Influence of pseudodiagnostic information on the evaluation of ischemic heart disease

Lamin A to Z in normal aging

Almost since the discovery that mutations in the LMNA gene, encoding the nuclear structure components lamin A and C, lead to Hutchinson-Gilford progeria syndrome, people have speculated that lamins may have a role in normal aging. The most common HPGS mutation creates a splice variant of lamin A, progerin, which promotes accelerated aging pathology. While some evidence exists that progerin accumulates with normal aging, an increasing body of work indicates that prelamin A, a precursor of lamin A prior to C-terminal proteolytic processing, accumulates with age and may be a driver of normal aging. Prelamin A shares properties with progerin and is also linked to a rare progeroid disease, restrictive dermopathy. Here, we describe mechanisms underlying changes in prelamin A with aging and lay out the case that this unprocessed protein impacts normative aging. This is important since intervention strategies can be developed to modify this pathway as a means to extend healthspan and lifespan.

The Impact of Unstable Angina Guidelines in the Triage of Emergency Department Patients with Possible Acute Coronary Syndrome

Objective. The primary aim of this study is to determine whether implementing the Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline improves emergency physician's decision making in patients with symptoms of possible acute coronary syndrome (ACS), including those for whom the diagnosis of unstable angina is uncertain. Methods. The authors conducted a prospective guideline implementation trial with pre-post design in the emergency departments of 1 university hospital and 1 university-affiliated community teaching hospital from January 2000 to May 2001. They enrolled 1140 adults who presented with chest pain or other symptoms of possible ACS. The intervention included the following: 1) physician training in use of the AHCPR risk groups, 2) algorithm for risk stratification, and 3) group feedback. To determine how accurately physicians interpreted the guideline algorithm, the authors compared their risk ratings with actual guideline risk groups. Results. No significant difference in physician triage decisions was observed between baseline and intervention periods. Analysis of physician's risk ratings during the intervention period revealed low overall concordance with actual guideline risk groups (kappa = 0.31); however, physician's risk ratings showed superior discrimination in identifying patients with confirmed ACS (receiver operating characteristic [ROC] area .81 v. .74, P = 0.008). Strict adherence to guideline recommendations would have resulted in hospitalizing 9% more non-ACS patients without lowering the rate of missed ACS. Conclusion. Implementation of the AHCPR guideline did not improve triage decisions in emergency department patients with possible ACS. Assessing physician triage solely based on concordance with the AHCPR guideline may not accurately reflect the quality of patient care.

Does Concordance with Guideline Triage Recommendations Affect Clinical Care of Patients with Possible Acute Coronary Syndrome?

Background. The Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline recommends outpatient management for patients at low risk and admission to a monitored bed for patients at intermediate-high risk of adverse short-term outcomes, but the clinical consequences of adhering to these recommendations are unclear. Methods. This analysis included 7466 adults who presented to the emergency department (ED) with symptoms of possible acute coronary syndrome (ACS) and who participated in 3 prospective clinical effectiveness trials during the period 1993 to 2001. The authors used logistic regression to assess the impact of concordance with guideline triage recommendations on subsequent diagnostic testing, follow-up care, and 30-day mortality and applied propensity score methods to adjust for selection bias. Results. Among low-risk patients (n = 1099), ED discharge was not associated with higher mortality and did not increase the need for emergency care or hospitalization during follow-up (adjusted odds ratio [OR] = 1.0, 95% confidence interval [CI] = 0.63—1.6 for ED revisits); however, 1.7% of discharged low-risk patients had confirmed ACS. Among intermediate- to high-risk patients (n = 6367), admission to a monitored bed was not associated with reduction in 30-day mortality but significantly reduced the need for follow-up ED care (adjusted OR = 0.81, 95% CI = 0.69—0.96). Conclusions. This analysis supports the practice of discharging low-risk ED patients with symptoms of possible ACS but highlights the need to arrange timely follow-up (or to perform additional risk stratification in the ED prior to discharge). It also confirms the benefit of admitting ED patients with intermediate- to high-risk characteristics to a monitored bed.

Evaluation of chest pain in the ED: factors affecting triage decisions

The emergency physician's (EP) fast and correct diagnosis of patients with chest pain is crucial for preventing inappropriate discharge and dire consequences. To determine which factors affect admission decisions in the ED, we studied epidemiologic characteristics of both discharged and admitted patients, and the percentage of discharged patients who returned to the ED with acute myocardial infarction. The study included 185 patients seen in the ED because of chest pain between July 1 and 31, 1997 (every third day not included). Ninety patients were admitted: 36.7% were admitted for "observation of chest pain" and 63.3% met the criteria for active coronary heart disease. A form was used to collect personal data, medical history, risk factors, clinical examination, electrocardiogram interpretation, laboratory data, and admittance decision. EPs' diagnosis of cardiac chest pain demonstrated a sensitivity of 93.4%, a specificity of 73.4%, and a positive predictive value of 63.3%. Sensitivity for diagnosing acute myocardial infarct was 100%, with no erroneous discharges. The EP's ability to integrate the medical history information, including risk factors and pain characteristics, had a marked influence on the admittance decision. Efforts to reduce missed diagnoses are warranted.

The beguiling pursuit of more information

BACKGROUND

The authors tested whether clinicians make different decisions if they pursue information than if they receive the same information from the start.

METHODS

Three groups of clinicians participated (N=1206): dialysis nurses (n=171), practicing urologists (n=461), and academic physicians (n=574). Surveys were sent to each group containing medical scenarios formulated in 1 of 2 versions. The simple version of each scenario presented a choice between 2 options. The search version presented the same choice but only after some information had been missing and subsequently obtained. The 2 versions otherwise contained identical data and were randomly assigned.

RESULTS

In one scenario involving a personal choice about kidney donation, more dialysis nurses were willing to donate when they first decided to be tested for compatibility and were found suitable than when theyknew they were suitable from the start (65% vs. 44%, P= 0.007). Similar discrepancies were found in decisions made by practicing urologists concerning surgery for a patient with prostate cancer and in decisions of academic physicians considering emergency management for a patient with acute chest pain.

CONCLUSIONS

The pursuit of information can increase its salience and cause clinicians to assign more importance to the information than if the same information was immediately available. An awareness of this cognitive bias may lead to improved decision making in difficult medical situations.

Effect of a patient's psychiatric history on physicians' estimation of probability of disease

A questionnaire was mailed to 300 Iowa family physicians to determine the influence of a prior psychiatric history on decision making. The response rate was 77%. Respondents were less likely to believe that a patient had serious illness when presenting with a severe headache or abdominal pain if the patient had a prior history of depression ( P <.05) or prior history of somatic complaints ( P <. 05), compared with a patient with no past history. Respondents were less likely to report that they would order testing for a patient with headache or abdominal pain if the patient had a history of depression ( P <.05, P =.08, respectively) or somatic complaints ( P <.01). Differences in likelihood of ordering tests were not significant after adjusting for differences in estimated probability of disease. We conclude that physicians respond differently to patients with psychiatric illness because of their estimation of pretest probability of disease rather than bias. We conclude that past psychiatric history influences physicians' estimation of disease presence and willingness to order tests.

Effect of diabetes mellitus on the presentation and triage of patients with acute chest pain without known coronary artery disease

PURPOSE

Patients with diabetes and acute chest pain may be admitted to hospitals more frequently than patients without diabetes because physicians suspect atypical presentations for ischemic heart disease. This study aimed to determine whether the presentation of acute myocardial infarction and risk for major cardiac complications differs among patients without known coronary artery disease who do or do not have diabetes.

PATIENTS AND METHODS

Data from an emergency department of an urban teaching hospital on the medical histories, physical examinations, and electrocardiograms of 2,694 subjects with acute chest pain and without known coronary artery disease were prospectively recorded.

RESULTS

Diabetes was present in 301 (11%) patients. Compared with patients without diabetes, patients with diabetes were more likely to be < or = 60 years old (51% versus 20%) and to have a history of hypertension (70% versus 35%) or high blood cholesterol (35% versus 19%). A discharge diagnosis of acute myocardial infarction was made in 25 diabetic (8%) and in 148 nondiabetic (6%; P = 0.16) patients. A major cardiac complication occurred in two patients with diabetes (0.7%) and in 20 patients without diabetes (0.8%; P = 1.0). Patients with and without diabetes who had atypical chest pain complaints had similar rates of myocardial infarction (3% and 4%, respectively; P = 0.6). Patients with diabetes were more likely to be hospitalized (67% versus 47%; P = 0.001) both before and after adjusting for clinical and electrocardiographic data.

CONCLUSIONS

For patients with acute chest pain without a prior history of coronary artery disease, diabetes was not associated with a higher rate of acute myocardial infarction or complications. However, diabetes was associated with a higher rate of hospitalization in this population, suggesting that physicians have a lower threshold for admission to the hospital of patients with diabetes.

Evaluation and risk stratification of patients with chest pain in the emergency department. Predictors of life-threatening events

While assessing chest pain in the emergency department, physicians must first estimate the probability of acute ischemic states in the patient. This first estimate is based on the patient's history, physical examination, and electrocardiogram. Patients who meet the threshold for acute cardiac ischemia are further evaluated to confirm or exclude this diagnosis, while other life-threatening factors are excluded.