Acute coronary syndrome rule-out strategies in the emergency department: an observational evaluation of clinical effectiveness and current UK practice (2025)

Type of publication:

Journal article

Author(s):

Ingram A.; Boldovjakova D.; Wilson H.; Noble J.; Prentice J.E.B.; Brasnic L.; Papala P.; Waite R.; Hatem S.M.K.; Hamad H.H.M.A.; Lilani M.J.; Hardwick S.; Pritchard W.; Cairns D.; Lamuren E.; Thomas J.; Eve M.; Gabiana P.; Matias S.; Harris S.; Christmas E.; Brockbank J.; Mackinnon L.; Chrysikopoulou M.; Vo O.K.; George R.J.; Alsaarti R.; Mohrsen S.; Macleod C.; Grossi I.; Feetham J.; Almousa O.; Lyle A.; Victoria A.; Fox C.; Mitchell C.; Kara C.; Catley C.; Shea D.; Cranmer K.; Sach L.; Willsher L.; Vitaglione M.; Forsey M.; Fox N.; Arnold R.; Reid S.; Cotterell S.; Smolen S.; Lester Y.; Dean A.; Fitchett J.; Hoyle R.; Duberley S.; Goddard W.; Lunney C.; Ogbeide C.; Mcsorland D.; Gibson M.; Riley M.R.; Bradley P.; Thomas Z.; Giles E.; Patel H.; Pathirana J.; Chappel P.; Balasingam S.; Webb S.; Elshobaky E.; Challen K.; Ibrahim M.; Connor S.; Aprjanto A.; Ghosh A.; Amer E.; Sinclair J.; Smith T.; Freitas T.D.; Smith J.; Peachey J.; Clymer J.; Squire R.; Lee A.R.; Szekeres C.; Jessup-Dunton E.; Irvine G.; Brookman I.; Grant I.; Abbas K.; Wanigabadu L.; Futcher M.; Awadalkarim M.; Parker M.; Thammaiah Y.; Blows G.R.; Evans L.; Rebolledo M.; Macfarlane R.; Felix R.B.; Baker E.; Clarke J.; Dinglasan M.; Aldridge P.; Marshall S.; Helyar S.; Kunnath T.; Baldwin G.; Lowdell J.; Vallotton N.; Dasilva R.; Sharaf T.; Awe A.; Kerr-Winter B.; Anomelechi E.; Emond F.; Sennitt H.; Khan I.; Aderounmu I.; Bath J.; Woods J.; Dudden K.; Rupchandani K.; Mccafferty L.; Aaron L.; Al-Mousa M.; Okere N.; Scott O.; Edwards R.; Copson S.; Burke S.A.; Nawaz S.; Muhammad Y.; Noor A.; Tizon A.; Passalacqua C.; Qureshi E.F.; Malik F.I.; Jaafaru H.I.; Raees H.; Khaliq M.A.; Layawen N.; Shah R.; Torres S.L.G.; Guglani S.; Ramraj S.; Sharma S.; Hassan T.M.; Betos V.; Drexel A.; Sakutombo D.; Mendes F.; Furreed H.; Morris M.G.; James M.; Fong T.; Hartin D.; Lloyd G.; Sundarraj S.T.; Rivers V.; Kelly C.; Sutherland H.; Boast M.; Kisakye E.; Britton H.; Sebastian J.; Puscas M.R.; George S.; Olawale-Fasua W.; Wood D.; Kaur J.; King S.; Heeley C.; Davy G.; Wilson G.; Bennett K.; Allsop L.; Gill M.; Thorpe N.; Turner S.; Whitworth V.; Prendergast A.D.; Jones A.; Sheppard C.; Jones K.A.; Mcgregor K.; Sekar P.; Aeman S.; O'donnell S.P.; Griffin S.; Sheikh A.; Chintamani A.; Shrestha B.; Bisht D.; Saliu E.J.; Fadhlillah F.; Mahmoud M.Y.; Wasil M.; Ragupathy R.; Moghal Z.S.; John A.; Lockett C.; Tomkinson J.; Rose K.; Aziz M.; Keenan N.; Sandhu B.; Bentley C.; Phiri E.; Adams L.; Page M.; Seaman R.; Asnani S.; Taylor C.; Butt M.; Doherty W.J.; Da'costa A.; Adedeji A.D.; Ibeh C.O.; Oduware E.O.; Dolan H.; Ofori L.; Brassington L.; Olusoga O.; Nkala P.; Gurung S.; Williams S.; Ndlovu T.; Akhuemokhan Z.B.; Gulati D.; Akande M.; Oshiotse S.; Chilcott G.; Battishill W.; Wood J.M.; Hendry R.; Pottelbergh T.M.V.; T-Michael H.; Rothwell J.; Connolly K.; Cooper L.; Quli A.; Corr H.; Orourke L.; Pettet A.; Kariyadil B.; Pile J.; Gallamoza K.; Foo M.; O'connell P.; Kirkup A.; Hall J.; Hudson L.; Waddell G.; Mckie H.; Beck J.; Harrison M.; Ternent M.; Crispin P.; Aladesanmi A.; Ahmed A.; Thomson D.; Moth G.; Haslam J.; Killeen J.; Philbin J.; Howard-Sandy L.; Warran S.; Munt S.; Humphrey C.; Langridge E.; Otoole K.; Pule P.; Miln R.; Death Y.; Davies A.; Dunn E.; Brittain E.; Kohler G.; Stacey J.; Bloch M.; Murphy M.; Griffiths O.; Awbery H.; Oyindamola O.; Aor S.S.; Gribbin A.; Edwards C.; Vorwerk C.; Jackman D.; Brown G.; Daly Z.; Naiyeju A.A.; Arrayeh A.; Giubileo A.; Sarvesh B.; Jafferji D.; Thornton H.; Mckenzie I.; Okwori I.; Rudnicka J.; Nasr M.; Hassan M.; Aliu M.; Osunsanya O.; Abdulsalam S.; Mbaekwe S.; Shedwell S.; Wickramanayake U.; Abdullahi Y.; Mcclelland B.; Willshire K.; Knight A.; Beranova E.; Tutt G.; Ramos H.; Mcarthur C.; Khoo E.; Hughes E.; Austin K.; Doran K.; Gordon M.W.G.; Oshaughnessy O.; Worgan R.; Matthews A.; Baddeley A.; Morris A.; Ndungu A.; Peters C.; Walker L.; Tilbury N.; Lubbock S.; Mapatuna C.; Kehlenbeck E.; Curtis K.; Tonkins M.; King P.; Walker R.; Gabriel Z.; Titu H.; Coyle J.; Waddington N.; Chotai C.; Ward C.; Elliott L.; Henshall A.; Pogorodnaja A.; Knowles C.; Mascia G.; Rai S.G.; Bartley S.; Ko S.T.S.; Perera Y.; Conroy E.; Nicholson J.; Taylor J.; Flanagan R.; Wilce A.; Lindsay C.; Bascombe C.; Osey C.; Tiller H.; Rogers L.; Agius N.; Barratt N.; Pitts S.; Mohammed A.; Eihebholo A.; Olaifa A.; Bowyer C.; Sutcliffe E.; Bishop O.J.; Jenkins O.; Kyriakides O.; Thomas S.; Ali S.; Mason S.; Ripsher W.; Cousins E.; Dhande K.S.; Wright L.; Bolus A.; Sykes D.; Faronbi G.O.; Slade L.; Page R.; Maiti M.; Hekal M.; Khadka S.; Border T.; Wilson W.; Lowe A.; Evans C.; Moceivei C.; Mcavoy D.; Hay F.; Homyer K.; Dunne M.; Goldmann N.; Mitchell R.; Geoghegan A.; Entwistle J.; *Marsh A.; *Stephens A.; *O'connell G.; *Gibson H.; *Stickley J.; *Witt J.; *Beekes M.; *Sowailam M.; *Ali N.A.; Stan A.; Boalch A.; Demetriou C.; Flitney C.; Munday C.; Khoory C.; Carter D.; Gould E.; Evans G.; Elghonemy H.; Latham J.; Zamari K.; Ramos L.; Howie L.; Gunning S.; Haskins W.; Ayodeji Y.S.; Potts A.; Kay D.; Perez J.; Holden J.; Pendlebury J.; Cawley K.; Shahedy N.; Doonan R.; Blevings R.; Anthony A.; Trim F.; Hadebe B.; Pherson A.M.; Mphansi E.; Tysoe S.; Masunda B.; Galliford J.; Pestell S.; Patel S.; Pickard A.; Hoare B.; Cox C.; Hart D.; Amarnani D.; Fay E.; Khedarun F.M.; Collins F.; Sysum K.; Fung M.; Corbin N.; Patel N.; Moss P.; Marques R.; Johnson R.; Parmar S.; Sarker S.; Lawrence G.; Romero M.R.; Felix R.M.B.; Raju T.; Clarson S.; Clarke B.D.; Philp E.; Wren G.; Gallacher S.; Sharir A.; Andrews B.; Faint C.; Caines C.; Everett C.; Newman D.; Cruz G.D.L.; Hughes G.; Carey H.; Reavley H.; Ayre J.; Quan J.; Caines L.; Wedge-Bull M.; Alzaatreh M.; Chong N.; Anthony N.; Chandler S.; Walford S.; Sharir T.; White T.; Heslop-Harrison W.; Dunphy A.; Trenwith B.; Coelho B.; Hunter L.; Moran R.; Pemberton A.; Suggitt B.; Pimlott B.; Bates C.; Tibke C.; Pegler D.; Daniel D.; Lamond D.; Pureti G.; Baxter H.; Melville J.; Zai K.F.T.; Mullane K.; Phyu M.P.; Gabriels N.; Mills R.; Bennett S.; Blenkinsop S.; Vikramadhithyan S.; Barnes S.; Hopkins S.; Doherty-Walls T.; Coughlan T.; Kinder J.; Clark M.; Islam M.N.; Gray R.; Ford A.; Florey L.; O'neill M.; Aspa P.; Mercer P.; Ackerley A.; Ironside J.; Haynes L.; Garcia B.; Elkhodair S.; Enegela A.; Leech C.; Hassanali F.; Rashid H.; Lalji J.; Akpoghene M.; Enegela O.A.; Hafeez-Bore O.; Oluwaseun O.; Pelasur R.; Ayres R.; Tariq R.; Mchenry R.D.; Bains B.; Jones B.; Tarant E.; Mundy M.; Pearse R.; Sibtain S.; Day A.; Campbell B.; Stagg C.; Jones D.; Atwal I.; Tompkins K.; Parsons P.; Dancer R.; Balaican A.M.; Ellis C.; Ede C.H.; Joseph J.; Hardaker O.; Ridwan R.; Khan S.; Zhao X.; Wood L.; Tampsett R.; Rao S.; Castillo W.P.H.; Ticehurst F.; Rocha J.G.D.; Chivers K.; Vecchione N.; Kader N.; Wilson S.; Adhikari S.; Ramsundar S.; Felix F.; Johnston R.; Jin Y.; Ingall E.; Rand J.; Solly R.; Naeem S.; Stirrup S.; Priestley V.; Pun A.; Olosho O.Z.; Board S.;

Citation:

Emergency Medicine Journal. (no pagination), 2025. Article Number: 214616. Date of Publication: 2025. [epub ahead of print]

Abstract:

Background: Numerous strategies have been developed to rapidly rule-out acute coronary syndrome (ACS) using high-sensitivity troponin. We aimed to establish their performance in terms of emergency care length of stay (LOS) in real-world practice. Method(s): A multicentre observational cohort study in 94 UK sites between March and April 2023. Recruitment was preferably prospective, with retrospective recruitment also allowed. Adults presenting to the ED with chest pain triggering assessment for possible ACS were eligible. Primary outcome was emergency care LOS. Secondary outcomes were index rate of acute myocardial infarction (MI), time to be seen (TTBS), disposition and discharge diagnosis. Details of ACS rule-out strategies in use were collected from local guidelines. Mixed effects linear regression models tested the association between rule-out strategy and LOS. Result(s): 8563 eligible patients were recruited, representing 5.3% of all ED attendances. Median LOS for all patients was 333 min (IQR 225, 510.5), for admitted patients was 460 min (IQR 239.75, 776.25) and for discharged patients was 313 min (IQR 221, 451). Heterogeneity was seen in the rule-out strategies with regard to recommended troponin timing. There was no significant difference in LOS in discharged patients between rule-out strategies defined by single and serial troponin timing (p=0.23 and p=0.41). The index rate of acute MI was 15.2% (1301/8563). Median TTBS was 120 min (IQR 57, 212). 24.4% (2087/8563) of patients were partly managed in a same day emergency care unit and 70% (5934/8563) of patients were discharged from emergency care. Conclusion(s): Despite heterogeneity in the ACS rule-out strategies in use and widespread adoption of rapid rule-out approaches, this study saw little effect on LOS in real-world practice. Suspected cardiac chest pain still accounts for a significant proportion of UK ED attendances. ED system pressures are likely to be explanatory, but further research is needed to understand the reasons for the unrealised potential of these strategies.

DOI: 10.1136/emermed-2024-214616

Link to full-text [NHS OpenAthens account required]

Point of View: A Holistic Four-Interface Conceptual Model for Personalizing Shock Resuscitation (2025)

Type of publication:

Journal article

Author(s):

Rola, Philippe; Kattan, Eduardo; Siuba, Matthew T; Haycock, Korbin; Crager, Sara; Spiegel, Rory; Hockstein, Max; Bhardwaj, Vimal; *Miller, Ashley; Kenny, Jon-Emile; Ospina-Tascon, Gustavo A; Hernandez, Glenn.

Citation:

Journal of Personalized Medicine. 15(5), 2025 May 20.

Abstract:

The resuscitation of a patient in shock is a highly complex endeavor that should go beyond normalizing mean arterial pressure and protocolized fluid loading. We propose a holistic, four-interface conceptual model of shock that we believe can benefit both clinicians at the bedside and researchers. The four circulatory interfaces whose uncoupling results in shock are as follows: the left ventricle to arterial, the arterial to capillary, the capillary to venular, and finally the right ventricle to pulmonary artery. We review the pathophysiology and clinical consequences behind the uncoupling of these interfaces, as well as how to assess them, and propose a strategy for approaching a patient in shock. Bedside assessment of shock may include these critical interfaces in order to avoid hemodynamic incoherence and to focus on microcirculatory restoration rather than simply mean arterial pressure. The purpose of this model is to serve as a mental model for learners as well as a framework for further resuscitation research that incorporates these concepts.

DOI: 10.3390/jpm15050207

Link to full-text [open access - no password required]

Improving CareFlow documentation in PRH Emergency Department (2025)

Type of publication:

Service improvement case study

Author(s):

*Luke Moss

Citation:

SaTH Improvement Hub, January 2025

Abstract:

To increase the number of ED Cas-cards that have allergy status recorded to 100% and to increase the number of Careflow allergy alerts by 100% by 23/11/24.

Link to PDF poster

Pulmonary Embolism Presenting As Shoulder and Back Pain: A Case Report (2024)

Type of publication:
Journal article

Author(s):
*Nwaneri, Chukwuemeka; *Race, Rebecca; *Oladele, Romoluwa; *Kumaran, Subramanian.

Citation:
Cureus. 16(7):e64016, 2024 Jul.

Abstract:
Pulmonary embolism (PE) is a common but life-threatening condition, and diagnosis can be challenging. Diagnosis is even more difficult in those patients with atypical presentations such as the absence of pleuritic chest pain, dyspnoea, tachycardia, or symptoms of deep vein thrombosis. We have delineated shoulder and back pain as an atypical sign of PE. However, the significant amount of misdiagnosis highlights the importance of other rare symptoms of this potentially fatal disease. Therefore, eliciting these rare presenting symptoms can significantly reduce morbidity and mortality. Here, we report the case of a patient who, 13 days after a laparoscopic Nissen fundoplication, presented to the emergency department (ED) with left shoulder and left-sided pleuritic back pain. She was managed in the resuscitation area in the ED and was subsequently diagnosed with a left-sided PE. Her care was taken over by the medical team, and she continued her recovery in the acute medical unit.

Link to full-text [no password required]

Altmetrics:

A QIP on the completion of the AMHT Form in the Emergency Department in SaTH (2024)

Type of publication:
Service improvement case study

Author(s):
*Kallum Claire

Citation:
SaTH Improvement Hub, April 2024

Abstract:
I aim to improve completion of the adult mental health triage form in SaTH ED by 20% by 31/05/2023 through the use of a poster, which will highlight the necessity of completion as well as serving as a reminder for staff to complete paperwork in the correct manner.

Link to full-text

Improvement to assessment and provision of analgesia for patients with suspected Neck of Femur Fracture in ED (2023)

Type of publication:
Service improvement case study

Author(s):
*Oleg Lujanschi

Citation:
SaTH Improvement Hub, November 2023

Abstract:
To improve the assessment and provision of analgesia (where required) for patients presenting in ED with a suspected Neck of Femur Fracture to ensure all patients meet the national standard by 15 December 2023. Additionally, the aim is to improve the percentage of patients who receive an x-ray when presenting to ED with a suspected Neck of Femur Fracture in line with the national standard of 90 minutes by 15 December 2023.

Link to PDF poster