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Abstract
Rapid and accurate triage of patients presenting with chest pain to an emergency department (ED) is critical to prevent ED overcrowding and unnecessary resource use in individuals at low risk of acute myocardial infarction (AMI) and to efficiently and effectively guide patients at high risk to definite therapy. The use of biomarkers for rule-out or rule-in of suspected AMI has evolved substantially over the last several decades. Previously well-established biomarkers have been replaced by cardiac troponin (cTn). High-sensitivity cTn (hs-cTn) assays represent the newest generation of cTn assays and offer tremendous advantages, including improved sensitivity and precision. Still, implementation of these assays in the United States lags behind several other areas of the world. Within this educational review, we discuss the evolution of biomarker testing for detection of myocardial injury, address the specifics of hs-cTn assays and their recommended use within triage algorithms, and highlight potential challenges in their use. Ultimately, we focus on implementation strategies for hs-cTn assays, as they are now clearly ready for prime time.
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Affiliation(s)
| | - L Kristin Newby
- Duke Clinical Research Institute, Durham, North Carolina, USA; ,
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Lee PY, Saad K, Hossain A, Lieu I, Allencherril J. Initial Evaluation and Management of Patients Presenting with Acute Chest Pain in the Emergency Department. Curr Cardiol Rep 2023; 25:1677-1686. [PMID: 37889421 DOI: 10.1007/s11886-023-01984-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE OF THE REVIEW To review the initial evaluation of chest pain in the emergency department (ED), with a focus on coronary artery disease (CAD) and acute coronary syndromes (ACS), using consensus statements from major cardiovascular disease organizations. RECENT FINDINGS Major cardiovascular organizations have released consensus statements on this topic, notably the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain and the 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department. Also, recent studies have evaluated the use of high sensitivity troponin (hs-cTn) to safely rule out myocardial infarction (MI), with the development of rule-out pathways designed to be utilized in the ED. This review highlights the comprehensive differential diagnoses of chest pain in the ED and urgent management of these etiologies, with a focus on cardiovascular etiologies. There exist a few rule-out pathways recommended by major cardiovascular organizations, notably the high-STEACS and the ESC 0/1 and 0/2 pathways that can safely and quickly discharge patients with low risk of MI.
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Affiliation(s)
- Paul Y Lee
- Department of Medicine, Rutgers New Jersey Medical School, 150 Bergen Street, UH I-248, Newark, NJ, 07101, USA.
| | - Kyrollos Saad
- Department of Medicine, Rutgers New Jersey Medical School, 150 Bergen Street, UH I-248, Newark, NJ, 07101, USA
| | - Afif Hossain
- Department of Cardiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Irene Lieu
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Joseph Allencherril
- Department of Medicine, Division of Cardiovascular Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
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Hill J, Yang EH, Lefebvre D, Doran S, Graham M, van Diepen S, Raizman JE, Tsui AK, Rowe BH. Effect of a High-Sensitivity Troponin I and Associated Diagnostic Protocol on Emergency Department Length of Stay: A Retrospective Cohort Study. CJC Open 2023; 5:925-933. [PMID: 38204856 PMCID: PMC10774082 DOI: 10.1016/j.cjco.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/11/2023] [Indexed: 01/12/2024] Open
Abstract
Background The objective of this study was to assess the introduction of a high-sensitivity troponin I (hs-TnI) assay and its associated accelerated protocol on emergency department (ED) length of stay (LOS) for patients presenting with chest pain, compared to an accelerated diagnostic protocol using conventional troponin (TnI) testing. Methods We conducted a retrospective cohort study of all adults with a primary presenting complaint of chest pain of cardiac origin and a Canadian Triage and Acuity Scale score of 2 or 3, between November 8, 2019 and November 9, 2021, to a tertiary-care urban Canadian ED. The primary outcome was ED LOS. Secondary outcomes included consultation proportions and major adverse cardiac events within 30 days of the index ED visit. Results A total of 2640 patients presenting with chest pain were included, with 1333 in the TnI group and 1307 in the hs-TnI group. Median ED LOS decreased significantly, from 392 minutes for the TnI group, and 371 minutes for the hs-TnI group (median difference = 21 minutes; 95% confidence interval: 5.3, 36.7). The numbers of consultations and admissions were not statistically different between study periods. The major adverse cardiac events outcomes did not change following the implementation of the hs-TnI test (13.6% vs 13.1%; P = 0.71). Conclusions The implementation of an accelerated chest pain protocol using an hs-TnI assay in a tertiary-care Canadian ED was associated with a modest reduction of LOS for all patients, and a substantial reduction of LOS for patients undergoing serial troponin testing. This strategy was safe, with no increase in adverse outcomes.
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Affiliation(s)
- Jesse Hill
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Esther H. Yang
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- The Alberta Strategy for Patient-Oriented Research Support Unit, Alberta Health Services (AHS), Edmonton, Alberta, Canada
| | - Dennis Lefebvre
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Shandra Doran
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle Graham
- Mazankowski Heart Institute, Division of Cardiology, Department of Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Sean van Diepen
- Mazankowski Heart Institute, Division of Cardiology, Department of Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Joshua E. Raizman
- Department of Laboratory Medicine and Pathology, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- Alberta Precision Laboratories (APL), Alberta Health Services (AHS), Edmonton, Alberta, Canada
| | - Albert K.Y. Tsui
- Department of Laboratory Medicine and Pathology, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- Alberta Precision Laboratories (APL), Alberta Health Services (AHS), Edmonton, Alberta, Canada
| | - Brian H. Rowe
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Heart Institute, Division of Cardiology, Department of Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
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Jaffe AS, Body R, Mills NL, Aakre KM, Collinson PO, Saenger A, Hammarsten O, Wereski R, Omland T, Sandoval Y, Ordonez-Llanos J, Apple FS. Single Troponin Measurement to Rule Out Myocardial Infarction: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:60-69. [PMID: 37380305 DOI: 10.1016/j.jacc.2023.04.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 06/30/2023]
Abstract
The term "single-sample rule-out" refers to the ability of very low concentrations of high-sensitivity cardiac troponin (hs-cTn) on presentation to exclude acute myocardial infarction with high clinical sensitivity and negative predictive value. Observational and randomized studies have confirmed this ability. Some guidelines endorse use of a concentration of hs-cTn at the assay's limit of detection, while other studies have validated the use of higher concentrations, allowing this approach to identify a greater proportion of patients at low risk. In most studies, at least 30% of patients can be triaged with this approach. The concentration of hs-cTn varies according to the assay used and sometimes how regulations permit reporting. It is clear that patients need to be at least 2 hours from the onset of symptoms being evaluated. Caution is warranted, particularly with older patients, women, and patients with underlying cardiac comorbidities.
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Affiliation(s)
- Allan S Jaffe
- Department of Cardiology, Mayo Clinic, Rochester, Minnesota, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Richard Body
- Emergency Department, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom; Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom; Healthcare Sciences Department, Manchester Metropolitan University, Manchester, United Kingdom
| | - Nicholas L Mills
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom; British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Kristin M Aakre
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway; Department of Heart Disease, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Paul O Collinson
- Department of Clinical Blood Sciences, St George's University Hospitals NHS Foundation Trust, London, United Kingdom; Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London, United Kingdom; St George's University of London, London, United Kingdom
| | - Amy Saenger
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center, Minneapolis, Minnesota, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ole Hammarsten
- Department of Clinical Chemistry and Transfusion Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ryan Wereski
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Jordi Ordonez-Llanos
- Clinical Biochemistry Department, Hospital de Sant Pau, Barcelona, Spain; Foundation for Biochemistry and Molecular Pathology, Barcelona, Spain
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center, Minneapolis, Minnesota, USA; Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
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Khera R, Kondamudi N, Liu M, Ayers C, Spatz ES, Rao S, Essien UR, Powell-Wiley TM, Nasir K, Das SR, Capers Q, Pandey A. Lifetime healthcare expenses across demographic and cardiovascular risk groups: The application of a novel modeling strategy in a large multiethnic cohort study. Am J Prev Cardiol 2023; 14:100493. [PMID: 37397263 PMCID: PMC10314135 DOI: 10.1016/j.ajpc.2023.100493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/16/2023] [Accepted: 03/21/2023] [Indexed: 04/03/2023] Open
Abstract
Objective To understand the burden of healthcare expenses over the lifetime of individuals and evaluate differences among those with cardiovascular risk factors and among disadvantaged groups based on race/ethnicity and sex. Methods We linked data from the longitudinal multiethnic Dallas Heart Study, which recruited participants between 2000 and 2002, with inpatient and outpatient claims from all hospitals in the Dallas-Fort Worth metroplex through December 2018, capturing encounter expenses. Race/ethnicity and sex, as well as five risk factors, hypertension, diabetes, hyperlipidemia, smoking, and overweight/obesity, were defined at cohort enrollment. For each individual, expenses were indexed to age and cumulated between 40 and 80 years of age. Lifetime expenses across exposures were evaluated as interactions in generalized additive models. Results A total of 2184 individuals (mean age, 45±10 years; 61% women, 53% Black) were followed between 2000 and 2018. The mean modeled lifetime cumulative healthcare expenses were $442,629 (IQR, $423,850 to $461,408). In models that included 5 risk factors, Black individuals had $21,306 higher lifetime healthcare spending compared with non-Black individuals (P < .001), and men had modestly higher expenses than women ($5987, P < .001). Across demographic groups, the presence of risk factors was associated with progressively higher lifetime expenses, with significant independent association of diabetes ($28,075, P < .001), overweight/obesity ($8816, P < .001), smoking ($3980, P = .009), and hypertension ($528, P = .02) with excess spending. Conclusion Our study suggests Black individuals have higher lifetime healthcare expenses, exaggerated by the substantially higher prevalence of risk factors, with differences emerging in older age.
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Affiliation(s)
- Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, United States
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, 60 College St, New Haven, CT, United States
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, United States
| | - Nitin Kondamudi
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Mengni Liu
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, United States
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, United States
| | - Colby Ayers
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Erica S Spatz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, United States
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, United States
| | - Shreya Rao
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, United States
| | - Utibe R Essien
- Department of Medicine, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA, United States
| | - Tiffany M Powell-Wiley
- Social Determinants of Obesity and Cardiovascular Risk Laboratory, Cardiovascular Branch, National Heart, Lung, and Blood Institute, NIH, 3131 Center Drive, Bethesda, MD, United States
- Intramural Research Program, National Institute on Minority Health and Health Disparities, NIH, 6707 Democracy Boulevard, Suite 800, Bethesda, MD, United States
| | - Khurram Nasir
- Department of Cardiology, Houston Methodist, 6565 Fannin St, Houston, TX, United States
| | - Sandeep R Das
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Quinn Capers
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
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Kontos MC, de Lemos JA, Deitelzweig SB, Diercks DB, Gore MO, Hess EP, McCarthy CP, McCord JK, Musey PI, Villines TC, Wright LJ. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2022; 80:1925-1960. [PMID: 36241466 PMCID: PMC10691881 DOI: 10.1016/j.jacc.2022.08.750] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Sandoval Y, Apple FS, Mahler SA, Body R, Collinson PO, Jaffe AS. High-Sensitivity Cardiac Troponin and the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guidelines for the Evaluation and Diagnosis of Acute Chest Pain. Circulation 2022; 146:569-581. [PMID: 35775423 DOI: 10.1161/circulationaha.122.059678] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The 2021 American Heart Association/American College of Cardiology/American Society of Echocardiography/American College of Chest Physicians/Society for Academic Emergency Medicine/Society of Cardiovascular Computed Tomography/Society for Cardiovascular Magnetic Resonance guidelines for the evaluation and diagnosis of acute chest pain make important recommendations that include the recognition of high-sensitivity cardiac troponin (hs-cTn) as the preferred biomarker, endorsement of 99th percentile upper reference limits to define myocardial injury, and the use of clinical decision pathways, as well as acknowledgment of the uniqueness of women and other patient subsets. Details on how to integrate hs-cTn into clinical practice are less extensively addressed. Clinicians should be aware of some of the analytical aspects related to hs-cTn assays regarding the limit of detection and the limit of quantitation and how they are used clinically, especially for the single sample strategy to rule out acute myocardial infarction. Likewise, it is important for clinicians to understand issues related to the derivation of the 99th percentile upper reference limit; the value of sex-specific 99th percentile upper reference limits; how to use changing concentrations (deltas) to facilitate diagnosis and risk stratification of patients with suspected acute coronary syndrome, including the differentiation of acute from chronic myocardial injury; and how to best integrate the use of hs-cTn with clinical decision pathways. With the use of hs-cTn, conditions such as type 2 myocardial infarction become more common, whereas others such as unstable angina become less frequent but still occur. Sections relating to these issues are included.
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Affiliation(s)
- Yader Sandoval
- Departments of Cardiovascular Diseases (Y.S., A.S.J.), Mayo Clinic, Rochester, MN
| | - Fred S Apple
- Departments of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis (F.S.A.)
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (S.A.M.)
| | - Richard Body
- Emergency Department, Manchester University NSH Foundation Trust, Manchester Academic Health Science Centre, UK (R.B.).,Division of Cardiovascular Sciences, The University of Manchester, UK (R.B.).,Healthcare Sciences Department, Manchester Metropolitan University, UK (R.B.)
| | - Paul O Collinson
- Department of Clinical Blood Sciences and Cardiology, St George's University Hospitals NHS Foundation Trust and St George's University of London, UK (P.O.C.)
| | - Allan S Jaffe
- Departments of Cardiovascular Diseases (Y.S., A.S.J.), Mayo Clinic, Rochester, MN.,Laboratory Medicine and Pathology (A.S.J.), Mayo Clinic, Rochester, MN
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Dawson LP, Smith K, Cullen L, Nehme Z, Lefkovits J, Taylor AJ, Stub D. Care Models for Acute Chest Pain That Improve Outcomes and Efficiency. J Am Coll Cardiol 2022; 79:2333-2348. [DOI: 10.1016/j.jacc.2022.03.380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
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Suh EH, Tichter AM, Ranard LS, Amaranto A, Chang BC, Huynh PA, Kratz A, Lee RJ, Rabbani LE, Sacco D, Einstein AJ. Impact of a rapid high‐sensitivity troponin pathway on patient flow in an urban emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12739. [PMID: 35571147 PMCID: PMC9071237 DOI: 10.1002/emp2.12739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/16/2022] [Accepted: 04/19/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Edward Hyun Suh
- Department of Emergency Medicine Columbia University Irving Medical Center New York City New York USA
| | | | - Lauren S. Ranard
- Division of Cardiology Columbia University Irving Medical Center New York City New York USA
| | - Andrew Amaranto
- Department of Emergency Medicine Hackensack School of Medicine Hackensack New Jersey USA
| | - Betty C. Chang
- Department of Emergency Medicine Columbia University Irving Medical Center New York City New York USA
| | - Phong Anh Huynh
- Department of Emergency Medicine Baylor College of Medicine Houston Texas USA
| | - Alexander Kratz
- Department of Pathology and Cell Biology Columbia University New York City New York USA
| | | | - LeRoy E. Rabbani
- Division of Cardiology Columbia University Irving Medical Center New York City New York USA
| | - Dana Sacco
- Department of Emergency Medicine Columbia University Irving Medical Center New York City New York USA
| | - Andrew J. Einstein
- Division of Cardiology Columbia University Irving Medical Center New York City New York USA
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Ola O, Akula A, De Michieli L, Dworak M, Crockford E, Lobo R, Rastas N, Knott JD, Mehta RA, Hodge DO, Grube E, Karturi S, Wohlrab S, Tak T, Cagin C, Gulati R, Jaffe AS, Sandoval Y. Clinical Impact of High-Sensitivity Cardiac Troponin T Implementation in the Community. J Am Coll Cardiol 2021; 77:3160-3170. [PMID: 34167641 DOI: 10.1016/j.jacc.2021.04.050] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Limited U.S. data exist regarding high-sensitivity cardiac troponin (cTn) implementation. OBJECTIVES This study sought to evaluate the impact of high-sensitivity cardiac troponin T (cTnT) implementation. METHODS Observational U.S. cohort study of emergency department (ED) patients undergoing measurement of cTnT during the transition from 4th (pre-implementation March 12, 2018, to September 11, 2018) to 5th generation (Gen) cTnT (post-implementation September 12, 2018, to March 11, 2019). Diagnoses were adjudicated following the Fourth Universal Definition of Myocardial Infarction (MI). Resources evaluated included length of stay, hospitalizations, and cardiac testing. RESULTS In this study, 3,536 unique patients were evaluated, including 2,069 and 2,491 ED encounters pre- and post-implementation. Compared with 4th Gen cTnT, encounters with ≥1 cTnT >99th percentile increased using 5th Gen cTnT (15% vs. 47%; p < 0.0001). Acute MI (3.3% vs. 8.1%; p < 0.0001) and myocardial injury (11% vs. 38%; p < 0.0001) increased. Although type 1 MIs increased (1.7% vs. 2.9%; p = 0.0097), the overall MI increase was largely due to more type 2 MIs (1.6% vs. 5.2%; p < 0.0001). Women were less likely than men to have MI using 4th Gen cTnT (2.3% vs. 4.4%; p = 0.008) but not 5th Gen cTnT (7.7% vs. 8.5%; p = 0.46). Overall length of stay and stress testing were reduced, and angiography was increased (all p < 0.05). Among those without cTnT increases, there were more ED discharges and a reduction in length of stay, echocardiography, and stress tests (all p < 0.05). CONCLUSIONS High-sensitivity cTnT implementation resulted in a marked increase in myocardial injury and MI, particularly in women and patients with type 2 MI. Despite this, except for angiography, overall resource use did not increase. Among those without cTnT increases, there were more ED discharges and fewer cardiac tests.
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Affiliation(s)
- Olatunde Ola
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin, USA; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, USA
| | - Ashok Akula
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin, USA; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, USA
| | - Laura De Michieli
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
| | - Marshall Dworak
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Erika Crockford
- Department of Family Medicine, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Ronstan Lobo
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas Rastas
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Jonathan D Knott
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ramila A Mehta
- Department of Health Sciences Research, Mayo College of Medicine, Rochester, Minnesota, USA
| | - David O Hodge
- Department of Health Sciences Research, Mayo College of Medicine, Jacksonville, Florida, USA
| | - Eric Grube
- Department of Emergency Medicine, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Swetha Karturi
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Scott Wohlrab
- Department of Laboratory Medicine and Pathology, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Tahir Tak
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Charles Cagin
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.
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11
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Ganguli I, Cui J, Thakore N, Orav EJ, Januzzi JL, Baugh CW, Sequist TD, Wasfy JH. Downstream Cascades of Care Following High-Sensitivity Troponin Test Implementation. J Am Coll Cardiol 2021; 77:3171-3179. [PMID: 34167642 DOI: 10.1016/j.jacc.2021.04.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with chest pain are often evaluated for acute myocardial infarction through troponin testing, which may prompt downstream services (cascades) of uncertain value. OBJECTIVES This study sought to determine the association of high-sensitivity cardiac troponin (hs-cTn) assay implementation with cascade events. METHODS Using electronic health record and billing data, this study examined patient-visits to 5 emergency departments from April 1, 2017, to April 1, 2019. Difference-in-differences analysis compared patient-visits for chest pain (n = 7,564) to patient-visits for other symptoms (n = 100,415) (irrespective of troponin testing) before and after hs-cTn assay implementation. Outcomes included presence of any cascade event potentially associated with an initial hs-cTn test (primary), individual cascade events, length of stay, and spending on cardiac services. RESULTS Following hs-cTn implementation, patients with chest pain had a 2.8% (95% confidence interval [CI]: 0.72% to 4.9%) net increase in experiencing any cascade event. They were more likely to have multiple troponin tests (10.5%; 95% CI: 9.0% to 12.0%) and electrocardiograms (7.1 per 100 patient-visits; 95% CI: 1.8 to 12.4). However, they received net fewer computed tomography scans (-1.5 per 100 patient-visits; 95% CI: -1.8 to -1.1), stress tests (-5.9 per 100 patient-visits; 95% CI: -6.5 to -5.3), and percutaneous coronary intervention (PCI) (-0.65 per 100 patient-visits; 95% CI: -1.01 to -0.30) and were less likely to receive cardiac medications, undergo cardiology evaluation (-3.5%; 95% CI: -4.5% to 2.6%), or be hospitalized (-5.8%; 95% CI: -7.7% to -3.8%). Patients with chest pain had lower net mean length of stay (-0.24 days; 95% CI: -0.32 to -0.16) but no net change in spending. CONCLUSIONS Hs-cTn assay implementation was associated with more net upfront tests yet fewer net stress tests, PCI, cardiology evaluations, and hospital admissions in patients with chest pain relative to patients with other symptoms.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts, USA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Jinghan Cui
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nitya Thakore
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - E John Orav
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - James L Januzzi
- Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher W Baugh
- Harvard Medical School, Boston, Massachusetts, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA. https://twitter.com/DrChrisBaugh
| | - Thomas D Sequist
- Harvard Medical School, Boston, Massachusetts, USA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Mass General Brigham, Boston, Massachusetts, USA. https://twitter.com/TomSequist
| | - Jason H Wasfy
- Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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12
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Fernández-Cisnal A, Valero E, García-Blas S, Pernias V, Pozo A, Carratalá A, González J, Noceda J, Miñana G, Núñez J, Sanchis J. Clinical History and Detectable Troponin Concentrations below the 99th Percentile for Risk Stratification of Patients with Chest Pain and First Normal Troponin. J Clin Med 2021; 10:jcm10081784. [PMID: 33923925 PMCID: PMC8073372 DOI: 10.3390/jcm10081784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 04/15/2021] [Accepted: 04/18/2021] [Indexed: 11/16/2022] Open
Abstract
Decision-making is challenging in patients with chest pain and normal high-sensitivity cardiac troponin T (hs-cTnT; <99th percentile; <14 ng/L) at hospital arrival. Most of these patients might be discharged early. We investigated clinical data and hs-cTnT concentrations for risk stratification. This is a retrospective study including 4476 consecutive patients presenting to the emergency department with chest pain and first normal hs-cTnT. The primary endpoint was one-year death or acute myocardial infarction, and the secondary endpoint added urgent revascularization. The number of primary and secondary endpoints was 173 (3.9%) and 252 (5.6%). Mean hs-cTnT concentrations were 6.9 ± 2.5 ng/L. Undetectable (<5 ng/L) hs-cTnT (n = 1847, 41%) had optimal negative predictive value (99.1%) but suboptimal sensitivity (90.2%) and discrimination accuracy (AUC = 0.664) for the primary endpoint. Multivariable analysis was used to identify the predictive clinical variables. The clinical model showed good discrimination accuracy (AUC = 0.810). The addition of undetectable hs-cTnT (≥ or <5 ng/L; HR, hazard ratio = 3.80; 95% CI, confidence interval 2.27–6.35; p = 0.00001) outperformed the clinical model alone (AUC = 0.836, p = 0.002 compared to the clinical model). Measurable hs-cTnT concentrations (between detection limit and 99th percentile; per 0.1 ng/L, HR = 1.13; CI 1.06–1.20; p = 0.0001) provided further predictive information (AUC = 0.844; p = 0.05 compared to the clinical plus undetectable hs-cTnT model). The results were reproducible for the secondary endpoint and 30-day events. Clinical assessment, undetectable hs-cTnT and measurable hs-cTnT concentrations must be considered for decision-making after a single negative hs-cTnT result in patients presenting to the emergency department with acute chest pain.
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Affiliation(s)
- Agustín Fernández-Cisnal
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Ernesto Valero
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Sergio García-Blas
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Vicente Pernias
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Adela Pozo
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Arturo Carratalá
- Clinical Biochemistry Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), 46010 València, Spain;
| | - Jessika González
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - José Noceda
- Emergency Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), 46010 València, Spain;
| | - Gema Miñana
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Julio Núñez
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Juan Sanchis
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
- Correspondence:
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13
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Bradley SM, Adusumalli S, Amin AP, Borden WB, Das SR, Downey WE, Ebinger JE, Gelbman J, Gluckman TJ, Goyal A, Gupta D, Khot UN, Levy AE, Mutharasan RK, Rush P, Strauss CE, Shreenivas S, Ho PM. The Cardiovascular Quality Improvement and Care Innovation Consortium: Inception of a Multicenter Collaborative to Improve Cardiovascular Care. Circ Cardiovasc Qual Outcomes 2021; 14:e006753. [PMID: 33430610 DOI: 10.1161/circoutcomes.120.006753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite decades of improvement in the quality and outcomes of cardiovascular care, significant gaps remain. Existing quality improvement strategies are often limited in scope to specific clinical conditions and episodic care. Health services and outcomes research is essential to inform gaps in care but rarely results in the development and implementation of care delivery solutions. Although individual health systems are engaged in projects to improve the quality of care delivery, these efforts often lack a robust study design or implementation evaluation that can inform generalizability and further dissemination. Aligning the work of health care systems and health services and outcomes researchers could serve as a strategy to overcome persisting gaps in cardiovascular quality and outcomes. We describe the inception of the Cardiovascular Quality Improvement and Care Innovation Consortium that seeks to rapidly improve cardiovascular care by (1) developing, implementing, and evaluating multicenter quality improvement projects using innovative care designs; (2) serving as a resource for quality improvement and care innovation partners; and (3) establishing a presence within existing quality improvement and care innovation structures. Success of the collaborative will be defined by projects that result in changes to care delivery with demonstrable impacts on the quality and outcomes of care across multiple health systems. Furthermore, insights gained from implementation of these projects across sites in Cardiovascular Quality Improvement and Care Innovation Consortium will inform and promote broad dissemination for greater impact.
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Affiliation(s)
| | - Steven M Bradley
- Healthcare Delivery Innovation Center, Minneapolis Heart Institute, MN (S.M.B., P.R., C.E.S.)
| | - Srinath Adusumalli
- Center for Healthcare Innovation, Hospital of the University of Pennsylvania, Philadelphia (S.A.)
| | - Amit P Amin
- Washington University School of Medicine, Barnes Jewish Hospital, St. Louis, MO (A.P.A.)
| | | | - Sandeep R Das
- University of Texas Southwestern Medical Center and Center for Innovation and Value at Parkland, Dallas (S.R.D.)
| | - William E Downey
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, NC (W.E.D.)
| | | | - Joy Gelbman
- New York Presbyterian Hospital, Weill Cornell Medicine (J.G.)
| | - Ty J Gluckman
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, Portland, OR (T.J.G.)
| | - Abhinav Goyal
- Emory Heart and Vascular Center and the Department of Medicine, Emory University School of Medicine (A.G., D.G.)
| | - Divya Gupta
- Emory Heart and Vascular Center and the Department of Medicine, Emory University School of Medicine (A.G., D.G.)
| | - Umesh N Khot
- Heart, Vascular and Thoracic Institute Center for Healthcare Delivery Innovation, Cleveland Clinic, OH (U.N.K.)
| | - Andrew E Levy
- University of Colorado School of Medicine, Aurora, CO (A.E.L.).,Denver Health and Hospital Authority, CO (A.E.L.)
| | | | - Pam Rush
- Healthcare Delivery Innovation Center, Minneapolis Heart Institute, MN (S.M.B., P.R., C.E.S.)
| | - Craig E Strauss
- Healthcare Delivery Innovation Center, Minneapolis Heart Institute, MN (S.M.B., P.R., C.E.S.)
| | - Satya Shreenivas
- Lindner Center for Research, The Christ Hospital, Cincinnati, OH (S.S.)
| | - P Michael Ho
- University of Colorado School of Medicine, Aurora (P.M.H.).,VA Eastern Colorado Health Care System, Aurora (P.M.H.)
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