Year : 2009 | Volume
: 34 | Issue : 4 | Page : 293--297
Study of risk factors affecting the survival rate of emergency victims with "chest pain" as chief complaint
Biranchi N Jena, Adibabu Kadithi
Department of Research and Analytics, Emergency Management and Research Institute, Devar Yamzal, Medchal Road, Secunderabad - 500 014, Andhra Pradesh, India
Biranchi N Jena
Department of Research and Analytics. Emergency Management and Research Institute, Devar Yamzal, Medchal Road, Secunderabad - 500 014, Andhra Pradesh
Research Question : What are the risk factors affecting the survival of emergency victims with chest pain as chief complaint. Objectives : 1. To find out the relative risk of different risk factors. 2. To find out whether the association between survival rate and various sociodemographic variables are statistically significant or not. Study Design : Descriptive study. Setting : This study is based on the Pre-hospital care Records (PCR) of the Emergency Management and Research Institute (EMRI) from May 2007 to December 2007, in Andhra Pradesh. Participants : 2020 emergency victims, with chest pain as the chief complaint, reported to EMRI from May to December 2007. Study Variables : Demographic characteristics of the victims, time and day of the incident, response time in handling the emergency, and so on. Statistical Analysis : Proportions, Chi-Square test, and Odds Ratio. Results : Of all the risk factors studied, gender (Male), age (65 +), and incident location (residence), proved to be the risk factors for the non-survival of the victims of medical emergencies, with chest pain as the chief complaint. It was also observed that there was a statistically significant association (P < 0.05) between age, gender, area (urban and rural), and occupation with the survival rate. The response time was significantly associated with the survival rate, only for critical cases. Survival rate increases to 33% with response time less than 15 minutes from less than 5% with the response time more than 15 minutes.
|How to cite this article:|
Jena BN, Kadithi A. Study of risk factors affecting the survival rate of emergency victims with "chest pain" as chief complaint.Indian J Community Med 2009;34:293-297
|How to cite this URL:|
Jena BN, Kadithi A. Study of risk factors affecting the survival rate of emergency victims with "chest pain" as chief complaint. Indian J Community Med [serial online] 2009 [cited 2020 Sep 23 ];34:293-297
Available from: http://www.ijcm.org.in/text.asp?2009/34/4/293/58385
Coronary heart disease is a leading factor causing morbidity and mortality, both in the developing and developed countries around the world. Angina pectoris (Chest pain caused by insufficient blood supply to the heart) and acute myocardial infarction (Heart attack) are the two most common features of coronary heart diseases, also known as coronary artery disease. According to the World Health Organization (WHO) estimates, in 2004, 17.1 million people around the world died from cardiovascular disease and the number is expected to grow to 23.4 million in 2030.  Chest pain is the most common initial symptom in patients diagnosed with coronary artery disease. "Non-specific" chest pain was the fourth most common cause of emergency visits, which accounted for 1.6 million visits in 23 selected states, in 2005, according to the latest news and numbers from the Agency for Healthcare Research and Quality. About one-fifth of the cases were admitted to hospitals for observation or treatment.  Out of the total number of patients who approached the Emergency Department with chest pain as the chief complaint, in the US, just five to 15 percent of them were found to be suffering from heart attacks or other cardiac diseases.  In countries like India, a sizable number of people seek emergency services with "Chest Pain" as the chief complaint. Therefore, it would be important to study the risk factors affecting the survival rate for those patients who sought the emergency services with chest pain as the chief complaint.
Materials and Methods
The study is based on all the emergencies with chest pain as chief complaint, who reported to the Emergency Management and Research Institute (EMRI) from May 2007 to December 2007, in Andhra Pradesh, India. EMRI, born in 2005, in the state of Andhra Pradesh, provides emergency medical services along with Pre-Hospital Care. Pre-Hospital Care Record (PCR) was the major source of data for the study. PCR was introduced along with the operation of the Emergency Management and Research Institute (EMRI), providing pre-hospital care while transporting the emergency patients to the appropriate definite care units. PCR is an instrument that captures the socioeconomic-demographic variables of the emergency victims along with the pre-existing ailments and the type of medical intervention given to the victims during the pre-hospital care. As the PCR forms are filled by qualified and trained Emergency Medical Technicians (EMTs), the quality of data is assumed to be good for research projects. Therefore, the PCR is considered to be a good data source for studying the risk factors affecting the survival rate of emergency victims, with chest pain as chief complaint.
The study preliminarily scanned all the PCRs (7516) for emergencies who reported to the EMRI with a chief complaint of "chest pain". However, based on the availability of variables identified for the study and the availability of the "Survival Status" of the victims, 2020 cases were included for the study. For the purpose of the study, the survival status was defined as whether the emergency victim was alive or not after 48 hours of providing the emergency transport with pre-hospital care to the patients. EMRI has a robust process for collecting the survival status of the victims after 48 hours of the incident. EMRI collects the information on the survival status in four major categories,namely, "alright and discharged from hospital", "Stable, out of danger but still in the hospital", "critical and still in the hospital," and "expired". In the current study, all the cases except "expired", in the survival status, are considered to be "alive".
The study is a descriptive study and uses the chi-square test for the significance in the association, odds ratio for the risk factors.
Out of the 2020 victims analyzed for chest pain, 92.23% (1863) had survived and 7.77% (157) had expired as per the "after 48 hours patient follow-up" information. It has been observed that more cases had been registered from the Krishna district (9.06%), followed by Chitoor (7.34%), and Guntur (7.33%). In the overall 2020, more cases of emergency with chest pain were recorded for males (58.16%) when compared to females (41.39%). The survival status shows that 9% of the male victims expired within 48 hours of the incident as compared to only 6% of the female victims. This indicates that the female were less susceptible to death resulting from "chest pain" as chief complaint as compared to their male counterparts, in the study of the selected reported cases to the EMRI. Age-wise analysis of victims revealed that a greater number of cases were reported for the people in the age group of 35 - 50 (32%) years. The mean age of the male victims was recorded as 49 years, whereas, the mean age for the female victims was comparatively low at 45 years. The mean age of the victims varied significantly (P P  Based on the study, it is deducted that around 11.7% of the total number of chest pain victims are diagnosed with some pre-existing cardiac-related ailments, and have a higher risk of death. Out of the total number of patients who approach the Emergency Department with a chief complaint of chest pain, in the US, just five to 15 percent of them are found to be suffering from heart attacks or other cardiac diseases  Proper evaluation of the patient with acute chest pain is a resource-intensive and expensive process. Physicians face enormous challenges in the management of these patients. The two major acute coronary syndromes (ACSs) that are encountered are acute myocardial infarction (AMI) and unstable angina pectoris. However, most chest pain patients do not have an ACS,  and most patients who do have an ACS have not had an AMI.  Therefore, most of the emergency victims seeking medical help because of chest pain, are less likely to have a cardiac-related emergency.
Shorter response time was significantly associated with increased probability of receiving defibrillation and survival to discharge, among those defibrillated. Reducing the response time to eight minutes from 15 minutes, increased the predicted survival to 8% and reducing it to five minutes increased the survival to 10 - 11%.  As the experience of AP shows that the mean response time in handling the emergencies with chief complaint of chest pain during the study period was 18.8 minutes, the survival rate was studied as a binary variable for critical cases, where CPR was administered as pre-hospital care. The response time was studied as more than 15 minutes and less than 15 minutes, and it showed that the survival rate increased by more than 28% in absolute terms if the response time was less than 15 minutes. Rade B Vukamir, in his study found that response time affected the survival rate in cardiac emergencies. He studied 874 pre-hospital cardiac arrest patients treated by urban, suburban, and rural emergency medical services and proved that survival was improved with a decrease in the response time (for BLS 5.52 minutes versus 6.81 minutes, for ACLS 7.29 minutes versus 9.49 minutes). 
The American Heart Association, in a study on "Blood pressure experience and risk of cardiovascular disease in the elderly," shows a relationship between BP and CVD. The study reveals that blood pressure > 160 mm Hg adds a small, but statistically significant increment in predicting the future cardiovascular disease in the elderly.  When the systolic blood pressure was studied as a risk factor (for NON survival) along with severe chest pain, a blood pressure count of 160 mm Hg or more was not exhibiting as a risk factor nor showing a statistically significant association with the survival rate. The gender difference in the incidence and prevalence of heart disease is well established and mortality for coronary heart disease is greater in men than in women. ,,,,, The present study also finds a similar pattern in the reporting of emergencies with chest pain as a major complaint by males and females. The reporting of male victims (58%) is more than the female victims (42%) and as far as the survival rate is concerned, female victims have a better survival rate (94%) than their male counterparts (91%) [P  In the current study also it is evident that the highest number of such emergencies were registered on Monday (17.7%), however, as far as survival in an emergency with chest pain as chief complaint is concerned, Monday has not been proved to be a risk factor.
Chest pain with diabetes, for male victims of more than 70 years, is the intermediate likelihood for acute coronary syndrome.  The present study implies that male victims of more than 65 years are more prone to death with the onset of the medical emergency with chest pain as chief complaint.
Out of all the medical emergencies with chest pain as chief complaint reported to the EMRI, around 10% of the cases are expected to be cardiac-related emergencies. Of all the risk factors studied, gender (Male), age (65+), and incident location (residence) have proved to be the risk factors for non survival of the victim in such emergencies. It is also observed that there is a statistically significant association (P <0.05) between age, gender, area (urban and rural), and occupation, with the survival rate. As all the emergency cases with chest pain as the major complaint are not life-threatening, the response time is neither significantly associated with the survival status, nor has it proved to be a risk factor. However, the response time studied for the critical cases has proved that it is associated with the survival rate of the emergency victims. It has been found that the survival rate increases to 33% with a response time of less than 15 minutes from 6% with the response time of more than 15 minutes.
Thus, by improving the response time especially for male victims with age more than 65 years, more lives can be saved.
|1||World Health Statistics. Available from: http://www.who.int/whosis/whostat/EN_WHS08_Full.pdf. [last cited on 2008].|
|2||Emergency Department Visits for Adults in Community Hospitals from Selected States, 2005.AHRQ. Available from: http://www.medicalnewstoday.com (Chest Pain A Leading Reason For Hospital Emergency Department Visits) [last on 2008 Feb 28].|
|3||Cheaper Chest Pain Screening In Emergency Rooms Offered By New CT Technology. Available from: http://www.medicalnewstoday.com [last cited on 2008 May 31].|
|4||Prina LD, Decker WW, Weaver AL, High WA, Smars PA, Locke GR 3rd, et al. Outcome of patients with a final diagnosis of chest pain of undetermined origin admitted under the suspicion of acute coronary syndrome: a report from the Rochester Epidemiology Project. Ann Emerg Med 2003;43:59-67.|
|5||Klootwijk P, Hamm C. Acute coronary syndromes: diagnosis. Lancet 1999;353:10-5.|
|6||Kahn SE. The challenge of evaluating the patient with chest pain. Arch Pathol Lab Med 2000;124:1418-9.|
|7||Pell JP, Sirel JM, Marsden AK, Ford I, Cobbe SM. Effect of reducing ambulance response time on deaths from out of hospital cardiac arrest: cohort study. BMJ 2001;322:1385-8.|
|8||Vukmir RB. Survival from pre-hospital cardiac arrest is critically dependent upon response time. Resuscitation 2006; 69: 229-34|
|9||Harris T, Cook EF, Kannel W, Schatzkin A, Goldman L. Blood pressure experience and risk of cardiovascular disease in the elderly. Hypertension 1985;7:118-23.|
|10||Kannel WB, Gagnon DR, Cupples LA. Epidemiology of sudden coronary death: population at risk. Can J Cardiol 1990;6:439-44.|
|11||Jones DW, Chambless LE, Folsom AR, Heiss G, Hutchinson RG, Sharrett AR, et al. Risk factor of coronary heart disease in African Americans: the atherosclerosis risk in communities study, 1987-97. Arch Intern Med 2002;162:2565-71.|
|12||Lawlor DA, Ebrahim S, Davey Smith G. Sex matters: Secular and Geographical trends in sex differences in coronary heart disease mortality. BMJ 2001;323:541-5.|
|13||Jousilahti P, Vartiainen E, Tuomilehto J, Puska P. Sex, Age, Cardiovascular risk factors and coronary heart disease; A propspective follow up study of 14786 middle aged men and women in Finland. Circulation 1999;99:1165-72.|
|14||Wingard DL, Suarez L, Barrett-Connor E. The sex differential in mortality from all causes and ischemic heart disease. Am J Epidemiol 1983;117:165-72.|
|15||Hossain A, Khan HT. Risk factors of coronary Heart Disease. Indian Heart J 2007;59:147-51. |
|16||Witte DR, Grobbee DE, Bots ML, Hoes AW. A meta -analysis of excess cardiac mortality on Monday. Eur J Epidemiol 2005;20:401-6.|
|17||Weiner SG, Grossman SA. Cardiac markers in the low-risk chest pain patient. Intern Emerg Med 2006;1:223-7.|