Advertisement
Heart, Lung and Circulation

Emergency Department Assessment of Suspected Acute Coronary Syndrome Using the IMPACT Pathway in Aboriginal and Torres Strait Islander People

Published:March 22, 2022DOI:https://doi.org/10.1016/j.hlc.2022.02.010

      Objectives

      The Improved Assessment of Chest pain Trial (IMPACT) pathway is an accelerated strategy for the assessment of emergency patients presenting with suspected acute coronary syndrome (ACS). The objective of this study was to report outcomes for Aboriginal and Torres Strait Islander patients deemed low-, intermediate-, or high-risk according to this pathway.

      Design

      This was a prospective observational trial conducted between November 2017 and December 2019.

      Setting

      Regional hospital in Far North Queensland.

      Participants

      Aboriginal and Torres Strait Islander people presenting to the Emergency Department with suspected ACS were asked to participate. Participants were stratified as low-, intermediate- or high-risk of ACS according to the IMPACT pathway. High-and intermediate risk patients were managed according to the IMPACT pathway. Management of low-risk patients included additional inpatient cardiac testing, which was not part of the original IMPACT pathway.

      Main Outcome Measures

      The primary outcome was acute coronary syndrome within 30-days. Secondary outcomes included length of stay and prevalence of objective testing.

      Results

      A total of 155 participants were classified as either at low-risk (n=18 11.6%), intermediate-risk (n=87 56.1%), or high-risk (n=50 32.3%) of ACS. Thirty-day (30-day) ACS occurred in 29 (18.6%) patients, which included 26 (52.0%) high-risk patients and three (3.4%) intermediate-risk patients. No patients in the low-risk group were diagnosed with ACS during their index presentation or by 30-days. Median hospital length-of-stay was 11.9 hours (interquartile range [IQR] 5.3–20.2 hrs) for low- and 15.5 hours (IQR 5.9–29.2 hrs) for intermediate-risk patients.

      Conclusion

      The IMPACT pathway, which has been associated with reduced LOS in other settings, could be safely implemented for patients of Aboriginal and Torres Strait Islander origin, classifying two-thirds as low- or intermediate risk. However, a clinically significant proportion of Aboriginal and Torres Strait Islander patients experience cardiac events, which supports the need to provide early objective testing for coronary artery disease.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Heart, Lung and Circulation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Mathur S.M.L.
        • Leigh S.
        Aboriginal and Torres Strait Islander people with coronary heart disease: further perspectives on health status and treatment. Cardiovascular diseases series no. 25. Cat. no. CVD 33.
        Australian Institute of Health and Welfare, Canberra2006
        • Chew D.P.
        • Scott I.A.
        • Cullen L.
        • French J.K.
        • Briffa T.G.
        • Tideman P.A.
        • et al.
        National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of Acute Coronary Syndromes 2016.
        Heart Lung Circ. 2016; 25: 895-951
        • Cullen L.
        • Greenslade J.
        • Hawkins T.
        • Hammett C.
        • O'Kane S.
        • Ryan K.
        • et al.
        IMProved assessment of chest pain trial (IMPACT): an intervention study of a new accelerated protocol for patients with possible acute coronary syndrome.
        Med J Aust. 2017; 207: 195-200
        • Parsonage W.
        • Milburn T.
        • Ashover S.
        • Skoien W.
        • Greenslade J.H.
        • McCormack L.
        • et al.
        Implementing change: evaluating the Accelerated Chest pain Risk Evaluation (ACRE) project.
        Med J Aust. 2017; 207: 201-205
        • Six A.J.
        • Cullen L.
        • Backus B.E.
        • Greenslade J.
        • WP
        • Aldous S.
        • et al.
        The HEART score for the assessment of patients with chest pain in the emergency department: a multinational validation study.
        Crit Pathw Cardiol. 2013; 12: 121-126
        • Bodapati S.N.
        • Gunnarsson R.
        • McBride W.J.
        • Stone R.
        • Sutcliffe S.
        Chest pain risk assessment in Indigenous and non-Indigenous Australians using HEART score.
        Emerg Med Australas. 2016; 28: 138-144
        • Fox K.A.
        • Dabbous O.H.
        • Goldberg R.J.
        • Pieper K.S.
        • Eagle K.A.
        • Van de Werf F.
        • et al.
        Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE).
        BMJ. 2006; 333: 1091
        • Bradshaw P.J.
        • Katzenellenbogen J.M.
        • Sanfilippo F.M.
        • Hobbs M.S.T.
        • Thompson P.L.
        • Thompson S.C.
        Validation study of GRACE risk scores in indigenous and non-indigenous patients hospitalized with acute coronary syndrome.
        BMC Cardiovasc Disord. 2015; 15
        • Cullen L.
        • Than M.
        • Brown A.F.
        • Richards M.
        • Parsonage W.
        • Flaws D.
        • et al.
        Comprehensive standardized data definitions for acute coronary syndrome research in emergency departments in Australasia.
        Emerg Med Australas. 2010; 22: 35-55
        • Thygesen S.K.
        • Alpert S.J.
        • Jaffe R.A.
        • Chaitman J.B.
        • Bax A.J.
        • Morrow D.D.
        • et al.
        Fourth universal definition of myocardial infarction (2018).
        Circulation. 2018; 138: e618-e651
        • National Health and Medical Research Council
        Ethical conduct in research with Aboriginal and Torres Strait Islander Peoples and Communities: Guidelines for researchers and stakeholders.
        Commonwealth of Australia, Canberra2018
      1. National Health and Medical Research Council. Keeping Research on Track II: A companion document to ethical conduct in research with Aboriginal and Torres Strait Islander Peoples and communities: Guidelines for researchers and stakeholders (2018). In: National Health and Medical Research Council, editor. Canberra: Commonwealth of Australia; 2018.

      2. Australian Institute of Aboriginal and Torres Strait Islander Studies. Guidelines for Ethical Research in Australian Indigenous Studies. In: Australian Institute of Aboriginal and Torres Strait Islander Studies, editor. Canberra2012.

        • Cullen L.
        • Greenslade J.H.
        • Merollini K.
        • Graves N.
        • Hammett C.J.
        • Hawkins T.
        • et al.
        Cost and outcomes of assessing patients with chest pain in an Australian Emergency Department.
        Med J Aust. 2015; 202: 427-432
        • Sandoval Y.
        • Jaffe A.S.
        Type 2 myocardial infarction: JACC Review Topic of the Week.
        J Am Coll Cardiol. 2019; 73: 1846-1860
        • Greenslade J.H.
        • Parsonage W.
        • Ho A.
        • Scott A.
        • Dalton E.
        • Hammett C.
        • et al.
        Utility of routine exercise stress testing among intermediate risk chest pain patients attending an emergency department.
        Heart Lung Circ. 2015; 24: 879-884
        • Cullen L.
        • Greenslade J.
        • Hammett C.J.
        • Brown A.F.
        • Chew D.P.
        • Bilesky J.
        • et al.
        Comparison of three risk stratification rules for predicting patients with acute coronary syndrome presenting to an Australian emergency department.
        Heart Lung Circ. 2013; 22: 844-851