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McMahon BJ, Shrestha P, Thode HC, Morley EJ, Rao B, Tawfik GA, Adhiyaman A, Devitt C, Godbole N, Pizzuti J, Shah K, Willems B, McKenna P, Singer AJ. Impact of HEART Score Decision Aid on Coronary Computed Tomography Angiography Utilization and Diagnostic Yield in the Emergency Department. Crit Pathw Cardiol 2023; 22:45-49. [PMID: 37220658 DOI: 10.1097/hpc.0000000000000318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE Emergency physicians are challenged to efficiently and reliably risk stratify patients presenting with chest pain (CP) to optimize diagnostic testing and avoid unnecessary hospital admissions. The objective of our study was to evaluate the impact of a HEART score-based decision aid (HSDA) integrated in the electronic health record on coronary computed tomography angiography (CCTA) utilization and diagnostic yield in adult emergency department (ED) CP patients with suspected acute coronary syndrome. METHODS We conducted a before and after study to determine whether implementation of a mandatory computerized HSDA would reduce CCTA utilization in ED CP patients and improve the diagnostic yield of obstructive coronary artery disease (CAD) (≥50%). We included all adult ED CP patients with suspected acute coronary syndrome during the first 6 months of 2018 (before) and 2020 (after) at a large academic center. CCTA utilization and obstructive CAD yield were compared in patients before and after implementing the HSDA using χ2 tests. Secondarily, we assessed the association of HEART scores and CCTA results. RESULTS Of the 3095 CP patients during the before study period, 733 underwent CCTA. Of the 2692 CP patients during the after study period, 339 underwent CCTA. CCTA utilization before and after HSDA was 23.4% [95% confidence interval (95% CI), 22.2-25.2] and 12.6% (95% CI, 11.4-13.0), respectively; mean difference was 11.1% (95% CI, 0.9-13.0). Among 1072 patients undergoing CCTA, mean (SD) age and percent females before versus after HSDA were 54 (11) versus 56 (11) years and 50% versus 49%, respectively. We included 1014 patients (686 before and 328 after) for the yield analysis. Obstructive CAD was present in 15% (95% CI, 12.7-17.9) and 20.1% (95% CI, 16.1-24.7) before and after HSDA, respectively; mean difference was 4.9% (95% CI, 0.1-10.1). CONCLUSIONS Implementation of a mandatory electronic health record HSDA aid reduced ED CCTA utilization by half and improved the diagnostic yield.
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Affiliation(s)
- Brian J McMahon
- From the Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
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Predictive Value of the HEART Score Combined with Hypersensitive C-Reactive Protein for 30 d Adverse Cardiovascular Events in Patients with Acute Chest Pain. Emerg Med Int 2022; 2022:3606169. [PMID: 36406928 PMCID: PMC9671716 DOI: 10.1155/2022/3606169] [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: 07/19/2022] [Accepted: 09/04/2022] [Indexed: 11/12/2022] Open
Abstract
Purpose This study aimed to explore the predictive value of the HEART score combined with hypersensitive C-reactive protein (hs-CRP) for 30 d major adverse cardiovascular events (MACEs) in patients with acute chest pain. Methods 103 patients with acute chest pain admitted to the emergency department of our hospital from May 2020 to May 2022 were selected as the study subjects. The patients' HEART score and plasma hs-CRP level were recorded. The patients were followed up for 30 d to observe whether MACE occurred. Results Among 103 patients with acute chest pain, MACE occurred in 8 cases within 30 d of follow-up, and the probability of MACE was 7.76%. There was a statistically significant difference in 30 d MACE risk among patients with different HEART score stratification (P < 0.05). The age, HEART score, and hs-CRP levels of patients in the MACE group were higher than those in the non-MACE group (P < 0.05). The HEART score and the hs-CRP level were independent risk factors for 30 d MACE in patients with acute chest pain (P < 0.05). The AUC of the HEART score combined with hs-CRP in the occurrence of 30 d MACE in patients with acute chest pain was 0.901, which was significantly higher than 0.720 and 0.758 of single detection. Conclusion The HEART score combined with hs-CRP can better predict the occurrence of 30 d MACE in patients with acute chest pain.
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Handagala R, Indrasena BSH, Subedi P, Nizam MS, Aylott J. Implementing the HEART score in an NHS emergency department: can identity leadership combined with quality improvement promote racial equality? Leadersh Health Serv (Bradf Engl) 2022; ahead-of-print. [PMID: 35815917 DOI: 10.1108/lhs-04-2022-0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to report on the dynamics of "identity leadership" with a quality improvement project undertaken by an International Medical Graduate (IMG) from Sri Lanka, on a two year Medical Training Initiative (MTI) placement in the National Health Service (NHS) [Academy of Medical Royal Colleges (AoMRC), 2017]. A combined MTI rotation with an integrated Fellowship in Quality Improvement (Subedi et al., 2019) provided the driver to implement the HEART score (HS) in an NHS Emergency Department (ED) in the UK. The project was undertaken across ED, Acute Medicine and Cardiology at the hospital, with stakeholders emphasizing different and conflicting priorities to improve the pathway for chest pain patients. DESIGN/METHODOLOGY/APPROACH A social identity approach to leadership provided a framework to understand the insider/outsider approach to leadership which helped RH to negotiate and navigate the conflicting priorities from each departments' perspective. A staff survey tool was undertaken to identify reasons for the lack of implementation of a clinical protocol for chest pain patients, specifically with reference to the use of the HS. A consensus was reached to develop and implement the pathway for multi-disciplinary use of the HS and a quality improvement methodology (with the use of plan do study act (PDSA) cycles) was used over a period of nine months. FINDINGS The results demonstrated significant improvements in the reduction (60%) of waiting time by chronic chest pain patients in the ED. The use of the HS as a stratified risk assessment tool resulted in a more efficient and safe way to manage patients. There are specific leadership challenges faced by an MTI doctor when they arrive in the NHS, as the MTI doctor is considered an outsider to the NHS, with reduced influence. Drawing upon the Social Identity Theory of Leadership, NHS Trusts can introduce inclusion strategies to enable greater alignment in social identity with doctors from overseas. RESEARCH LIMITATIONS/IMPLICATIONS More than one third of doctors (40%) in the English NHS are IMGs and identify as black and minority ethnic (GMC, 2019a) a trend that sees no sign of abating as the NHS continues its international medical workforce recruitment strategy for its survival (NHS England, 2019; Beech et al., 2019). IMGs can provide significant value to improving the NHS using skills developed from their own health-care system. This paper recommends a need for reciprocal learning from low to medium income countries by UK doctors to encourage the development of an inclusive global medical social identity. ORIGINALITY/VALUE This quality improvement research combined with identity leadership provides new insights into how overseas doctors can successfully lead sustainable improvement across different departments within one hospital in the NHS.
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Affiliation(s)
- Rangani Handagala
- Emergency Department, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Buddhike Sri Harsha Indrasena
- Institute for Quality Improvement (IQI), World Academy of Medical Leadership, Sheffield, UK and Department of General Surgery, Provincial General Hospital, Badulla, Sri Lanka
| | - Prakash Subedi
- Emergency Department, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK and QiMET Medical Institute (QMI), QiMET International, Doncaster, UK
| | - Mohammed Shihaam Nizam
- Acute Medicine Department, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Jill Aylott
- Institute for Quality Improvement (IQI), World Academy of Medical Leadership, Sheffield, UK and QiMET Medical Institute (QMI), QiMET International, Doncaster, UK
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Pawlukiewicz AJ, Geringer MR, Davis WT, Nassery DR, April MD, Streitz MJ, Hyams JM, Martin AW, Martin SA, Oliver JJ. Interrater agreement of the HEART score history component: A chart review study. J Am Coll Emerg Physicians Open 2022; 3:e12732. [PMID: 35505933 PMCID: PMC9051859 DOI: 10.1002/emp2.12732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/07/2022] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
Study objectives This study investigated the interrater reliability of the history component of the HEART (history, electrocardiogram, age, risk, troponin) score between physicians in emergency medicine (EM) and internal medicine (IM) at 1 tertiary‐care center. Methods We conducted a retrospective, secondary analysis of 60 encounters selected randomly from a database of 417 patients with chest pain presenting from January to June 2016 to an urban tertiary‐care center. A total of 4 raters (1 EM attending, 1 EM resident, 1 IM attending, and 1 IM resident) scored the previously abstracted history data from these encounters. The primary outcome was the interrater agreement of HEART score history components, as measured by kappa coefficient, between EM and IM attending physicians. Secondary outcomes included the agreement between attending and resident physicians, overall agreement, pairwise percent agreement, and differences in scores assigned. Results The kappa value for the EM attending physician and IM attending physician was 0.33 with 55% agreement. Interrater agreement of the other pairs was substantial between EM attending and resident but was otherwise fair to moderate. Percent agreement between the other pairs ranged from 48.3% to 80%. There was a significant difference in scores assigned and the subgroup in which there was disagreement between the raters demonstrated significantly higher scores by the EM attending and resident when compared to the IM attending. Conclusion This study demonstrates fair agreement between EM and IM attending physicians in the history component of the HEART score with significantly higher scores by the EM attending physician in cases of disagreement at 1 tertiary‐care center.
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Affiliation(s)
- Alec J. Pawlukiewicz
- Department of Emergency Medicine San Antonio Uniformed Services Health Education Consortium San Antonio Texas USA
| | - Matthew R. Geringer
- Department of Internal Medicine San Antonio Uniformed Services Health Education Consortium San Antonio Texas USA
| | - W. Tyler Davis
- Department of Emergency Medicine San Antonio Uniformed Services Health Education Consortium San Antonio Texas USA
| | - Daniel R. Nassery
- Department of Internal Medicine San Antonio Uniformed Services Health Education Consortium San Antonio Texas USA
| | - Michael D. April
- Department of Emergency Medicine San Antonio Uniformed Services Health Education Consortium San Antonio Texas USA
| | - Matthew J. Streitz
- Department of Emergency Medicine San Antonio Uniformed Services Health Education Consortium San Antonio Texas USA
| | - Jessica M. Hyams
- Department of Emergency Medicine San Antonio Uniformed Services Health Education Consortium San Antonio Texas USA
| | | | | | - Joshua J. Oliver
- Leadership and Faculty Development Fellowship Madigan Army Medical Center, 9040 Fitzsimmons Dr, Joint Base Lewis‐McChord Washington USA
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5
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O'Rielly CM, Andruchow JE, McRae AD. External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing. CAN J EMERG MED 2022; 24:68-74. [PMID: 34273102 DOI: 10.1007/s43678-021-00159-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 06/05/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The history, ECG, age, risk factor (HEAR) score has been proposed to identify patients at sufficiently low risk of acute coronary syndrome that they may not require troponin testing. The objective of this study was to externally validate a low HEAR score to identify emergency department (ED) patients with chest pain at very low risk of 30-day major adverse cardiac events (MACE). METHODS This was a secondary analysis of a prospective cohort of patients requiring troponin testing to rule out myocardial infarction (MI) in a large urban ED. HEAR scores were calculated in two cohorts: (1) patients with no known history of coronary artery disease (CAD); and (2) all eligible patients. The proportion of patients classified as very low risk, sensitivity, specificity, predictive values and likelihood ratios at each cut-off were quantified for index acute myocardial infarction (AMI) and 30-day MACE at HEAR = 0 and HEAR ≤ 1 thresholds. RESULTS Of the 1150 patients included in this study, 820 (71.3%) had no history of CAD, 97 (8.4%) had index AMI and 123 (10.7%) had 30-day MACE. In patients with no prior history of CAD, HEAR ≤ 1 identified 202 (24.6%) of patients as very low risk for 30-day MACE with 98.4% (95% CI 91.6-99.9%) sensitivity. Among all patients, HEAR ≤ 1 identified 202 (17.6%) patients as very low risk for 30-day MACE with 99.2% (95% CI 95.6-99.9%) sensitivity. CONCLUSIONS A HEAR score ≤ 1 can identify more than 17% of all patients as very low risk for index AMI and 30-day MACE and unlikely to benefit from troponin testing. Broad implementation of this strategy could lead to significant resource savings.
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Affiliation(s)
- Connor M O'Rielly
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Room 3E34, Calgary, AB, T2N 4Z6, Canada
| | - James E Andruchow
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Room 3E34, Calgary, AB, T2N 4Z6, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Room 3E34, Calgary, AB, T2N 4Z6, Canada.
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Kim MJ, Ha SO, Park YS, Yi JH, Yang WS, Kim JH. Validation and modification of HEART score components for patients with chest pain in the emergency department. Clin Exp Emerg Med 2021; 8:279-288. [PMID: 35000355 PMCID: PMC8743685 DOI: 10.15441/ceem.20.106] [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: 08/20/2020] [Accepted: 09/24/2020] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE This study aimed to clarify the relative prognostic value of each History, Electrocardiography, Age, Risk Factors, and Troponin (HEART) score component for major adverse cardiac events (MACE) within 3 months and validate the modified HEART (mHEART) score. METHODS This study evaluated the HEART score components for patients with chest symptoms visiting the emergency department from November 19, 2018 to November 19, 2019. All components were evaluated using logistic regression analysis and the scores for HEART, mHEART, and Thrombolysis in Myocardial Infarction (TIMI) were determined using the receiver operating characteristics curve. RESULTS The patients were divided into a derivation (809 patients) and a validation group (298 patients). In multivariate analysis, age did not show statistical significance in the detection of MACE within 3 months and the mHEART score was calculated after omitting the age component. The areas under the receiver operating characteristics curves for HEART, mHEART and TIMI scores in the prediction of MACE within 3 months were 0.88, 0.91, and 0.83, respectively, in the derivation group; and 0.88, 0.91, and 0.81, respectively, in the validation group. When the cutoff value for each scoring system was determined for the maintenance of a negative predictive value for a MACE rate >99%, the mHEART score showed the highest sensitivity, specificity, positive predictive value, and negative predictive value (97.4%, 54.2%, 23.7%, and 99.3%, respectively). CONCLUSION Our study showed that the mHEART score better detects short-term MACE in high-risk patients and ensures the safe disposition of low-risk patients than the HEART and TIMI scores.
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Affiliation(s)
- Min Jae Kim
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang, Korea
| | - Sang Ook Ha
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang, Korea,Correspondence to: Sang Ook Ha Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, 22 Gwanpyeong-ro 170 beongil, Donan-gu, Anyang 14068, Korea E-mail:
| | - Young Sun Park
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang, Korea
| | - Jeong Hyeon Yi
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang, Korea
| | - Won Seok Yang
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang, Korea
| | - Jin Hyuck Kim
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang, Korea
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Khalil MH, Sekma A, Yaakoubi H, Bel Haj Ali K, Msolli MA, Beltaief K, Grissa MH, Boubaker H, Sassi M, Chouchene H, Hassen Y, Ben Soltane H, Mezgar Z, Boukef R, Bouida W, Nouira S. 30 day predicted outcome in undifferentiated chest pain: multicenter validation of the HEART score in Tunisian population. BMC Cardiovasc Disord 2021; 21:555. [PMID: 34798811 PMCID: PMC8603499 DOI: 10.1186/s12872-021-02381-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 11/02/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Chest pain remains one of the most challenging serious complaints in the emergency department (ED). A prompt and accurate risk stratification tool for chest pain patients is paramount to help physcian effectively progrnosticate outcomes. HEART score is considered one of the best scores for chest pain risk stratification. However, most validation studies of HEART score were not performed in populations different from those included in the original one. OBJECTIVE To validate HEART score as a prognostication tool, among Tunisian ED patients with undifferentiated chest pain. METHODS Our prospective, multicenter study enrolled adult patients presenting with chest pain at chest pain units. Patients over 30 years of age with a primary complaint of chest pain were enrolled. HEART score was calculated for every patient. The primary outcome was major cardiovascular events (MACE) occurrence, including all-cause mortality, non-fatal myocardial infarction (MI), and coronary revascularisation over 30 days following the ED visit. The discriminative power of HEART score was evaluated by the area under the ROC curve. A calibration analysis of the HEART score in this population was performed using Hosmer-Lemeshow goodness of test. RESULTS We enrolled 3880 patients (age 56.3; 59.5% males). The application of HEART score showed that most patients were in intermediate risk category (55.3%). Within 30 days of ED visit, MACE were reported in 628 (16.2%) patients, with an incidence of 1.2% in the low risk group, 10.8% in the intermediate risk group and 62.4% in the high risk group. The area under receiver operating characteristic curve was 0.87 (95% CI 0.85-0.88). HEART score was not well calibrated (χ2 statistic = 12.34; p = 0.03). CONCLUSION HEART score showed a good discrimination performance in predicting MACE occurrence at 30 days for Tunisian patients with undifferentiated acute chest pain. Heart score was not well calibrated in our population.
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Affiliation(s)
- Mohamed Hassene Khalil
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia. .,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia.
| | - Adel Sekma
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Hajer Yaakoubi
- Emergency Department, Sahloul University Hospital, 4011, Sousse, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Khaoula Bel Haj Ali
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Mohamed Amine Msolli
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Kaouthar Beltaief
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Mohamed Habib Grissa
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Hamdi Boubaker
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Mohamed Sassi
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Hamadi Chouchene
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Youssef Hassen
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Houda Ben Soltane
- Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia.,Emergency Department, Farhat Hached University Hospital, 4031, Sousse, Tunisia
| | - Zied Mezgar
- Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia.,Emergency Department, Farhat Hached University Hospital, 4031, Sousse, Tunisia
| | - Riadh Boukef
- Emergency Department, Sahloul University Hospital, 4011, Sousse, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Wahid Bouida
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Semir Nouira
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
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Janes JL, Streitz MJ, Hyams JM, Schauer SG, Arana AA, Ng PC, Small J, Bridwell RE, April MD, Oliver JJ. Are Patients Discharged on the HEART Pathway Following Up? Mil Med 2020; 185:e2110-e2114. [DOI: 10.1093/milmed/usaa228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
The HEART (history, electrocardiogram [ECG], age, risk factors, troponin) pathway is a useful tool in the emergency department to identify patients that are safe for outpatient evaluation of chest pain. A dedicated HEART Clinic to follow-up versus primary care remains a topic that requires further delineation. We sought to identify how many patients discharged on the HEART pathway specifically followed up with the established HEART Clinic.
Materials and Methods
This is a secondary analysis of a previously published dataset. In an initial validation study of the HEART Pathway, 625 consecutive subjects were identified via chart review, 449 of which were included. We identified subjects for inclusion in this study if they were found to have a HEART score of 3 or less. Subjects were excluded if they were admitted or if their follow-up was beyond 6 weeks.
Results
Of the 449 subjects, 185 met criteria for study inclusion. 125 (67.6%) had follow-up with an average time of 7.94 days (95% CI: 6.54-9.34). Of those, half had additional testing such as ECG, cardiac computed tomography angiography, and treadmill stress testing. The most common clinics for follow-up were the Family Medicine, Internal Medicine, and HEART Clinic representing 35.8, 29, and 18% of the follow-ups, respectively. No subject died, had a myocardial infarction, or required reperfusion.
Conclusions
Of the subjects discharged on the HEART Pathway, 67.6% followed up. Of those subjects that followed up, 18% did so at the HEART Clinic.
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Affiliation(s)
- Jordyn L Janes
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | - Matthew J Streitz
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | - Jessica M Hyams
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | - Steven G Schauer
- Combat Mortality Prevention Division, United States Army Institute of Surgical Research, 3698 Chambers Rd, San Antonio, TX 78234
| | - Allyson A Arana
- Combat Mortality Prevention Division, United States Army Institute of Surgical Research, 3698 Chambers Rd, San Antonio, TX 78234
| | - Patrick C Ng
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | - Jessica Small
- Medical Section, Chehalis Tribal Wellness Center, Oakville, WA 98568
| | - Rachel E Bridwell
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | - Michael D April
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | - Joshua J Oliver
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
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Webb JL, Streitz M, Hyams J, April M, Oliver JJ. HEART Score of Four for Age and Risk Factors: A Case Series. Cureus 2020; 12:e9576. [PMID: 32913692 PMCID: PMC7474560 DOI: 10.7759/cureus.9576] [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] [Indexed: 11/05/2022] Open
Abstract
Chest pain is a frequent chief complaint in the ED. Identifying acute coronary syndrome (ACS) and establishing proper disposition for further risk assessment for major adverse cardiac events are paramount. The HEART Score is a key decision-making tool used to determine patient risk and disposition. One scenario with a potential drawback of the HEART Score is found in patients with a score of four based solely on age and risk factors. The HEART Score categorizes a score of three or less as low risk, and patients with scores above this threshold are typically admitted. We present six cases of chest pain presenting to a military emergency department with a score of four based solely on age and risk factors. They represent every such case found in a previously created database used to validate the HEART Score. We followed each case forward one year in electronic medical records to identify major adverse cardiac events. With the exception of one case that was placed on hospice for non-cardiac reasons and subsequently lost to follow up, there were no adverse events. There is a rising concern for increasing hospital admission rates, overuse of resources, and cost. We highlight that this subset of HEART Score patients requires a more nuanced risk stratification in the ED. It may be worth the time and effort to risk stratify this subset with coronary computed tomography angiography. This additional effort may help reduce admission at such a patient's current and future presentations to the ED for chest pain.
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Affiliation(s)
- James L Webb
- Emergency Department, San Antonio Uniformed Services Health Education Consortium, San Antonio, USA
| | - Matthew Streitz
- Emergency Department, San Antonio Uniformed Services Health Education Consortium, San Antonio, USA
| | - Jessica Hyams
- Emergency Department, San Antonio Uniformed Services Health Education Consortium, San Antonio, USA
| | - Michael April
- Emergency Department, San Antonio Uniformed Services Health Education Consortium, San Antonio, USA
| | - Joshua J Oliver
- Emergency Department, San Antonio Uniformed Services Health Education Consortium, San Antonio, USA
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10
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Oliver JJ, Streitz MJ, Hyams JM, Wood RM, Maksimenko YM, Schauer SG, Long B, Barnwell RM, Bridwell RE, April MD. The HEART score as a prognostic tool for revascularization. Intern Emerg Med 2020; 15:607-612. [PMID: 31625076 DOI: 10.1007/s11739-019-02206-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 09/27/2019] [Indexed: 11/29/2022]
Abstract
The History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) score is a useful tool in the Emergency Department setting to identify those patients safe for outpatient evaluation of chest pain. Its utility for predicting cardiac interventions is unclear. Our objective was to evaluate the prognostic accuracy of the HEART score to predict the need for cardiac stent or coronary artery bypass grafting (CABG). We conducted a retrospective chart review of 625 consecutive subjects with chest pain presenting to an Emergency Department (ED) with a HEART pathway protocol in place. We also reviewed each subject's record for evidence of major adverse cardiac events within 6 weeks following their ED visit. We double-abstracted 10% of the charts for quality assurance. We included subjects if they were ≥ 18 at the time of presentation and had a chief complaint of chest pain. We excluded subjects if they did not have an electrocardiogram or troponin, or if their chart lacked sufficient information to calculate the history portion of their HEART score. Of 625 charts, 449 subjects met criteria for study inclusion. The area under the receiver operator curve reported as c-statistics was 0.877 [95% confidence interval (CI) 0.806-0.949] for the HEART score's ability to predict cardiac stent and 0.921 (95% CI 0.858-0.984) for CABG. There is a strong association between increasing HEART scores and the need for revascularization which may provide emergency physicians justification for expedited cardiology consultation and admission for these patients. These findings require further prospective validation.
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Affiliation(s)
- Joshua James Oliver
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA.
| | - Matthew Jay Streitz
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Jessica Marie Hyams
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Richard Michael Wood
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | | | - Steven Gremel Schauer
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Brit Long
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Robert Michael Barnwell
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Rachel Elisabeth Bridwell
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Michael David April
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
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Jenniskens K, Lagerweij GR, Naaktgeboren CA, Hooft L, Moons KGM, Poldervaart JM, Koffijberg H, Reitsma JB. Decision analytic modeling was useful to assess the impact of a prediction model on health outcomes before a randomized trial. J Clin Epidemiol 2019; 115:106-115. [PMID: 31330250 DOI: 10.1016/j.jclinepi.2019.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 06/11/2019] [Accepted: 07/16/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To demonstrate how decision analytic models (DAMs) can be used to quantify impact of using a (diagnostic or prognostic) prediction model in clinical practice and provide general guidance on how to perform such assessments. STUDY DESIGN AND SETTING A DAM was developed to assess the impact of using the HEART score for predicting major adverse cardiac events (MACE). Impact on patient health outcomes and health care costs was assessed in scenarios by varying compliance with and informed deviation (ID) (using additional clinical knowledge) from HEART score management recommendations. Probabilistic sensitivity analysis was used to assess estimated impact robustness. RESULTS Impact of using the HEART score on health outcomes and health care costs was influenced by an interplay of compliance with and ID from HEART score management recommendations. Compliance of 50% (with 0% ID) resulted in increased missed MACE and costs compared with usual care. Any compliance combined with at least 50% ID reduced both costs and missed MACE. Other scenarios yielded a reduction in missed MACE at higher costs. CONCLUSION Decision analytic modeling is a useful approach to assess impact of using a prediction model in practice on health outcomes and health care costs. This approach is recommended before conducting an impact trial to improve its design and conduct.
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Affiliation(s)
- Kevin Jenniskens
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands.
| | - Ghizelda R Lagerweij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Christiana A Naaktgeboren
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Lotty Hooft
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands; Cochrane Netherlands, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands; Cochrane Netherlands, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Judith M Poldervaart
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Hendrik Koffijberg
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Johannes B Reitsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands; Cochrane Netherlands, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
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12
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Fernando SM, Tran A, Cheng W, Rochwerg B, Taljaard M, Thiruganasambandamoorthy V, Kyeremanteng K, Perry JJ. Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac Events in Patients Presenting With Chest Pain: A Systematic Review and Meta-analysis. Acad Emerg Med 2019; 26:140-151. [PMID: 30375097 DOI: 10.1111/acem.13649] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/04/2018] [Accepted: 08/13/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The HEART score has been proposed for emergency department (ED) prediction of major adverse cardiac events (MACE). We sought to summarize all studies assessing the prognostic accuracy of the HEART score for prediction of MACE in adult ED patients presenting with chest pain. METHODS We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception through May 2018 and included studies using the HEART score for the prediction of short-term MACE in adult patients presenting to the ED with chest pain. The main outcome was short-term (i.e., 30-day or 6-week) incidence of MACE. We secondarily evaluated the prognostic accuracy of the HEART score for prediction of mortality and myocardial infarction (MI). Where available, accuracy of the Thrombolysis in Myocardial Infarction (TIMI) score was determined. RESULTS We included 30 studies (n = 44,202) in analysis. A HEART score above the low-risk threshold (≥4) had a sensitivity of 95.9% (95% confidence interval [CI] = 93.3%-97.5%) and specificity of 44.6% (95% CI = 38.8%-50.5%) for MACE. A high-risk HEART score (≥7) had a sensitivity of 39.5% (95% CI = 31.6%-48.1%) and specificity of 95.0% (95% CI = 92.6%-96.6%) for MACE, whereas a TIMI score above the low-risk threshold (≥2) had a sensitivity of 87.8% (95% CI = 80.2%-92.8%) and specificity of 48.1% (95% CI = 38.9%-57.5%) for MACE. A high-risk TIMI score (≥6) was 2.8% sensitive (95% CI = 0.8%-9.6%), but 99.6% (95% CI = 98.5%-99.9%) specific for MACE. A HEART score ≥ 4 had a sensitivity of 95.0% (95% CI = 87.2%-98.2%) for prediction of mortality and 97.5% (95% CI = 93.7%-99.0%) for prediction of MI. CONCLUSIONS The HEART score has excellent performance for prediction of MACE (particularly mortality and MI) in chest pain patients and should be the primary clinical decision instrument used for the risk stratification of this patient population.
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Affiliation(s)
- Shannon M. Fernando
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario
- Division of Critical Care; Department of Medicine; University of Ottawa; Ottawa Ontario
| | - Alexandre Tran
- School of Epidemiology and Public Health; University of Ottawa; Ottawa Ontario
- Department of Surgery; University of Ottawa; Ottawa Ontario
| | - Wei Cheng
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Ontario
| | - Bram Rochwerg
- Department of Medicine; Division of Critical Care, and Department of Health Research Methods, Evidence, and Impact; McMaster University; Hamilton Ontario Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health; University of Ottawa; Ottawa Ontario
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Ontario
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario
- School of Epidemiology and Public Health; University of Ottawa; Ottawa Ontario
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Ontario
| | - Kwadwo Kyeremanteng
- Division of Critical Care; Department of Medicine; University of Ottawa; Ottawa Ontario
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Ontario
| | - Jeffrey J. Perry
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario
- School of Epidemiology and Public Health; University of Ottawa; Ottawa Ontario
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Ontario
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13
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Oliver JJ, Streitz MJ, Hyams JM, Wood RM, Maksimenko YM, Long B, Barnwell RM, April MD. An external validation of the HEART pathway among Emergency Department patients with chest pain. Intern Emerg Med 2018; 13:1249-1255. [PMID: 29512019 DOI: 10.1007/s11739-018-1809-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 02/25/2018] [Indexed: 12/27/2022]
Abstract
The impact of an outpatient disposition strategy for patients with HEART score 0-3 (HEART pathway) on HEART score prognostic accuracy is unclear. Our objective is to perform an external validation the HEART score in the setting of recent implementation of the HEART pathway. We conducted an external validation study of the HEART pathway among patients presenting to our ED with chest pain 6 weeks after institutional implementation of a HEART pathway outpatient disposition pathway. We reviewed the charts of 625 consecutive patients with chest pain. Data abstracted included all elements of the HEART score to include history, electrocardiogram (ECG) read, patient age, patient risk factors, and troponin levels. We also reviewed each patient's record for evidence of major adverse cardiac events (MACE) to include mortality, myocardial infarction, or coronary revascularization over 6 weeks following their initial ED visit. We double-abstracted 10% of the charts for quality assurance purposes. Of 625 charts, 449 patients met all criteria for study inclusion. Of these, 25 subjects (5.56%) experience 6-week MACE. No subject with a score of 3 or less has a MACE at 6 weeks (100% sensitivity, 38.7% specificity). The area under the receiver operator curve (AUROC) is 0.898 (95% confidence interval 0.847-0.950). Kappa coefficients for inter-rater reliability range from 0.62 for the history component of the HEART score to 1.0 for troponin. A low HEART score (0-3) maintains excellent sensitivity for predicting 6-week MACE in the setting of an outpatient disposition pathway for these patients.
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Affiliation(s)
- Joshua James Oliver
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA.
- , 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78216, USA.
| | - Matthew Jay Streitz
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Jessica Marie Hyams
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Richard Michael Wood
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA
| | | | - Brit Long
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Robert Michael Barnwell
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Michael David April
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA
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14
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Oliver JJ, Streitz MJ, Hyams JM, Beall JP, Long B, April MD. A HEART Pathway pitfall in an admitted patient. Am J Emerg Med 2018; 37:177.e5-177.e6. [PMID: 30343962 DOI: 10.1016/j.ajem.2018.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 10/10/2018] [Accepted: 10/14/2018] [Indexed: 10/28/2022] Open
Abstract
This paper discusses a possible weakness of the HEART Pathway specific to patients identified as high risk, requiring admission for inpatient risk stratification. Emergency Department (ED) crowding is at an all-time high and the possibility that many of these patients will board in the ED for a period of time before they are transported to an inpatient ward is becoming more likely. Given troponins peak at 6 h after the initial cardiac injury, it is plausible an initial troponin could still remain negative upon arrival. Extending the HEART Pathway to include a 3-hour delta troponin for admitted patients boarded in the emergency department may help alert the patient's inpatient team of those requiring more aggressive evaluations or more timely interventions. The case discussed herein highlights the course of a patient who was admitted to a medicine floor for chest pain along the HEART Pathway. After remaining in the ED for 3 h following admission a second troponin was drawn that resulted in the diagnosis of a non-ST segment myocardial infarction. The patient then received further management in the ED and a change in admission to the Cardiac Care Unit instead of the medicine floor. The patient ultimately received a Coronary Artery Bypass Graft during admission. If the patient had not had the second troponin while in the ED this care would have been delayed.
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Affiliation(s)
- Joshua J Oliver
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Matthew J Streitz
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
| | - Jessica M Hyams
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
| | - Jackson P Beall
- North Thurston High School, 600 Sleater-Kinney RD NE, Lacey, WA 98516, United States
| | - Brit Long
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
| | - Michael D April
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
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