Health care utilization among adenosine-sensitive supraventricular tachycardia patients presenting to the emergency department

The Role of Troponin Testing in Patients with Supraventricular Tachycardia, Systematic Review and Meta-Analysis

BACKGROUND

Supraventricular tachycardia (SVT) is commonly evaluated in the emergency department (ED). While troponin has been shown to be elevated in SVT, its usefulness for predicting coronary artery disease and future adverse cardiovascular outcomes has not been shown.

OBJECTIVES

We aimed to evaluate the prognostic utility of troponin measurement as part of SVT management in the ED.

METHODS

We performed a literature search in the PubMed and Scopus databases from inception to August 30, 2023, including all studies reporting troponin measurements in adult patients (age > 18 years) presenting to the ED with supraventricular tachycardia. The primary outcome of interest for this study was the prevalence of elevated troponin in patients with SVT. Secondary outcomes included the prevalence of major adverse cardiac events (MACE) and additional cardiac testing with significant findings.

RESULTS

We included 7 studies (500 patients) in our analysis. Six studies reported the number of patients with SVT and elevated troponin, with a pooled prevalence of 46% (95% CI 27-66%, I2 93%). The pooled prevalence of all MACE in our study was 6% (95% CI 1-25%), while the prevalence for MACE among patients with elevated serum troponin levels was 11% (95% CI 4-27%).

CONCLUSIONS

Troponin levels are frequently ordered for ED patients with SVT and are often elevated. However, this review suggests that they have low prognostic value in predicting MACE.

Health care centre and emergency department utilization by patients with episodes of tachycardia

BACKGROUND

Outpatients seek to visit health care facilities for episodes of tachycardia-related signs and symptoms. The challenge for physicians is to balance a proper initial assessment and avoid overlooking a possible arrhythmia. This common clinical situation affects individuals and health care utilization, and effective management may substantially affect health care resources. This study aimed to explore health care utilization for outpatients with episodes of tachycardia visiting health care centres (HCCs) and/or emergency departments (EDs).

METHOD

This retrospective study used data of adult outpatients (≥ 18 years) who were assessed by a physician as having a specific or nonspecific diagnosis of arrhythmia between 2017 and 2018, and data were retrieved from medical records and a regional registry database. Data was analysed with appropriate statistical analyses to identify disparities between sex, age and terms of search pattern for each health care facility. Analysis of variance was used to test disparities between the sexes, and one-factor ANOVA was used for the incidence of missed arrhythmias.

RESULTS

A total of 2719 visits with 2373 outpatients were included in the study. The result showed a significant difference in the total number of visits (n = 2719) between female and male patients (68% vs. 32%, p < .001). In the 60-69- and 70-79-year age groups, females had significantly higher frequencies of visits than males (p = .018). A significant difference was also observed between sexes in terms of which health care facility they tended to visit (p < .001). Ninety-five percent of the outpatients visiting EDs were hospitalized. When estimating the incidence of missed arrhythmias (diagnoses) in relation to assessments, the results showed a 5% missed diagnosis involving potential atrioventricular nodal re-entry tachycardia and atrioventricular re-entry tachycardia. Moreover, the referral rate was low, especially from HCCs to cardiologists.

CONCLUSIONS

This study shows a significant difference in total visits in HCCs and/or EDs by patients of different sexes and indicates the need for improved care for outpatients with episodes of tachycardia. Sex- and age-related differences must be addressed with an aim of providing equal care. Finally, the low rate of referral from HCCs to cardiologists compared to the high proportion of hospitalizations from EDs, deserves further investigation.

Trends in health care resource use and expenditures in patients with newly diagnosed paroxysmal supraventricular tachycardia in the United States

BACKGROUND

Few data are available on the temporal patterns of health resource utilization (HRU) and expenditures around paroxysmal supraventricular tachycardia (PSVT) diagnosis. This study assessed the longitudinal trends in HRU and expenditures in the 3 years preceding and subsequent to PSVT diagnosis.

METHODS

Adult patients (age 18-65 years) with newly diagnosed PSVT were identified using administrative claims from the IBM MarketScan Research Database between January 1, 2008 and December 31, 2016 and propensity-score matched (1:1) with non-PSVT controls.

RESULTS

Among the 12,305 PSVT patients compared with matched controls, PSVT was associated with statistically significant higher annual rates of emergency department visits, physician office visits, inpatient hospitalizations, and diagnostic testing. HRU increased in the years preceding PSVT diagnosis, reaching its peak in the year following PSVT diagnosis. Over the 6-year follow-up period, PSVT was associated with higher mean annual per patient expenditures ($12,665) compared to matched controls ($6,004; P < .001). Upon diagnosis of PSVT, the mean expenditures per PSVT patient doubled from $11,714 in the year immediately preceding index diagnosis to $23,335 in the first postdiagnosis year. Inpatient services, diagnostic testing, and ablation procedures were the principle drivers of higher mean expenditures in the first year post-PSVT diagnosis versus the year prior to PSVT diagnosis.

CONCLUSIONS

PSVT presents a substantial economic burden to health care systems. The annual expenditure per PSVT patient is within the range previously reported for atrial fibrillation. The increased HRU and expenditures in the year following diagnosis, which do not return to baseline, suggest a potential gap in non-interventional, long-term PSVT management.

Unmasking Adenosine: The Purinergic Signalling Molecule Critical to Arrhythmia Pathophysiology and Management

Adenosine was identified in 1929 and immediately recognised as having a potential role in therapy for arrhythmia because of its negative chronotropic and dromotropic effects. Adenosine entered mainstream use in the 1980s as a highly effective agent for the termination of supraventricular tachycardia (SVT) involving the atrioventricular node, as well as for its ability to unmask the underlying rhythm in other SVTs. Adenosine has subsequently been found to have applications in interventional electrophysiology. While considered a safe agent because of its short half-life, adenosine may provoke arrhythmias in the form of AF, bradyarrhythmia and ventricular tachyarrhythmia. Adenosine is also associated with bronchospasm, although this may reflect irritant-induced dyspnoea rather than true obstruction. Adenosine is linked to numerous pathologies relevant to arrhythmia predisposition, including heart failure, obesity, ischaemia and the ageing process itself. This article examines 90 years of experience with adenosine in the light of new European Society of Cardiology guidelines for the management of SVT.

Healthcare Resource Use and Expenditures in Patients Newly Diagnosed With Paroxysmal Supraventricular Tachycardia

Information on paroxysmal supraventricular tachycardia (PSVT) patient characteristics and the associated economic burden of the disease is limited. Therefore, we sought to characterize newly diagnosed PSVT patients and quantify their healthcare resource use and expenditures. We used enrollment, demographic, and claims data from IBM MarketScan Research Database and Medicare Limited Data Set (LDS) to identify patients newly diagnosed with PSVT (ICD-9: 427.0; ICD-10: I47.1) from 10/1/2012 to 9/30/2016. Patients were required to be observable 1-year before and after index diagnosis. Patients were stratified by age (<65 years and ≥65 years), and propensity-matched to patients without PSVT. Expenditures and healthcare resource use were analyzed 1 year before and 1-year following index diagnosis. Among 49,316 patients <65 years and 23,954 patients ≥65 years, most were female (64% and 63%, respectively). Compared with matched controls, all PSVT patients had significantly more emergency department visits pre- and postdiagnosis, and more hospitalizations following diagnosis. Mean annual per patient expenditures paid by insurers were significantly higher in the year post-PSVT diagnosis, tripling for patients <65 years ($9,028 to $29,867) and nearly doubling for patients ≥65 years ($10,867 to $20,143). Spending for PSVT services accounted for 43% and 33% of the increase in expenditures in these patient-groups, respectively. Few patients had an ablation within 1 year of diagnosis, although ablations were more frequent in patients age <65 years (13% vs 3%). In conclusion, PSVT imposes a substantial economic burden, with increases in expenditures following initial diagnosis in both younger (<65 years) and older (≥65 years) patients who are not accounted for by cardiac ablation spending alone.

Assessment of the Utility of Ordering a Troponin in Low- and Intermediate-Risk Patients Presenting to the Emergency Department with Supraventricular Tachycardia: A Retrospective Chart Review

BACKGROUND

A troponin assay is commonly sent for patients presenting to emergency departments (EDs) with supraventricular tachycardia (SVT). Multiple studies suggest that elevated troponin levels do not predict coronary artery disease in these patients. Patients with elevated troponins are more likely to have additional cardiac testing, which can lead to increased health care costs and unnecessary invasive procedures.

OBJECTIVE

Our objective was to evaluate low- to intermediate-risk patients (HEART [history, electrocardiography, age, risk factors and troponin] Score 1-6) presenting to the ED with SVT. Our hypothesis was that an elevated troponin would not predict major adverse cardiac events (MACE), but would be associated with increased hospital admission rates and lengths of stay.

METHODS

This was a retrospective cohort study of adult patients who presented with SVT to a large, urban, academic hospital ED over 4 years who had a troponin result. A total of 46 patients were included in the study.

RESULTS

Patients with a positive troponin (>0.05 ng/mL) had a hospital admission rate of 86% versus 21% for patients with negative troponin (p = 0.006); rate of cardiology consult of 86% versus 21% (p < 0.001); and a mean total length of stay of 4157 min versus 1347 min (p = 0.04). At 3 months, none of the patients with a positive troponin had an MACE, death from any cause, or positive results of cardiac testing.

CONCLUSIONS

Patients with a positive troponin result had significantly more admissions, cardiology consults, and longer hospital stays. These patients did not have an increased prevalence of MACE.