Transcript Emergency Department Triage and Evaluation of the Patient with
Emergency Department Triage and Evaluation of the Patient with Chest Pain
Department of Emergency Medicine
University of Pennsylvania Health System
Judd E. Hollander, MD Professor, Clinical Research Director Department of Emergency Medicine University of Pennsylvania
ED Visits
130,000,000 visits annually 3,000,000 likely noncardiac sent home 8,000,000 chest pain 40,000 MIs 5,000,000 suspected or actual cardiac
Goals of Triage
Identify patients with AMI
Identify patients with unstable angina
Identify patients at high risk of cardiovascular complications
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resource utilization in hospital
•
CCU vs. monitored vs. floor beds
Identify patients safe for ED release
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need for treatment
Your Risk Tolerance…
5%
2%
1%
Why Do More?
The missed AMI rate is inversely proportional to the admission rate for ED chest pain patients
Kontos MC & Jesse RL. Am J Cardiol 2000;85:32B-39B
Outline
Gut Impression
Clinical Parameters
Electrocardiography
Cardiac Markers
Disposition with or without Telemetry
Prior Testing
Acute Cardiac Imaging
Initial Impression = “Noncardiac Pain” Patients with initial emergency impression of “noncardiac chest pain” 2,992
itrACS 17,737 patients enrolled Conclusion: Even patients thought to have noncardiac pain can suffer adverse cardiac events, especially if risk factors are present 2.8% had adverse cardiac events (infarction, revascularization, or death) within 30 days 85
Miller CD, et al. Ann Emerg Med. 2004;44:565.
Clinical Parameters
Department of Emergency Medicine
University of Pennsylvania Health System
Clinical Parameters
Identifying low risk patients
Lee et al. 1985 Arch IM 1985;145:65.
596 ED patients
MI USA Other
Clinical Parameters
MI USA Other
Lee et al. Arch IM 1985;145:65.
Clinical Parameters
MI USA Other
Lee et al. Arch IM 1985;145:65.
Clinical Parameters: Risk Factors
Risk factors do not affect likelihood of AMI
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1700 patients
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Cholesterol
• •
Hypertension Family history
Slight increase in risk in men only
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Diabetes mellitus
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2.4 (1.2 - 4.8)
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Family history
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2.1 (1.4 - 3.3)
Jayes et al. J Clin Epidemiol 1992;45:621.
Clinical Parameters: Risk Factors
CRF Burden and ACS (AUC=0.591)
Han et al. Ann Emerg Med 2007;49:145.
Costochondritis
122 patients evaluated for ARA definition of costochondritis
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pain caused by pressure enough to blanch skin
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whether or not it precisely reproduced CC
6% of patients had AMI
Disla et al. Arch Intern Med. 1994;154:2466.
“Clear Cut Alt Diagnosis”
Of 1995 pts, 599 pts had an Alt Dx
Presence of an Alternative Diagnosis
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Reduced the likelihood of 30 day death, MI, revascularization
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8.8 to 4.0%
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Risk ratio, 0.45 (95% confidence interval, 0.29-0.69) 4% risk of 30 death, MI, revascularization is not low enough to allow safe release from the ED
Hollander et al. Acad Emerg Med., 2007:14:215
Clinical Parameters
History and physical examination are not real helpful in identifying patients with AMI.
Electrocardiograms
Lee et al. 1985 Arch IM 1985;145:65.
Electrocardiograms
Patients admitted to CCU
Morbidity and mortality related to ECG
Slater et al. Am J Cardiol 1987;60:766.
Electrocardiograms
Patients admitted to CCU (n=469) 25
%
20 46 15 Neg ECG n=167 Pos ECG n=302 10 5 0 0
VF
18 18 1
Sus VT
4
NS VT
1
Cond Dist
Brush et al. NEJM 1985;312:1137.
Late Electrocardiograms
Does the NPV of the ECG increase with time?
Normal ECG over time Symptom duration 0-3 hrs 3-6 hrs 6-9 hrs 9-12 hrs NPV 93% 93% 93% 94%
Singer et al. Annals EM 1997;29:575.
Combination of Clinical Parameters and Electrocardiography
Department of Emergency Medicine
University of Pennsylvania Health System
Chest Pain Study Group
Chest Pain Study Group Risk
Heavily dependent on ECG
No group of patients at less than 1% risk of AMI
Cardiac risk factors not useful
Defined high and low risk as 7% cut-off
May be useful for triage
No patients deemed safe for release from ED
Lee et al. NEJM 1991;324:1239.
Young Patients-Validated
Of 4492 visits for CP, 1023 visits were pts<40 yrs If no cardiac risk factors and no prior cardiac history (n=436) – 6 USA (1.4%) initial diagnosis – 2 AMI (0.5%) during index visit – 30 days – no death, AMI, PCI or CABG (0.5%, 95% CI, 0-1.1%). Normal ECG and no prior cardiac history (n=593) – 6 USA (1%) initial diagnosis – 1 AMI (0.17%) during index visit – no AMI, PCI or CV deaths during follow up (0%, 95% CI, 0-0.5%).
– Risk of 30 day adverse events 0.3 (0-0.8%) No prior history, no risks, normal ECG (n=299) – 3 USA (1%), no AMI – No 30 day adverse events (0%; 0-1%) Add initial marker – Only 1 ACS, nothing else for any of the groups (0.14%; 0.1-0.2%)
Marsan et al. AEM 2005;128:26.
Clinical Parameters: Risk Factors
.763 .602
.518
CRF Burden and ACS
Han et al. Ann Emerg Med 2007;49:145.
TIMI Risk Score
TIMI Risk Score for UA
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Age > 65
– –
3 or more CRF’s Known CAD > 50%
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ST segment changes on ECG 2 or more anginal events in past 24 hours
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ASA use within 7 days prior Elevated cardiac markers
TIMI Risk in the ED
# of TIMI Risk Factors
Chase, et al. Ann Emerg Med. 2006:48:252
High Sensitivity Cardiac Markers
Department of Emergency Medicine
University of Pennsylvania Health System
TnI-Ultra: 60d AMI/CV Death
371 patients with symptoms suggestive of ACS
cTnI <0.006
0.006-0.04
>0.04-0.10
>0.10
N 108 (29%) 174 (47%) 38 (10%) 51 (14%) # Events 2 11 9 28 Rate, % 1.9
6.4
24.1
55.1
RR 3.3
13.0
34.9
Apple et al. Clin Chem 2008;54:723
High Sensitivity Troponin
718 patients with potential AMI; 123 had AMI Presentation
Sens = 84-95%
Spec = 80-84%
Reichlin et al. NEJM 2009;361:858
High Sensitivity Troponin
1818 patients with potential AMI; 413 had AMI Presentation
Sens = 90%
Spec = 90% Within 3 hours
Sens = 100%
Keller et al. NEJM 2009;361:868
hsTnI in UA: Protect TIMI 30
Wilson et al. Am Heart J 2009;158:386
2009
100 potential ACS patients 35% discharged 65% admitted 85% bogus 15% real
The Future
100 potential ACS patients 35% discharged 65% admitted
90% Sens 80% Spec 35 discharged 71 discharged
8 44 85% bogus 15% real
55 not sick (IM) 10 real (cards) 19 (trop FP) 9-10 real
Stuck with Admissions?
Department of Emergency Medicine
University of Pennsylvania Health System
Evidence Based Work Arounds
Observation Unit Rationale
Cannot identify a group of clinical and/or ECG variables that identifies patients at such low risk for AMI/complications that they can be safely released from the ED
No single test sufficiently excludes risk of AMI or complications
Attempts to shorten evaluation
Telemetry
Hollander et al – Prospective study
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AJC 1997;110
460 CP pts with normal or nonspecific ECG’s
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4 CV complications (1 VT/VF post op; 1 SVT in CHF pt; 2 sinus pauses of 2.4 and 4 seconds without intervention)
Schull et al – Retrospective study
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AEM 2000;7:647
8932 pts admitted to tele ward
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20 cardiac arrest
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9 detected by monitor
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3 survival to discharge
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1 definitely detected by monitor; 1 detected by neighbor when he fell to floor; 1 no record of when it began on monitor (?detected)
Telemetry: HUP Data
Total Patients (n=3686) ICU/cath lab 424 (12%) Telemetry 1748 (47%) Floor 110 (3%) Goldman < 7 1157 (66%) Goldman > 7 591 (34%) Home 1383 (38%) Markers positive 130 (11%) Markers negative 1027 (89%)
Hollander et al. Annals EM 2004;43:71.
Telemetry: HUP Data
Sustained VT/VF
Bradydysrrhythmias requiring treatment 0% (95 CI, 0-0.3%)
Preventable CV Death
0% (95
CI
, 0-0.3%)
Hollander et al. Annals EM 2004;43:71.
Telemetry: HUP Outcomes
Initial Hospitalization Myocardial infarction Unstable angina Percutaneous intervention Stent Placement CABG Death No. Percent 15 1.5% 121 11 10 4 2 12% 1.1% 1.0% 0.4% 0.2%
Hollander et al. Annals EM 2004;43:71.
It’s Not My Heart I Had a Test Already Department of Emergency Medicine
University of Pennsylvania Health System
Stress Tests and ED Disposition
92%
100 90 80 70 60 50 40 30 20 10 0
72% 67%
Abnormal Normal None Disposition (% admitted)
Nerenberg et al. AmJEM 2007;25:39.
Stress Tests & 30-Day Outcomes
12 10 8 6 4
10.1% 4.8% 5.2%
2 0 Abnormal Normal None 30-Day Adverse Cardiovascular Outcomes (%)
Nerenberg et al. AmJEM 2007;25:39.
Maybe It Keeps Them Away?
Shaver et al demonstrated that patients evaluated with stress testing were just as likely to:
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Return to the ED (39 vs 40%) Be admitted to the hospital (29 vs 32%)
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Receive cardiac catheterization (12.5 vs 10.4%)
Shaver et al. Acad EM 2005;11:1272
Better Than Stress Testing
deFillipi et al found that compared with patients who were evaluated with stress testing, patients evaluated with coronary angiography (CA) had:
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Fewer repeat ED visits
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Fewer hospitalizations Higher satisfaction rates Better understanding of their disease
deFillipi et al. JACC 2001
Acute Cardiac Imaging (in the ED) Department of Emergency Medicine
University of Pennsylvania Health System
Echocardiography
Detects wall motion abnormality
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sensitivity moderate high
Cannot distinguish old from new
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many “false positives”
May miss non-Q wave AMI
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usually small infarcts
Never compared to physician judgment or cardiac markers to assess incremental value
Sestamibi Imaging
338 ED chest pain patients with normal scans
– – –
None had a cardiac death during 1 year period None had an MI 7 required coronary revascularization
100 abnormal scans
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7 AMI 30 revascularization within one year
Tatum et al. Annals EM 1997;29:116.
Sestamibi Imaging
Relative risks of abnormal scans
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AMI 50 (2.8-890)
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Revascularization 14.5 (6-34) Death by 1 year 30 (1.6-570)
Sensitivity for AMI
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100% (64-100)
Specificity
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78% (74-82)
Tatum et al. Annals EM 1997;29:116.
ER Assessment of Sestamibi (ERASE)
RCT of 2475 ED chest pain patients with normal or nondiagnostic ECGs
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Usual ED evaluation (n=1260)
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Usual evaluation & resting MPI (n= 1215)
Primary outcome
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Appropriateness of initial triage decision
Udelson JE et al. JAMA. 2002;288:2693
ERASE
Sensitivity for MI and acute ischemia were not significantly different
Patients in the acute MPI arm had a significantly lower hospitalization rate
Costs reduced in the MPI arm by an average of $70/patient 100 75 50 25 97 NS 96 0 NS 83 81 MPI Standard P<.01
42 52 MI ACS Admit
Udelson JE et al. JAMA. 2002;288:2693
Coronary CTA Accuracy
Correlation with cardiac catheterization Study Janne d’Othee Janne d’Othee Heuschmid Weustnik Scheffel Scanner All 64 slice Dual source Dual source Dual source Sensitivity 95% 98% 96% 99% 96% Specificity 85% 91% 87% 87% 98%
Coronary CTA Prognosis
Meta-analysis 9592 patients Median f/u
20 months MACE
Sensitivity = 99%
LR - = 0.008
Hulton et al. JACC 2011:57:1237
No / noncritical disease
Hollander et al.
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100% NPV for D/AMI/revasc in 525 patients at 30 days
Hoffman et al.
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100% NPV for ACS in 73 pts over 5 months
Rubinshtein et al.
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100% NPV for 35 pts over 15 months
Pundziate et al.
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100% NPV for 20 pts over 13 months
No / noncritical disease
Goldstein et al.
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100% NPV for D/AMI/revasc in 67 patients at 30 days
Hoffman et al. (ROMICAT)
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Any plaque
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100% NPV for ACS/events in 183 pts over 6 months
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Stenosis < 50%
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98% NPV for ACS/events in 300 pts over 6 months
CT Coronary Angiography
Largest cohort study
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525 of 568 patients with negative CTA
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30 day follow-up No cardiac deaths (95% CI, 0-0.8%)
No AMI (95% CI, 0-0.8%) No revascularization (95% CI, 0-0.8%)
Hollander et al Ann EM 2009;53:295.
No stenosis or maximal stenosis < 50% (n=508) None 473 Stress 32 Cath 3
-
32 0
+ -
3
+
0 All CTA (n=568) CTA with contrast injection (n=562) Ca>400, no contrast injection (n=6) Maximal stenosis 50-69% (n=41) None 18 Stress 21
3
Cath 5
-
16 5
+
0
-
50-69% 3*
+
1 Maximal stenosis >70% (n=13)
5
None 3 Stress 5
1
Cath 6 2
+
3 0
-
50-69% 4
+
2
CT Coronary Angiography
RCT of CCTA v MPI post CDU (n=197)
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Normal CCTA discharged home (75%)
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9 with severe disease to catheterization
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Intermediate disease to stress test
CCTA reduced LOS (3.4 v 15.0 hours)
CCTA reduced costs ($1586 v $1872)
Re-evaluation of chest pain (2% v 7%)
Goldstein et al JACC 2007;49:863-871
CT STAT
Time to Diagnosis ED Cost Death within 6 months AMI within 6 months ED revisit, cardiac Rehospitalization, cards Normal test MACE with nl test CCTA (n=361) 7.9 hrs $2137 0 1 (0.3%) 2 (0.6%) 0 82% 2/268 (0.8%) MPI (n=338) 6.2 hrs $3458 0 5 (1.5%) 4 (1.3%) 0 90% 1/266 (0.4%)
Goldstein et al . JACC 2011;58:1414-22
Main Outcomes: Efficacy
CTA (N=98) Obs/CTA (N=102) Obs/Stress (N=154) Tele (N=289) $4154 Total Facility Cost $ (IQR) 1240 (723-1943) 2318 (2000-3041) LOS hours (IQR) 8.1 (5.9-13.7) 20.9 (15.1-26.5) 4024 (3322-4751) 26.2 (21.3-32.1) 2913 (1713-5592) 30.2 (24.0-73.1)
Chang et al. AEM 2008;15:649.
Main Outcomes: Safety
% CAD % Death/MI CTA (N=98) 5.1 (1.7-11.5) 0 (0-3.7) % Rehosp 0 (0.0-4.0) Obs/CTA (N=102) 5.9 (2.2-12.4) 0 (0-3.6) 3.2
(0.7-9.0) Obs/Stress (N=154) 5.8 (2.7-10.8) 0.7 (0.1-3.6) Tele (N=289) 6.6 (4.0-10.1) 3.1 (1.4-5.8) 2.3
(.06-12.0) 12.2
(8.5-16.7)
Chang et al. AEM 2008;15:649.
Fagan’s Nomogram for MACE
Hulton et al. JACC 2011:57:1237
CT Coronary Angiography
Volume rendered (VR) LAO view: Normal LAD and diagonal branches VR images provide an overview of the coronary arteries but can not be used on their own to exclude stenosis.
CT Coronary Angiography
Thin-slab MIP (maximum intensity projection): No stenosis in proximal LAD, circumflex and ramus medianus (RM) arteries.
CT Coronary Angiography
L Main: Calcified plaque with 50% stenosis of the left main LAD: Mixed calcified and noncalcified plaque resulting in 70% stenosis Diagonal: mild stenosis LCx: Patent
CT Coronary Angiography
Low density noncalcified plaque (arrow) causing >50% stenosis of the proximal right coronary artery.
CT Coronary Angiography
Severe RCA lesion
ACRIN
Randomized 2:1 to Coronary CTA Coronary CTA group
Coronary CTA
Clinical bloods (c/w guidelines) at time 0 & 90-180 minutes Banked bloods at T0, 90-180 and 6 hours Dispo per physicians Traditional care group
Anything but coronary CTA
Banked bloods at T0, 90-180 and 6 hours Dispo per physicians Results March 26 at ACC
ROMICAT 2 – March 27
Putting It Together
Department of Emergency Medicine
University of Pennsylvania Health System
Triage
Clinical Presentation
ECG Past history
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CAD Available technology
Required medications
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Fibrinolytics
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IV nitrates Heparin
Triage
Risk stratification
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TIMI Risk Score
– – – –
HEART Score GRACE or PURSUIT Lee and Goldman algorithm Clinical impression
Adjunctive Testing
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Markers
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Imaging
Triage
High risk patients
– – – – – – –
ECG abnormalities Heart failure Dysrrhythmias Unstable vital signs Need for IV drips Positive markers or MPI scans in the ED Positive CCTA with good story
Admit to Cardiac Care Unit
Triage
Lowest risk patients
– – – – –
Young patients Normal electrocardiograms Low risk story TIMI Score <3 Normal markers and sestamibi scans, if done Triage to
– – –
Observation unit Nonmonitored beds Home if lowest possible risk
• •
Normal CCTA goes home individual and institutional cut-off for misses
Triage
Intermediate Risk Patients
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Equivocal stories
– – – –
Abnormal but not diagnostic ECG’s TIMI Score > 3 Markers normal or slightly elevated Scans with old abnormalities (CAD)
Most should be admitted to monitored beds
Unstable Angina
Distinguish real unstable angina from need to “rule out” AMI
Single atypical episode of chest pain
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“rule out MI” unstable angina?
Summary
ACS versus anything else for dispo/triage
CTA to allow discharge
AMI is ANY elevation in markers above normal
STEMI or NSTEMI drive treatment
Words of wisdom? (without evidence)
Short cuts to “r/o MI”
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90 minute to 3 hour “rule outs”
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Rising or delta cardiac markers
Incidental abnormal ECG’s
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Always make referral
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QTc intervals Admission diagnosis also should include
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“rule out life threatening conditions” Stable angina
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Whatever it is – it is stable for outpt evaluation The ROS curse