interval = 23% to 43%) of subjects with possible ACS. Coinvestigators acting as judges and blinded to each other's determinations agreed that 25 of these subjects had ACS and three did not; they disagreed on four subjects (kappa = 0.54). Among these four subjects, a Delphi consensus technique determined that two subjects had AMI and two had no ACS. CONCLUSIONS: In a single-site study, among subjects who have possible ACS as determined by either or both formal and medical record criteria, these two sets of criteria disagree in almost one third of cases. Among discordant cases, even two expert judges frequently disagreed on the final diagnosis. A modified Delphi technique to address these disagreements is described.

Acute Disease↗

PubMed2005

The accuracy and completeness of data collected by prospective and retrospective methods.

OBJECTIVES: To describe and test a model that compares the accuracy of data gathered prospectively versus retrospectively among adult emergency department patients admitted with chest pain. METHODS: The authors developed a model of information flow from subject to medical record to the clinical study case report form, based on a literature review. To test this model, a bidirectional (prospective and retrospective) study was conducted, enrolling all eligible adult patients who were admitted with a chief complaint of chest pain. The authors interviewed patients in the emergency department to determine their chest pain history and established a prospective database; this was considered the criterion standard. Then, patient medical records were reviewed to determine the accuracy and completeness of the information available through a retrospective medical record review. RESULTS: The model described applies the concepts of reliability and validity to information passed on by the study subject, the clinician, and the medical record abstractor. This study was comprised of 104 subjects, of which 63% were men and the median age was 63 years. Subjects were uncertain of responses for 0-8% of questions and responded differently upon reinterview for subsets of questions 0-30% of the time. The sensitivity of the medical record for risk factors for coronary artery disease was 0.77 to 0.93. Among the 88 subjects (85%) who indicated that their chest pain was substernal or left chest, the medical record described this location in 44%. Timing of the chest pain was the most difficult item to accurately capture from the medical record. CONCLUSIONS: Information obtained retrospectively from the abstraction of medical records is measurably less accurate than information obtained prospectively from research subjects. For certain items, more than half of the information is not available. This loss of information is related to the data types included in the study and by the assumptions that a researcher performing a retrospective study makes about implied versus explicitly stated responses. A model of information flow that incorporates the concepts of reliability and validity can be used to measure some of the loss of information that occurs at each step along the way from subject to clinician to medical record abstractor.

Adult↗