The ACI time-insensitive predictive instrument (ACI-TIPI) represents the next generation of ACI predictive models developed by Selker and colleagues (62,63). The ACI-TIPI, like the original ACI predictive instrument (64,65), provides the ED physician with the 0-100% probability that a given patient truly has ACI to supplement the ED triage decision. The variables used for the ACI-TIPI are (i) age; (ii) sex; (iii) the presence or absence of chest pain or pressure or left arm pain; (iv) whether chest pain or pressure is

Table 5 ECG Exercise Stress Test

ED diagnostic performance ED clinical impact

Quality Accuracy Quality evidence (max = + + +) of evidence Impact

the patient's most important presenting symptom; (v) the presence or absence of ECG Q waves; (vi) the presence and degree of ECG ST-segment elevation or depression; and (vii) the presence and degree of ECG T-wave elevation or inversion. Its diagnostic performance has been tested in large studies that included ED (62,66) and EMS (67) patients and has been demonstrated to be diagnostically equivalent to the earlier version (62), except for a slightly higher sensitivity for AMI. Thus, it should be comparable to the original ACI predictive instrument (62), with two advantages for clinical use. First, its incorporation into the conventional computerized electrocardiograph allows direct measurement of details of the ECG waveform without the need for physician interpretation, with automatic printing of the ACI probability on the ECG header (Fig. 1). Second, its "time-insensitivity" makes it valid for retrospective review and assessment of care as well as for real-time ED clinical care.

Fig. 1. ACI-TIPI

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