***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: A prospect i ve study of the clinical findings and transfer decision in 278 patients admitted to the emergency ward for chest pain showed that a combination of 115 clinical and ECG data makes it possible to predict 86 % of acute myocardial infa rct ions and unstable angina ( specificity 76 % ) . However , the diagnosis of the emergency medical team was adequate in 91 % of cases , yielding a 5 % rate of unjustified admissions to the intensive care unit . Therefore , the utility of a decision algorithm based upon clinical and ECG data , as proposed by American authors , is question able . Finally , the indication for transfer to the intensive care unit was not followed in a quarter of patients due to old age and /or associated diseases STUDY OBJECTIVE Current risk stratification tools do not identify very-low-risk patients who can be safely discharged without prolonged emergency department ( ED ) observation , expensive rule-out protocol s , or provocative testing . We seek to develop a clinical prediction rule applicable within 2 hours of ED arrival that would miss fewer than 2 % of acute coronary syndrome patients and allow discharge within 2 to 3 hours for at least 30 % of patients without acute coronary syndrome . METHODS This prospect i ve , cohort study enrolled consenting eligible subjects at least 25 years old at a single site . At 30 days , investigators assigned a diagnosis of acute coronary syndrome or no acute coronary syndrome according to predefined explicit definitions . A recursive partitioning model included risk factors , pain characteristics , physical and ECG findings , and cardiac marker results . RESULTS Of 769 patients studied , 77 ( 10.0 % ) had acute myocardial infa rct ion and 88 ( 11.4 % ) definite unstable angina . We derived a clinical prediction rule that was 98.8 % sensitive and 32.5 % specific . Patients have very low risk of acute coronary syndrome if they have a normal initial ECG , no previous ischemic chest pain , and age younger than 40 years . In addition , patients at least 40 years old and with a normal ECG result , no previous ischemic chest pain , and low-risk pain characteristics have very low risk if they have an initial creatine kinase-MB ( CK-MB ) less than 3.0 microg/L or an initial CK-MB greater than or equal to 3.0 microg/L but no ECG or serum-marker increase at 2 hours . CONCLUSION The Vancouver Chest Pain Rule for early discharge defines a group of patients who can be safely discharged after a brief evaluation in the ED . Prospect i ve validation is needed Aims : To examine the feasibility of using the ROMEO ( rule out myocardial events on “ obs ” ward ) pathway for low risk patients with chest pain in a UK emergency department . Methods : A prospect i ve study was undertaken to determine outcomes for the first 100 patients entering the pathway ( from May to Oct 1999 ) .  Serum troponin levels , serial ECG recordings , exercise test result , total length of stay , and final diagnoses were review ed . Patients were telephoned after discharge to inquire about persisting or recurrent pain , and further investigations after completing the ROMEO pathway . Results : 82 of 100 ( 82 % ) had myocardial damage excluded by serum troponin assay . Sixty two of 82 ( 76 % ) of these completed exercise tolerance testing ( ETT ) . Fifty seven of 62 ( 92 % ) ETTs were negative . Twenty of 82 ( 26 % ) did not undergo ETT because of mobility problems , recent ETT , or if considered very low probability of cardiac pain on consultant review . Five of 100 ( 5 % ) had an increased initial troponin and five of 100 ( 5 % ) had an increased 12 hour troponin . These patients were referred for admission under the general physicians . Seven of 100 ( 7 % ) were referred for other reasons ( late ECG changes , continuing or worsening pain ) . One patient self discharged . Length of stay varied because of changes to arrangements for ETT . The median time for all patients over the period studied was 23 hours . All patients were discharged within an hour of a negative ETT . Follow up results : 67 of 74 ( 91 % ) eligible patients were contacted by telephone . Forty six of 67 ( 69 % ) had no further pain , attendances , or GP consultations . Six of 67 ( 9 % ) had further cardiological investigation or treatment . Conclusions : A rapid rule out strategy such as the ROMEO pathway is feasible in the UK healthcare setting and provides st and ardised and consistent evaluation AIM The aim of the study was to establish a triage flowchart to rule out acute coronary syndrome ( ACS ) among patients with chest pain ( CP ) arriving on an Emergency Department ( ED ) . PATIENTS AND METHOD This prospect i ve observational study included 1000 consecutive patients with CP arriving on an ED CP unit . Demographic and clinical characteristics along with vital signs were recorded as independent variables . After CP unit protocol completion and 1-month follow-up , patients were classified as ( dependent variable ) ( 1 ) true non-ACS ( all noncoronary patients at the first visit that kept this condition when called 1 month later ) or ( 2 ) true ACS ( all the remaining patients ) . Relationship among variables was assessed by multiple logistic regression analysis . A triage flowchart was obtained from significant variables and applied to patients with CP who were then grouped in " triage non-ACS " and " triage ACS . " Validity indexes to exclude ACS for triage flowchart were measured . RESULTS Variables significantly associated with non-ACS and included in the triage flowchart were age < 40 years ( odds ratio 3.61 , 95 % CI 1.63 - 7.99 ) , absence of diabetes ( 2.74 , 1.53 - 4.88 ) , no previously known coronary artery disease ( 5.46 , 3.42 - 8.71 ) , nonoppressive pain ( 10.63 , 6.04 - 18.70 ) , and nonretrosternal pain ( 5.16 , 2.82 - 9.42 ) . For the triage flowchart , both specificity and positive predictive value to rule out ACS were 100 % . CONCLUSIONS The triage flowchart is able to accurately identify patients with CP not having an ACS . It may help triage nurses make quick decisions on who should be immediately seen and who could safely wait when delays in medical attention are unavoidable . Prospect i ve validation is needed A mathematical instrument was developed to supplement the diagnostic information available to physicians in the emergency room to improve physicians ' diagnostic accuracy in managing patients with acute ischemic heart disease and thereby reduce inappropriate coronary care unit admissions . The instrument was empirically derived and is based on nine clinical , historical , and electrocardiographic predictive variables . Probabilities of acute ischemic heart disease generated by the instrument were given to the house staff in an emergency room during alternate months . Comparison of the control months ( 455 patients ) with the experimental months ( 401 patients ) showed the following : The overall diagnostic accuracy increased from 83 % to 91 % ( P less than 0.005 ) , the overdiagnostic accuracy increased from 51 % to 33 % ( P less than 0.01 ) , and the admission rate to the coronary care unit fell from 26 % to 14 % ( P less than 0.001 ) , while the inappropriate discharge rate from the emergency room did not change , 3 % versus 3 % ( not significant ) BACKGROUND Most studies of emergency department ( ED ) chest pain patients exclude patients < 30 - 40 years old . As a result , the clinical course of these patients is poorly described . OBJECTIVE To study the clinical characteristics , hospital course , and 30-day outcomes of ED chest pain patients < 40 years old . The hypothesis was that patients < 40 years old without a cardiac history and with normal electro-cardiograms ( ECGs ) or no cardiac risk factors would be at a < 1 % risk for acute coronary syndromes ( ACSs ) and 30-day adverse cardiovascular ( CV ) events . METHODS This was a prospect i ve cohort study of non-cocaine-using ED patients , 24 - 39 years old , who received an ECG for chest pain between July 9 , 1999 , and October 23 , 2000 . Structured data collection at presentation included demographics , chest pain description , history , laboratory , and ECG data . Hospital course was followed daily . Thirty-day follow-up was performed by telephone . The main outcomes were discharge diagnosis and 30-day adverse CV events [ acute myocardial infa rct ion ( AMI ) , death , percutaneous intervention ( PCI ) , or coronary artery bypass grafting ( CABG ) ] . RESULTS A total of 487 patients presented 527 times and comprised the study group . Patients were most often 30 - 39 years old ( 71 % ) , female ( 60 % ) , and African-American ( 73 % ) . Thirty-two percent were admitted . Five hundred seven of 527 patient visits ( 96 % ) had 30-day follow-up . Patients had the following cardiac risk factors : tobacco , 37 % ; hypertension , 22 % ; family history , 19 % ; diabetes mellitus , 6 % ; cholesterol , 6 % ; prior angina , 3 % ; known coronary artery disease , 3 % ; and prior AMI , 2 % . Patients usually had unremarkable ECGs ( 61 % normal , 98 % nonischemic ) . Overall , 11 of 527 patients had adverse CV events ( 2.1 % ; 95 % CI = 0.9 % to 3.3 % ) : 8 AMIs ( 1.5 % ) , 4 deaths ( 0.8 % ) , 5 PCIs ( 0.9 % ) , and no CABG . Twenty-five patients had a final diagnosis of ACS ( 4.7 % ; 95 % CI = 2.9 % to 6.5 % ) . The incidence of ACS in the 210 patients without a cardiac history and without cardiac risk factors was 0.5 % ( 95 % CI = 0 % to 1.4 % ) . At 30 days , none of these 210 patients had AMI , PCI , CABG , or death ( 0 % , 95 % CI = 0 % to 1.4 % ) . The incidence of ACS in the 312 patients with normal ECGs and a negative cardiac history was 0.3 % ( 95 % CI = 0 % to 0.9 % ) . At 30 days , there was no AMI , PCI , or CABG in these 312 patients , and one patient with metastatic cancer died ( adverse CV event 0.3 % , 95 % CI = 0 % to 0.9 % ) . CONCLUSIONS Although young patients , as a whole , have a 4.7 % risk of ACSs and a 2.1 % risk of adverse CV events at 30 days , those without known cardiac disease or any cardiac risk factors had a < 1 % risk of ACSs and were free from adverse CV events over 30 days . Likewise , young patients without a cardiac history and with a normal ECG had a < 1 % risk of ACSs and adverse CV events at 30 days . It may be reasonable to expedite outpatient management and limit unnecessary admissions in these cohorts The aim of this study was to determine which , and how many , data items are required to construct a decision support algorithm for early diagnosis of acute myocardial infa rct ion using clinical and electrocardiographic data available at presentation . Logistic regression models were derived using data items from 600 consecutive patients at one centre ( Edinburgh ) , then tested prospect ively on 510 cases from the same centre and 662 consecutive cases from another centre ( Sheffield ) . Although performance of the models increased with progressive addition of data inputs when applied to training data , a simple six-factor model was the most effective on test data , yielding accuracies of 84.3 and 83.6 % on the two test sets . A model constructed solely of electrocardiographic data performed nearly as well as those incorporating clinical data . Previously published logistic regression models did not perform so well as the models derived from data collected for this study & NA ; We conducted a prospect i ve study of 152 adult patients presenting to an emergency department with chest pain or symptoms suggestive of acute myocardial infa rct ion ( AMI ) to evaluate the first electrocardiogram ( ECG ) , creatine kinase (CK)‐MB and Troponin‐T Rapid Assay ( TnT ) alone or in combination with chest pain in the initial diagnosis of AMI . A provisional diagnosis was made after the history , physical examination and the first ECG reading . Blood specimens were taken for TnT , CK and CK‐MB mass . A final discharge diagnosis of AMI was made according to World Health Organization criteria . Seventy‐six ( 50 % ) of patients had a final diagnosis of AMI . The sensitivities of the first ECG , first CK‐MB mass and first TnT were 76.3 % ( 95 % confidence interval ( CI ) , 66.8‐85.9 ) , 38.2 % ( 95 % CI , 27.2‐49.1 ) and 31.6 % ( 95 % CI , 21.2‐42.0 ) respectively . The area under the curve for a combination of ECG , CK‐MB mass , TnT and chest pain was the highest at 0.937 when compared with chest pain with varying combinations of tests . A combination of the first ECG , CK‐MB mass and TnT had a negative predictive 
    Output:
    
No instrument assisting clinicians in the diagnostic investigation of patients with suspected acute coronary syndrome consistently fulfils the safety requirements of clinicians