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Zilinyi RS, Fertel BS, Chang BC, Abrukin L, Suh EH, Sayan OR, McCarty M, Stant JA, Chuich T, Smyth ET, Neuberg G, Collins MB, Kirtane AJ, Moses J, Rabbani L. Updating a Healthcare System-wide Clinical Pathway for Managing Chest Pain and Acute Coronary Syndromes. Crit Pathw Cardiol 2023; 22:103-109. [PMID: 37782621 DOI: 10.1097/hpc.0000000000000334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Clinical pathways are useful tools for conveying and reinforcing best practices to standardize care and optimize patient outcomes across myriad conditions. The NewYork-Presbyterian Healthcare System has utilized a clinical chest pain pathway for more than 20 years to facilitate the timely recognition and management of patients presenting with chest pain syndromes and acute coronary syndromes. This chest pain pathway is regularly updated by an expanding group of key stakeholders, which has extended from the Columbia University Irving Medical Center to encompass the entire regional healthcare system, which includes 8 hospitals. In this 2023 update of the NewYork-Presbyterian clinical chest pain pathway, we present the key changes to the healthcare system-wide clinical chest pain pathway.
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Affiliation(s)
- Robert S Zilinyi
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Baruch S Fertel
- Quality and Patient Safety, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Betty C Chang
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Liliya Abrukin
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Edward H Suh
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Osman R Sayan
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Matthew McCarty
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Jennifer A Stant
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | | | - Emily T Smyth
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Gerald Neuberg
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Allen Hospital, New York, NY
| | - Michael B Collins
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Ajay J Kirtane
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Jeffrey Moses
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - LeRoy Rabbani
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
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Zilinyi RS, Stant JA, Sayan OR, Collins MB, Rabbani LE. Twenty Years of an Institutional Chest Pain Pathway: What's Come and What's Yet to Come. Crit Pathw Cardiol 2023; 22:41-44. [PMID: 37220657 DOI: 10.1097/hpc.0000000000000315] [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
Acute coronary syndromes (ACS) remain one of the leading causes of cardiovascular morbidity and mortality in the United States and around the world. Because of the acute nature of ACS presentations, timely identification, risk stratification, and intervention are of the utmost importance. Twenty years ago, we published the first iteration of our institutional chest pain clinical pathway in this journal, which separated patients presenting with chest pain into one of the 4 levels of decreasing acuity, with associated actions and interventions for providers based on the level. This chest pain clinical pathway has undergone regular review and updates under a collaborative team of cardiologists, emergency department physicians, cardiac nurse practitioners, and other associated stakeholders in the treatment of patients presenting with chest pain. This review will discuss the key changes that our institutional chest pain algorithm has undergone over the last 2 decades and what the future holds for chest pain algorithms.
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Affiliation(s)
- Robert S Zilinyi
- From the Department of Medicine, Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Jennifer A Stant
- From the Department of Medicine, Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Osman R Sayan
- Department of Emergency Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Michael B Collins
- From the Department of Medicine, Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - LeRoy E Rabbani
- From the Department of Medicine, Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
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An Updated Healthcare System-Wide Clinical Pathway for Managing Patients With Chest Pain and Acute Coronary Syndromes. Crit Pathw Cardiol 2020; 18:167-175. [PMID: 31725507 DOI: 10.1097/hpc.0000000000000189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Clinical pathways reinforce best practices and help healthcare institutions standardize care delivery. The NewYork-Presbyterian/Columbia University Irving Medical Center has used such a pathway for the management of patients with chest pain and acute coronary syndromes for almost 2 decades. A multidisciplinary panel of stakeholders serially updates the algorithm according to new data and recently published guidelines. Herein, we present the 2019 version of the clinical pathway. We explain the rationale for changes to the algorithm and describe our experience expanding the pathway to all the 8 affiliated institutions within the NewYork Presbyterian healthcare system.
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Abstract
Clinical pathways can optimize care both across and within institutions, but regular updates to these pathways based on new clinical trials, professional guidelines, and Food and Drug Administration approvals are essential. Herein we describe the most recent revisions to the New York-Presbyterian Hospital (Columbia University Medical Center and Weill Cornell Medical Center) clinical pathway for acute coronary syndromes and chest pain, which incorporates novel data regarding the timing and administration of P2Y12 inhibition (including the intravenous P2Y12 inhibitor cangrelor) and the appropriateness of prolonged (>1 year) dual antiplatelet therapy for the secondary prevention of ischemic events.
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Wessler JD, Stant J, Duru S, Rabbani L, Kirtane AJ. Updates to the ACCF/AHA and ESC STEMI and NSTEMI guidelines: putting guidelines into clinical practice. Am J Cardiol 2015; 115:23A-8A. [PMID: 25728971 DOI: 10.1016/j.amjcard.2015.01.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jeffrey D Wessler
- Department of Medicine, Columbia University Medical Center New York-Presbyterian Hospital, New York, New York
| | - Jennifer Stant
- Division of Cardiology, Columbia University Medical Center New York-Presbyterian Hospital, New York, New York
| | - Safiye Duru
- Division of Cardiology, Columbia University Medical Center New York-Presbyterian Hospital, New York, New York
| | - LeRoy Rabbani
- Division of Cardiology, Columbia University Medical Center New York-Presbyterian Hospital, New York, New York
| | - Ajay J Kirtane
- Division of Cardiology, Columbia University Medical Center New York-Presbyterian Hospital, New York, New York.
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Einstein AJ, Johnson LL, DeLuca AJ, Kontak AC, Groves DW, Stant J, Pozniakoff T, Cheng B, Rabbani LE, Bokhari S. Radiation dose and prognosis of ultra-low-dose stress-first myocardial perfusion SPECT in patients with chest pain using a high-efficiency camera. J Nucl Med 2015; 56:545-51. [PMID: 25745089 DOI: 10.2967/jnumed.114.150664] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 01/30/2015] [Indexed: 01/29/2023] Open
Abstract
UNLABELLED Although SPECT myocardial perfusion imaging (MPI) provides valuable information about patients with chest pain, there is growing concern regarding its radiation burden and lengthy duration. New high-efficiency (HE) cameras and stress-first protocols both offer the potential to markedly reduce radiation. No previous study has assessed outcomes and radiation doses of patients undergoing MPI on an HE-SPECT camera using an ultra-low-dose stress-first protocol. METHODS One hundred patients presenting to the emergency department with chest pain who were candidates for stress-first MPI underwent injection of approximately 185 MBq (5 mCi) of (99m)Tc-tetrofosmin at peak stress, followed by supine and prone imaging on an HE-SPECT camera. Same-day rest imaging was performed on patients with any abnormality on imaging after stress. Radiation effective dose was calculated from administered and residual activities. Patients were contacted 3 mo after discharge, and electronic records were accessed to evaluate the need for reevaluation for chest pain, additional imaging, or cardiac events. RESULTS Stress-only imaging was performed in 69 patients, for whom radiation effective dose averaged 0.99 mSv and study duration, 117 min. Radiation dose averaged 2.22 mSv over all patients. At 3 mo, 96 patients were free of major adverse cardiac events, repeat hospital chest pain evaluation, and repeat imaging or stress testing. One year after MPI and hospital discharge, all patients were living and without acute coronary syndrome. CONCLUSION HE-SPECT stress-only imaging can be performed in more than two thirds of chest pain patients without a high pretest probability of a stress perfusion defect, with excellent prognosis, a radiation dose averaging 1 mSv, and a test duration of less than 2 h.
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Affiliation(s)
- Andrew J Einstein
- Cardiology Division, Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York Department of Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York; and
| | - Lynne L Johnson
- Cardiology Division, Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York
| | - Albert J DeLuca
- Cardiology Division, Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York
| | - Andrew C Kontak
- Cardiology Division, Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York
| | - Daniel W Groves
- Cardiology Division, Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York
| | - Jennifer Stant
- Cardiology Division, Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York
| | - Ted Pozniakoff
- Cardiology Division, Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York
| | - Bin Cheng
- Department of Biostatistics, Columbia University, New York, New York
| | - LeRoy E Rabbani
- Cardiology Division, Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York
| | - Sabahat Bokhari
- Cardiology Division, Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York
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