Austin Wu – Urgent Matters

A patient presents to the emergency department presenting with precordial chest discomfort, pain radiating to the jaw, dyspnea, and diaphoresis. These are some of the typical symptoms highly indicative of acute coronary syndrome (ACS) [i]. However, not all patients have “typical” symptoms. Prior studies have shown that certain demographic groups, specifically patients of older age, black or Asian race, and female gender are less likely to present with these typical symptoms despite later having the diagnosis of ACS [ii]. In addition, other factors have been associated with atypical presentations including older age, and the presence of comorbid conditions such as diabetes.

While there is a large literature on atypical presentations of ACS, the combination of demographic factors – specifically combinations of race and gender – has not been closely explored until now. A recent study by researchers Drs. Ahmed Allabban, Judd Hollander and Jesse Pines at the George Washington University School of Medicine and Thomas Jefferson University published in the Emergency Medicine Journal focused on the combination of race and gender, and how the intersection of these two factors correlate with presentation of 30-day ACS or other serious cardiopulmonary diagnoses [iii]. The four subgroups were analyzed: black males, white males, black females, and white females.

The study was a secondary analysis of data collected from a prospective, observational cohort study of ED patients presenting with chest pain, with timeframe spanning from 1999 to 2008. The entire dataset was more than 4000 patients, and the study was conducted at an inner city academic hospital. Inclusion criteria included 30 years of age or older, presentation of chest pain where an ECG was ordered, and provision of informed consent. Patients who had chest trauma within the past week, a measured temperature of 101°F, used home oxygen, had metastatic cancer or had symptoms of palpitation alone without chest pain were excluded from the study.

The study found that symptoms associated with a higher risk of ACS in white males were left arm radiation, chest pressure and tightness, and substernal chest pain. These are typical symptoms of ACS. For black males, the symptom associated with a higher risk of ACS was diaphoresis. For black females, symptoms indicating higher risk of ACS included diaphoresis, palpitations, and left arm radiation, while symptoms indicating lower risk for ACS included pleuritic chest pain and left anterior chest pain. No symptoms were predictive of ACS for white females. For serious cardiopulmonary diagnoses, there were largely similar findings. Results are displayed in the figure below.

The data demonstrates that dividing patient populations by a combination of race and gender produces variably predictive symptoms of both ACS and other serious cardiopulmonary diagnoses. Thus, relying on a particular set of typical symptoms regardless of demographic representation may not be an optimal form of practice.

This study had several limitations, including being a single center study, using convenience sampling, and having variations in sample size for each subgroup. Further, while this study highlights differences in symptoms among race and gender subgroups, the question of what causes these differences remains an area to be explored. Preliminary explanations include hormonal, physiological, and sociocultural differences among each of these subgroups, though these have not been substantiated. The main takeaway is that physicians in the ED should keep these symptomatic differences between race and gender in mind when assessing a patient for chest pain.

[i] Ayman El-Menyar et al., “Atypical Presentation of Acute Coronary Syndrome: A Significant Independent Predictor of in-Hospital Mortality,” Journal of Cardiology 57, no. 2 (March 2011): 165–71, doi:10.1016/j.jjcc.2010.11.008.

[ii] H. Lee et al., “Typical and Atypical Symptoms of Myocardial Infarction among African-Americans, Whites, and Koreans,” Critical Care Nursing Clinics of North America 13, no. 4 (December 2001): 531–39.

[iii] Ahmed Allabban, Judd E. Hollander, and Jesse M. Pines, “Gender, Race and the Presentation of Acute Coronary Syndrome and Serious Cardiopulmonary Diagnoses in ED Patients with Chest Pain,” Emerg Med J, June 16, 2017, emermed-2016-206104, doi:10.1136/emermed-2016-206104.

Austin Wu is a medical student at the GW School of Medicine & Health Sciences

As described in a previous Urgent Matters blog post, opioid prescriptions in the emergency department (ED) have the potential to cause long-term opioid use (defined as 180 days or more of opioids within 12 months of the index ED visit). Further, prescription opioids continue to be the number one cause of drug overdose deaths in the US.[1] These trends indicate a dire need for effective interventions to curb unnecessary opioid prescriptions and prevent opioid abuse by patients.

A recent study in the Annals of Emergency Medicine examines the effects of one such intervention: opioid prescribing guidelines. Specifically, the study examined opioid prescription rates by ED physicians in Ohio, comparing pre and post guideline data.[2] The goal was to determine whether the implementation of Ohio’s April 2012 opioid prescription guidelines for ED physicians reduced the number of opioid prescriptions by ED physicians.

Researchers utilized data from Ohio’s prescription drug monitoring program from 2010 – 2014, and conducted an interrupted time series analysis. Ohio’s Prescription Drug Monitoring Program includes all prescriptions for schedule II to IV medications dispensed by a pharmacy within the state. Prescriptions written in Ohio but dispensed outside the state were not included. The 5 most commonly prescribed opioids (hydrocodone, oxycodone, tramadol, codeine, and hydromorphone) were examined in this study, and prescriptions counted were limited to those prescribed by physicians with a primary specialty of emergency medicine, pediatric emergency medicine, and sports medicine. Orthopedic surgery opioid prescriptions were utilized as a control against confounding variables, primarily from opioid-related interventions initiated in parallel with the new guidelines.

Three measurements were followed in the study: 1) Total opioid prescriptions in Ohio per month by ED physicians 2) Total morphine milligram equivalents contained in these monthly prescription totals 3) Number of opioid prescriptions greater than 3 days’ duration (specifically discouraged by guidelines). The data in January of 2010 showed that total opioid prescriptions dispensed by all ED physicians in Ohio declined by 0.31% per month, which than changed to a 11.98% decrease per month after guideline implementation, starting April of 2012. Total morphine milligram equivalents improved from a 0.29% decrease per month to 17.36% decrease per month. Opioid prescriptions greater than 3 days’ duration improved from 0.04% per month to 11.2% per month. Further, the rate of decline in all three of these measures continued to decline at approximately 0.9% per month. The graphs below depict total prescription trends when stratified into the 5 most commonly prescribed opioids. A, B, C, D, and E represent Hydrocodone, Oxycodone, Tramadol, Codeine, and Hydromorphone, respectively.

SOURCE: Scott G. Weiner et al., “The Effect of Opioid Prescribing Guidelines on Prescriptions by Emergency Physicians in Ohio,” Annals of Emergency Medicine, May 2017, doi:10.1016/j.annemergmed.2017.03.057.

As demonstrated by the downward shift after the May 2012 time point, all five opioids displayed a reduction in number of prescriptions after the guidelines were implemented. The steeper slopes also demonstrate an increased rate of decline in opioid prescriptions post-guidelines.

There were several limitations to this study, including possible data entry errors, a focus on a specialty representing only 5% of total opioid prescriptions, and limited generalizability as a statewide study. However, this research suggests promise for using guidelines, both within and outside the specialty of emergency medicine, as one effective tool for combating the opioid epidemic.

[1] Rose A. Rudd, “Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015,” MMWR. Morbidity and Mortality Weekly Report 65 (2016), doi:10.15585/mmwr.mm655051e1.

[2] Scott G. Weiner et al., “The Effect of Opioid Prescribing Guidelines on Prescriptions by Emergency Physicians in Ohio,” Annals of Emergency Medicine, May 2017, doi:10.1016/j.annemergmed.2017.03.057.

Austin Wu is a medical student at the GW School of Medicine & Health Sciences

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Atypical presentations of acute coronary syndrome: the role of gender and race 1

Efficacy of Prescription Guidelines on Opioid Prescriptions in the ED 1

SOURCE: Scott G. Weiner et al., “The Effect of Opioid Prescribing Guidelines on Prescriptions by Emergency Physicians in Ohio,” Annals of Emergency Medicine, May 2017, doi:10.1016/j.annemergmed.2017.03.057.

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