İnvestigating the diagnostic value of cardiogoniometry i̇n identifying patients with low-probability acute coronary syndrome i̇n the emergency department

INTRODUCTION: Coronary diseases are the most common cause of non-traumatic deaths in emergency departments. The latest data published by the World Health Organization suggests that cardiovascular disease is the leading cause of deaths worldwide. In the management of patients suspected of ACS, guidelines recommend the probability classification for management strategy and choice of care place, and patients with low-middle probability are discharged from emergency services. However, studies show that 4-6% of patients with chest pain from the emergency department are discharged accidentally by skipping the diagnosis of acute coronary syndrome. It is of vital importance to evaluate and refer to relevant clinics for appropriate examinations and treatments. OBJECTIVE: To compare CGM with myocardial perfusion scintigraphy / single-photon emission computed tomography (SPECT) in patients who were discharged from the hospital with the Low-likelihood ACS protocol in emergency departments and to investigate the diagnostic value of CGM in these patients. METHOD: The study was conducted by the ethics committee, and it was held between June 2017 and October 2018 at the Emergency Service Clinic of Ege University Medical Faculty, after the approval of the T.C. Medicines and Medical Devices was obtained. The study included 416 patients who were admitted to the emergency department with anginal complaints such as chest pain, shortness of breath, and were referred to the outpatient clinic for the planning of Myocardial Perfusion Gated SPECT for the diagnosis of Low Probability ACS. All patients received informed consent form, and CGM was applied. Emergency physicians and cardiologists did not intervene in the diagnosis and treatment. CGM measurements were obtained by placing five electrodes on the lying patient and using commercially available hardware and software (Cardiologic Explorer, Enverdis, Jena, Germany). ST-segment elevation myocardial infarction (STEMI), cardiogenic shock, presence of significant cardiac ectopic beats, presence of pacemaker in the emergency department, low-middle risk group in follow-up NSTEMI / AAP patients follow-up ), patients who were not asked for myocardial scintigraphy or who could not be performed for any reason, and patients who did not want to participate in the study and who did not get consent were excluded from the study. The diagnostic efficacy of CGM in myocardial perfusion scintigraphy, which is defined as the gold standard in the first step centers, was compared in the patients who were given discharge decision as a result of the Low likelihood ACS protocol in emergency departments. RESULTS: The study included 4160 patients who were admitted to the emergency department with complaints of chest pain, and chest pain equivalent to 6808 patients and 6392 patients were excluded because of meeting the exclusion criteria or because they refused to participate in the study and/or refused treatment. The main data of the study were the MPS with the use of 193 of these patients. The mean age of the patients was 50.34 ± 12.47. The lowest age was 18, and the highest age was 84 years. While 86.1% (n = 358) of these patients were under 65 years of age, 13.9% (n = 58) were older than 65 years. Of the patients included in the study, 52.4% (n = 218) were male and 47.6% (n = 198) were female. The relationship between the sex and age of the patients was 27.6% (n = 16) were male, 72.4% (n = 42) were female. A statistically significant difference was found between them (p <0.001). The relationship between age groups and comorbid diseases was found to be 81% (n = 47) of patients over 65 years of age. There was a significant difference in comorbid diseases compared to patients under 65 years of age (p <0.001). There was no correlation between age and MPS results (p = 0.270). When MPS results were examined with the patients' gender, 13.7% (n = 13) of the patients with MPS were pathologic, and 19.4% (n = 19) were male. There was no significant relationship between these values. (p = 0,383) There was no significant relationship between MPS results and the patients' arrival tensions (p = 0,715) and arrival pulses (p = 0,280). 85.3% (n = 355) of the patients presented with chest pain. When the comorbid diseases of the patients were evaluated, it was found that 53.8% (n = 224) of the patients had at least one comorbid disease. It was noted that 36.1% (n = 150) had HT and 16.1% (n = 67) had DM. When the relationship between comorbid diseases and CGM results was examined, 61.6% (n = 130) of the patients with the comorbid disease were evaluated as positive. This finding was statistically significant (p = 0.001), and the probability of CGM positivity was higher in individuals with the comorbid disease. When the relationship between HT and CGM was investigated, it was found that HT diagnosis was statistically significant (p = 0.026), while 41,2% of patients with CGM were diagnosed with HT, while 57.4% of patients with HT had positive CGM. Confirms that hypertension is associated with CGM positive. When the history of coronary artery disease affects CGM results, only 1% (n = 2) of patients with CAD were negative for CGM. When evaluated statistically, the probability of the positive outcome of CGM measurements of patients with CAD was significantly higher. (p = 0.001) According to antihypertensive use, the distribution of CGM results was significantly higher than CGM positivity in patients with antihypertensive use. (P = 0.040) When the drug usage of the patients was examined, it was found that 51,2% (n = 213) of the patients used at least one drug and 48,8% (n = 203) were not using drugs. The most commonly used drug was beta blocker with 19% (n = 79). The most commonly used drug was found to be oral antidiabetic with 13,9% (n = 58). When the duration of stay in the emergency room was affected by the consultation request, 25,5% (n = 106) of the patients requested that the number of patients staying in the emergency room more than 6 hours was n = 75 (43.1%) and the patients who were consulted were in urgent care. Staying were detected. 31.9% of the patients who were not consulted (n = 310) remained in the emergency department for more than 6 hours, while 68,1% (n = 211) remained statistically shorter in the emergency department. According to these results, the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy rates of the patients were compared according to the presence of pathology in MPS. As a result of the comparison of CGM with MPS which is considered as the gold standard in the diagnosis of low probability acute coronary syndrome in the patients included in the study, the sensitivity of CGM was found to be 100% and its specificity was 55.28%. Simultaneously, the positive predictive value of CGM for patients with pathologic results in MPS was 30.77%, and the negative predictive value was 100%. The diagnostic accuracy rate of CGM results in predicting MPS results was calculated as 62.69%. The sensitivity of CGM was found to be higher than the ECG used in the differential diagnosis. ECG sensitivity was found to be 62,50%, and specificity was 76,40%. However, the positive predictive value of ECG for MPS pathologies was 34.48%, and the negative predictive value was 91.11%. The diagnostic accuracy rate of the ECG results in estimating MPS results was calculated as 74.09%. CGM sensitivity was found 100% (95% confidence interval 89,11% to 100%) in the patients included in the study. This result was significantly higher than the sensitivity of ECG used in ACS follow-up (ECG sensitivity in all patient groups was 62,50%). Cardiogonyometry has been evaluated as an important diagnostic tool because it will enable patients to be faster and easier to exclude when they are used together with other diagnostic tests used in patients with the low-probability acute coronary syndrome, and they will provide confidence in discharge and shorten the stay of patients with low risk in emergency services. 100% (n = 32) of the patients who had pathological results in MPS were evaluated as positive in CGM. The positive evaluation of CGM of 72 (44.7%) patients with normal MPS results indicates that attention should be paid to overdiagnosis. With CGM's 100% (95% confidence interval, 89,11% to 100%) sensitivity and 100% negative predictive value, patients can safely be discharged with low/medium risk patients safely. It can be used as a possible first-line test for patients. CONCLUSION: Because of the high sensitivity of cardiogonyometry, it was concluded that chest pain and equivalent symptoms could be used as a screening test in patients with pre-diagnosis of low-to-medium probability ACS, but it could not be used as a definitive diagnostic test due to its low specificity. With CGM's 100% (95% confidence interval 89,11% to 100%) sensitivity and 100% negative predictive value, patients can be safely secured with low / medium probability patients with discharge. Due to the automatic interpretation of the results with simple and quick application, it can be used as a possible first-step test for patients. Due to the fact that it is a costefective examination that can be used to meet the patient during the ACS examination, it can be a very important one in reducing the number of emergency services in the light of the new studies conducted with the device. CGM result of patients negative, 0-6 cardiac enzyme monitoring is negative, ECG findings and ECG changes are not available from the emergency department can be safely discharged from the emergency service. The accuracy of CGM has been proven in a comorbid disease, such as diabetes, where the accuracy of ECG has decreased. In this type of patients, CGM may enter patient discharge algorithms in the future with new studies.