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October 02, 2007
ACS Outcomes
An interesting study in Annals of Emergency Medicine demonstrates a few points that I have been exploring lately. There has been a strong bias in favor of admitting all patients with Acute Coronary Syndrome (ACS- anything that sounds like a heart attack that hasn't been proven to be yet) to the Coronary Care Unit or some special cardiology floor.
This study challenges that demand. They found that the group admitted to the noncardiology service did just as well in all outcome measures (recommended therapies, ED revisits and rehospitalizations, functional status, and adverse cardiovascular events). The only difference was that the cardiology group were much more (2-4 times) likely to undergo evaluation for ischemic heart disease.
So for more worry, more money and more tests, the outcome was the same.
But the best part of this study ("best" as in the punchline of this joke), like most studies, is the exclusions. Anyone who presented to the ED with symptoms that sounded cardiac was initially considered. But they excluded anyone with a known non-cardiac condition (which included panic attacks among others), with inability to give informed consent, who left the ED prior to enrollment, or was medically unstable, or had trauma, or was unreachable at follow-up. 2,817 were excluded and only 544 were included, for a Terrell's ratio of 1:6. For every six patients that were considered for the study, only one was eligible.
So although this study confirms common sense, and confirms my studied opinion of the (lack of) value of cardiac interventions (which I am reviewing in tedious detail currently), it still falls prey to the common pitfall of the modern scientific medicine -- it does not deal with reality. By eliminating the majority of patients from the study, it purports to narrow the scientific question and isolate the one factor that they wish to study. But ironically, it simultaneously makes the results irrelevant to the population in question.
| By Robert Maddox | 11:27 AM