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This article presents a response to several letters to the editor about a previously published article which features a citation error.

Abstract: Background: Little is known about why patients choose emergency departments (EDs) to receive care. Objective: Our aim was to measure the distribution and frequency of the stated reasons why patients choose the ED for care and why primary care physicians (PCPs) think their patients utilize the ED. Methods: The authors conducted a survey of patients presenting to an ED with 92,000 annual visits. Appropriate parametric tests were used for univariate and multivariate analysis and results were presented as frequencies with 95% confidence intervals. The authors also performed a cross-sectional survey of PCPs through a web-based survey. Results: Of the 1515 patients approached, 1083 (71%) agreed to participate and 1062 (98%) of them completed the survey. The most common reason patients gave for coming to the ED was their belief that their problem was serious (61%), followed by being referred (35%). In addition, 48% came at the advice of a provider, family member, or friend. By self-report, 354 (33%) patients attempted to reach their PCPs and 306 (86%) of them were successful. Two hundred and seventy-five PCPs were also surveyed. The most frequent reasons PCPs thought their patients came to an ED were that the patient chose to go on their own (80%) and the patients felt that they were too sick to be seen in the PCP's office (80%). Conclusions: The majority of patients stated that the most common reason for seeking care in an ED was that they thought their problem was serious. Almost half sought ED care on the advice of a family member, friend, or health care provider, and a sizable minority were actually referred in by a health care provider. PCPs agree that most patients come to EDs because they believe they are too sick to be seen in their office or become sick after office hours. [Copyright &y& Elsevier]

Background: Copeptin in combination with troponin has been shown to have incremental value for the early rule-out of myocardial infarction, but its performance in Black patients specifically has never been examined. In light of a potential for wider use, data on copeptin in different relevant cohorts are needed. This is the first study to determine whether copeptin is equally effective at ruling out myocardial infarction in Black and Caucasian races., Methods: This analysis of the CHOPIN trial included 792 Black and 1075 Caucasian patients who presented to the emergency department with chest pain and had troponin-I and copeptin levels drawn., Results: One hundred and forty-nine patients were diagnosed with myocardial infarction (54 Black and 95 Caucasian). The negative predictive value of copeptin at a cut-off of 14 pmol/l (as in the CHOPIN study) for myocardial infarction was higher in Blacks (98.0%, 95% confidence interval (CI) 96.2-99.1%) than Caucasians (94.1%, 95% CI 92.1-95.7%). The sensitivity at 14 pmol/l was higher in Blacks (83.3%, 95% CI 70.7-92.1%) than Caucasians (53.7%, 95% CI 43.2-64.0%). After controlling for age, hypertension, heart failure, chronic kidney disease and body mass index in a logistic regression model, the interaction term had a P value of 0.03. A cut-off of 6 pmol/l showed similar sensitivity in Caucasians as 14 pmol/l in Blacks., Conclusions: This is the first study to identify a difference in the performance of copeptin to rule out myocardial infarction between Blacks and Caucasians, with increased negative predictive value and sensitivity in the Black population at a cut-off of 14 pmol/l. This also holds true for non-ST-segment elevation myocardial infarction and, although numbers were small, similar trends exist in the normal troponin population. This may have significant implications for early rule-out strategies using copeptin.

Objectives: The goal of this study was to determine the ability of a single, resting high-sensitivity troponin T (hsTnT) measurement to predict abnormal myocardial perfusion imaging (MPI) in patients presenting with acute chest pain to the emergency department (ED)., Background: HsTnT assays precisely detect very low levels of troponin T, which may be a surrogate for the presence and extent of myocardial ischemia., Methods: We included all patients from the ROMICAT I (Rule Out Myocardial Infarction Using Computer Assisted Tomography) trial, an observational cohort study, who underwent both single-photon emission computed tomography (SPECT)-MPI stress testing and 64-slice computed tomography angiography (CTA) and in whom hsTnT measurements were available. We assessed the discriminatory value of hsTnT for abnormal SPECT-MPI and the association of reversible myocardial ischemia by SPECT-MPI and the extent of coronary atherosclerosis by CTA to hsTnT levels., Results: Of the 138 patients (mean age 54 ± 11 years, 46% male), 19 (13.7%) had abnormal SPECT-MPI. Median hsTnT levels were significantly different between patients with normal and abnormal SPECT-MPI (9.41 pg/ml [interquartile range (IQR): 5.73 to 19.20 pg/ml] vs. 4.89 pg/ml [IQR: 2.34 to 7.68 pg/ml], p = 0.001). Sensitivity of 80% and 90% to detect abnormal SPECT-MPI was reached at hsTnT levels as low as 5.73 and 4.26 pg/ml, respectively. Corresponding specificity was 62% and 46%, and negative predictive value was 96% and 96%, respectively. HsTnT levels had good discriminatory ability for prediction of abnormal SPECT-MPI (area under the curve: 0.739, 95% confidence interval: 0.609 to 0.868). Both reversible myocardial ischemia and the extent of coronary atherosclerosis (combined model r(2) = 0.19 with partial of r(2) = 0.12 and r(2) = 0.05, respectively) independently and incrementally predicted the measured hsTnT levels., Conclusions: In patients with acute chest pain, myocardial perfusion abnormalities and coronary artery disease are predicted by resting hsTnT levels. Prospective evaluations are warranted to confirm whether resting hsTnT could serve as a powerful triage tool in chest pain patients in the ED before diagnostic testing and improve the effectiveness of patient management., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

We tested the hypothesis that morphologic lesion assessment helps detect acute coronary syndrome (ACS) during index hospitalization in patients with acute chest pain and significant stenosis on coronary computed tomographic angiogram (CTA). Patients who presented to an emergency department with chest pain but no objective signs of myocardial ischemia (nondiagnostic electrocardiogram and negative initial biomarkers) underwent CT angiography. CTA was analyzed for degree and length of stenosis, plaque area and volume, remodeling index, CT attenuation of plaque, and spotty calcium in all patients with significant stenosis (>50% in diameter) on CTA. ACS during index hospitalization was determined by a panel of 2 physicians blinded to results of CT angiography. For lesion characteristics associated with ACS, we determined cutpoints optimized for diagnostic accuracy and created lesion scores. For each score, we determined the odds ratio (OR) and discriminatory capacity for the prediction of ACS. Of the overall population of 368 patients, 34 had significant stenosis and 21 of those had ACS. Scores A (remodeling index plus spotty calcium: OR 3.5, 95% confidence interval [CI] 1.2 to 10.1, area under curve [AUC] 0.734), B (remodeling index plus spotty calcium plus stenosis length: OR 4.6, 95% CI 1.6 to 13.7, AUC 0.824), and C (remodeling index plus spotty calcium plus stenosis length plus plaque volume <90 HU: OR 3.4, 95% CI 1.5 to 7.9, AUC 0.833) were significantly associated with ACS. In conclusion, in patients presenting with acute chest pain and stenosis on coronary CTA, a CT-based score incorporating morphologic characteristics of coronary lesions had a good discriminatory value for detection of ACS during index hospitalization., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: Patients at low risk for acute coronary syndrome (ACS) who present to the emergency department complaining of acute chest pain place a substantial economic burden on the U.S. health care system. Noninvasive 64-MDCT coronary angiography may facilitate their triage, and we evaluated its cost-effectiveness., Materials and Methods: A microsimulation model was developed to compare costs and health effects of performing CT coronary angiography and either discharging, stress testing, or referring emergency department patients for invasive coronary angiography, depending on their severity of atherosclerosis, compared with a standard-of-care (SOC) algorithm that based management on biomarkers and stress tests alone., Results: Using CT coronary angiography to triage 55-year-old men with acute chest pain increased emergency department and hospital costs by $110 and raised total health care costs by $200. In 55-year-old women, the technology was cost-saving; emergency department and hospital costs decreased by $410, and total health care costs decreased by $380. Compared with the SOC, CT coronary angiography-based triage extended life expectancy by 10 days in men and by 6 days in women. This translated into corresponding improvements of 0.03 quality-adjusted life years (QALYs) and 0.01 QALYs, respectively. The incremental cost-effectiveness ratio for CT coronary angiography was $6,400 per QALY in men; in women, CT coronary angiography was cost-saving. Cost-effectiveness ratios were sensitive to several parameters but generally remained in the range of what is typically considered cost-effective., Conclusion: CT coronary angiography-based triage for patients with low-risk chest pain is modestly more effective than the SOC. It is also cost-saving in women and associated with low cost-effectiveness ratios in men.

Objective: Current risk stratification of patients with acute chest pain but normal initial cardiac enzymes and nondiagnostic ECG is inefficient. We sought to determine whether contrast-enhanced MDCT-based detection of stenosis is feasible and improves early and accurate triage of patients with acute chest pain., Subjects and Methods: We studied 40 patients (53% men; mean age, 57 +/- 13 years) with chest pain who were awaiting hospital admission to rule out an acute coronary syndrome (ACS) despite the absence of diagnostic ECG changes and normal cardiac enzymes on emergency department presentation. Patients underwent contrast-enhanced MDCT before hospital admission. Afterward, patients received standard clinical care. All physicians involved in the patients' care were blinded to the results of MDCT. An expert panel established the presence or absence of ACS based on American Heart Association (AHA) guidelines. The MDCT images were evaluated for the presence of significant coronary artery stenosis (diameter reduction > 50%) and were used to make a triage decision., Results: All five patients (12.5%) with ACS (one with non-ST elevation myocardial infarction, four with unstable angina pectoris) had at least one significant coronary stenosis on MDCT (sensitivity, 100% [95% CI, 49-100%)]. ACS was ruled out in 35 patients (87.5%). Significant coronary stenosis was excluded in 26 of the 35 patients without ACS by MDCT (specificity, 74% [CI, 75-88%]), potentially saving 70% of unnecessary hospital admissions., Conclusion: MDCT-based detection of significant coronary stenoses has tremendous potential to decrease the number of unnecessary hospital admissions, without reducing appropriate admission rates, in patients with chest pain who have nondiagnostic ECG results and normal cardiac enzymes. These results are likely to further improve with advances in MDCT technology.