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Danagoulian S, Miller J, Cook B, Gunaga S, Fadel R, Gandolfo C, Mills NL, Modi S, Mahler SA, Levy PD, Parikh S, Krupp S, Abdul‐Nour K, Klausner H, Rockoff S, Gindi R, Lewandowski A, Hudson M, Perrotta G, Zweig B, Lanfear D, Kim H, Shaheen E, Darnell G, Nassereddine H, Hawatian K, Tang A, Keerie C, McCord J. Is rapid acute coronary syndrome evaluation with high-sensitivity cardiac troponin less costly? An economic evaluation. J Am Coll Emerg Physicians Open 2024; 5:e13140. [PMID: 38567033 PMCID: PMC10985545 DOI: 10.1002/emp2.13140] [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: 08/22/2023] [Revised: 02/04/2024] [Accepted: 02/22/2024] [Indexed: 04/04/2024] Open
Abstract
Objective Protocols to evaluate for myocardial infarction (MI) using high-sensitivity cardiac troponin (hs-cTn) have the potential to drive costs upward due to the added sensitivity. We performed an economic evaluation of an accelerated protocol (AP) to evaluate for MI using hs-cTn to identify changes in costs of treatment and length of stay compared with conventional testing. Methods We performed a planned secondary economic analysis of a large, cluster randomized trial across nine emergency departments (EDs) from July 2020 to April 2021. Patients were included if they were 18 years or older with clinical suspicion for MI. In the AP, patients could be discharged without further testing at 0 h if they had a hs-cTnI < 4 ng/L and at 1 h if the initial value were 4 ng/L and the 1-h value ≤7 ng/L. Patients in the standard of care (SC) protocol used conventional cTn testing at 0 and 3 h. The primary outcome was the total cost of treatment, and the secondary outcome was ED length of stay. Results Among 32,450 included patients, an AP had no significant differences in cost (+$89, CI: -$714, $893 hospital cost, +$362, CI: -$414, $1138 health system cost) or ED length of stay (+46, CI: -28, 120 min) compared with the SC protocol. In lower acuity, free-standing EDs, patients under the AP experienced shorter length of stay (-37 min, CI: -62, 12 min) and reduced health system cost (-$112, CI: -$250, $25). Conclusion Overall, the implementation of AP using hs-cTn does not result in higher costs.
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Affiliation(s)
| | - Joseph Miller
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - Bernard Cook
- Department of ChemistryHenry Ford Health SystemDetroitMichiganUSA
| | - Satheesh Gunaga
- Department of Emergency MedicineHenry Ford Wyandotte HospitalWyandotteMichiganUSA
| | - Raef Fadel
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Chaun Gandolfo
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Nicholas L. Mills
- Department of CardiologyThe University of Edinburgh Usher Institute of Population Health Sciences and InformaticsUnited Kingdom of Great Britain and Northern IrelandEdinburghUK
| | - Shalini Modi
- Department of CardiologyHenry Ford West Bloomfield HospitalWest Bloomfield TownshipMichiganUSA
| | - Simon A. Mahler
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Phillip D. Levy
- Department of Emergency Medicine and Integrative Biosciences CenterWayne State University School of MedicineDetroitMichiganUSA
| | - Sachin Parikh
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Seth Krupp
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | | | - Howard Klausner
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - Steven Rockoff
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - Ryan Gindi
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Aaron Lewandowski
- Department of CardiologyHenry Ford West Bloomfield HospitalWest Bloomfield TownshipMichiganUSA
| | - Michael Hudson
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Giuseppe Perrotta
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - Bryan Zweig
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - David Lanfear
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Henry Kim
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
| | - Elizabeth Shaheen
- Department of Emergency MedicineHenry Ford Wyandotte HospitalWyandotteMichiganUSA
| | - Gale Darnell
- Department of Emergency MedicineHenry Ford Wyandotte HospitalWyandotteMichiganUSA
| | | | - Kegham Hawatian
- Department of Emergency MedicineHenry Ford Health SystemDetroitMichiganUSA
| | - Amy Tang
- Department of ResearchHenry Ford Health SystemDetroitMichiganUSA
| | - Catriona Keerie
- Department of CardiologyThe University of Edinburgh Usher Institute of Population Health Sciences and InformaticsUnited Kingdom of Great Britain and Northern IrelandEdinburghUK
| | - James McCord
- Department of CardiologyHenry Ford Health SystemDetroitMichiganUSA
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Aarts GWA, Camaro C, Adang EMM, Rodwell L, van Hout R, Brok G, Hoare A, de Pooter F, de Wit W, Cramer GE, van Kimmenade RRJ, Ouwendijk E, Rutten MH, Zegers E, van Geuns RJM, Gomes MER, Damman P, van Royen N. Pre-hospital rule-out of non-ST-segment elevation acute coronary syndrome by a single troponin: final one-year outcomes of the ARTICA randomised trial. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024:qcae004. [PMID: 38236708 DOI: 10.1093/ehjqcco/qcae004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
BACKGROUND AND AIMS The healthcare burden of acute chest pain is enormous. In the randomised ARTICA trial we showed that pre-hospital identification of low-risk patients and rule-out of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) with point-of-care (POC) troponin measurement reduces 30-day healthcare costs with low major adverse cardiac events (MACE) incidence. Here we present the final one-year results of the ARTICA trial. METHODS Low-risk patients with suspected NSTE-ACS were randomised to pre-hospital rule-out with POC troponin measurement or emergency department (ED) transfer. Primary one-year outcome was healthcare costs. Secondary outcomes were safety, quality of life (QoL) and cost-effectiveness. Safety was defined as one-year MACE, consisting of ACS, unplanned revascularisation or all-cause death. QoL was measured with EuroQol-5D-5 L questionnaires. Cost-effectiveness was defined as one-year healthcare costs difference per QoL difference. RESULTS Follow-up was completed in all 863 patients. Healthcare costs were significantly lower in the pre-hospital strategy (€1932±€2784 vs €2649±€2750), mean difference €717 (95% confidence interval [CI] €347 to €1087; P < 0.001). In the total population, one-year MACE rate was comparable between groups (5.1% [22/434] in the pre-hospital strategy vs 4.2% [18/429] in the ED strategy; P = 0.54). In the ruled-out ACS population, one-year MACE remained low (1.7% [7/419] vs 1.4% [6/417]), risk difference 0.2% (95% CI -1.4% to 1.9%; P = 0.79). QoL showed no significant difference between strategies. CONCLUSIONS Pre-hospital rule-out of NSTE-ACS with POC troponin testing in low-risk patients is cost-effective, expressed by a sustainable healthcare costs reduction and no significant effect on QoL. One-year MACE remained low for both strategies. Trial registration: Clinicaltrials.gov: NCT05466591, International Clinical Trials Registry Platform: NTR7346.
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Affiliation(s)
- Goaris W A Aarts
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Cyril Camaro
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Eddy M M Adang
- Department of Health Evidence, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Laura Rodwell
- Department of Health Evidence, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Roger van Hout
- Ambulance Service, Safety region Gelderland-Zuid, Nijmegen, The Netherlands
| | - Gijs Brok
- Ambulance Service, Safety region Gelderland-Zuid, Nijmegen, The Netherlands
| | - Anouk Hoare
- Ambulance Service, Witte Kruis, Houten, The Netherlands
| | - Frank de Pooter
- Ambulance Service Witte Kruis, Safety region Noord- en Oost-Gelderland, Elburg, The Netherlands
| | - Walter de Wit
- Ambulance Service Witte Kruis, Safety region Zeeland, Goes, The Netherlands
| | - Gilbert E Cramer
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Eva Ouwendijk
- General Practitioner Centre Nijmegen and Boxmeer, Nijmegen, The Netherlands
| | - Martijn H Rutten
- General Practitioner Cooperative Noord-Limburg, Venlo, The Netherlands
| | - Erwin Zegers
- Department of Cardiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - Marc E R Gomes
- Department of Cardiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Ljubojevic A, Neskovic SA, Vranic I, Stankovic I. Characteristics of Patients With Acute Coronary Syndrome and Normal Electrocardiogram. Med Arch 2024; 78:100-104. [PMID: 38566875 PMCID: PMC10983090 DOI: 10.5455/medarh.2024.78.100-104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024] Open
Abstract
Background Patients with acute coronary syndrome (ACS) and normal electrocardiogram (ECG) may have an increased risk of late diagnosis and complications of the disease. Objective To study the demographic, angiographic and echocardiographic characteristics of patients hospitalized for ACS in whom the ECG was normal on admission to the hospital. Methods This retrospective study included patients who were hospitalized for ACS without ST-elevation between 2015 and 2023 and who had coronary artery disease (CAD) confirmed by coronary angiography. By further inspection of the electronic databases, patients with ACS who had a normal ECG on admission were filtered out and analyzed separately. Results Of the total 3137 patients with suspected ACS without ST-elevation, 129 patients (4.1%) were diagnosed as having ACS with a normal ECG. In three patients a non-atherosclerotic cause for the ACS was found. A significantly higher proportion of patients had single-vessel (54.3%) compared to two-vessel (29.5%) and three-vessel (14%) CAD. In addition to a normal ECG, 5.7% of patients with single-vessel CAD and 3.5% of patients with multi-vessel CAD had normal troponin levels and normal regional LV systolic function on echocardiography. Conclusion Less than 5% of hospitalized patients with ACS without ST-elevation had a normal ECG on admission. The majority of these patients have single-vessel CAD. In about 5% of patients with single-vessel CAD, neither elevated troponin levels nor LV asynergy are detected.
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Affiliation(s)
| | | | - Ivona Vranic
- Clinical Hospital Centre Zemun, Department of Cardiology, Belgrade, Serbia
| | - Ivan Stankovic
- Clinical Hospital Centre Zemun, Department of Cardiology, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Kaski JC, Lluch N, Lopez-Sendon JL, Gorog DA, Antorrena-Miranda I, Avanzas P, Herrero Puente P, Sionis A, González-Juanatey JR, Íñiguez A, Cordero A, Ako E, Fernández-Avilés F, Atienza F, Recio-Mayoral A, Wu AHB, Crea F, Storey R, Badimon L, Cubedo J. Changes in circulating ApoJ-Glyc levels in patients with suspected acute coronary syndrome: The EDICA trial. Int J Cardiol 2023; 391:131291. [PMID: 37619880 DOI: 10.1016/j.ijcard.2023.131291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/08/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Myocardial ischemia induces intracellular accumulation of non-glycosylated apolipoprotein J that results in a reduction of circulating glycosylated ApoJ (ApoJ-Glyc). The latter has been suggested to be a marker of transient myocardial ischemia. OBJECTIVE This proof-of-concept clinical study aimed to assess whether changes in circulating ApoJ-Glyc could detect myocardial ischemia in patients attending the emergency department (ED) with chest pain suggestive of acute coronary syndrome (ACS). METHODS In suspected ACS patients, EDICA (Early Detection of Myocardial Ischemia in Suspected Acute Coronary Syndromes by ApoJ-Glyc a Novel Pathologically based Ischemia Biomarker), a multicentre, international, cohort study assessed changes in 2 glycosylated variants of ApoJ-Glyc, (ApoJ-GlycA2 and ApoJ-GlycA6), in serum samples obtained at ED admission (0 h), and 1 h and 3 h thereafter, blinded to the clinical diagnosis (i.e. STEMI, NSTEMI, unstable angina, non-ischemic). RESULTS 404 patients were recruited; 291 were given a clinical diagnosis of "non-ischemic" chest pain and 113 were considered to have had an ischemic event. ApoJ-GlycA6 was lower on admission in ischemic compared with "non-ischemic" patients (66 [46-90] vs. 73 [56-95] μg/ml; P = 0.04). 74% of unstable angina patients (all with undetectable hs-Tn), had ischemic changes in ApoJ-Glyc at 0 h and 89% at 1 h. Initially low ApoJ-Glyc levels in 62 patients requiring coronary revascularization increased significantly after successful percutaneous intervention. CONCLUSIONS Circulating ApoJ-Glyc concentrations decrease early in ED patients with myocardial ischemia compared with "non-ischemic" patients, even in the absence of troponin elevations. ApoJ-Glyc may be a useful marker of myocardial ischemia in the ED setting.
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Affiliation(s)
- Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom; GlyCardial Diagnostics, S.L., Barcelona, Spain
| | - Nuria Lluch
- GlyCardial Diagnostics, S.L., Barcelona, Spain
| | | | - Diana A Gorog
- Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom; Faculty of Medicine, National Heart and Lung Institute, Imperial College, London
| | | | - Pablo Avanzas
- Interventional Cardiology Unit, Hospital Universitario Central de Asturias, Department of Medicine, University of Oviedo, Oviedo, Spain Sanitaria del Principado de Asturias, Spain
| | - Pablo Herrero Puente
- Emergency Department, University Central Hospital of Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Spain
| | - Alessandro Sionis
- Cardiology Department Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | | | - Andrés Íñiguez
- Department of Cardiology, Hospital Universitario Álvaro Cunqueiro, Vigo, Spain
| | - Alberto Cordero
- Cardiology Department, Hospital Universitario de San Juan, Alicante, Spain
| | - Emmanuel Ako
- Chelsea & Westminster Hospital, London, United Kingdom
| | - Francisco Fernández-Avilés
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Ciber Cardiovascular (CiberCV), Madrid, Spain
| | - Felipe Atienza
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Ciber Cardiovascular (CiberCV), Madrid, Spain
| | | | - Alan H B Wu
- Clinical Chemistry and Toxicology Laboratories, San Francisco General Hospital and Dept. Lab. Medicine, University of California, San Francisco, USA
| | - Filippo Crea
- Università Cattolica del Sacro Cuore, and Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Robert Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Lina Badimon
- GlyCardial Diagnostics, S.L., Barcelona, Spain; Cardiovascular-Program-ICCC, IR-Hospital Santa Creu i Sant Pau, IIB-Sant Pau, 08025 Barcelona, Spain; Cardiovascular Research, Universitat Autònoma de Barcelona, Barcelona, Spain
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5
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Meier M, Boeddinghaus J, Nestelberger T, Koechlin L, Lopez-Ayala P, Wussler D, Walter JE, Zimmermann T, Badertscher P, Wildi K, Giménez MR, Puelacher C, Glarner N, Magni J, Miró Ò, Martin-Sanchez FJ, Kawecki D, Keller DI, Gualandro DM, Twerenbold R, Nickel CH, Bingisser R, Mueller C. Comparing the utility of clinical risk scores and integrated clinical judgement in patients with suspected acute coronary syndrome. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:693-702. [PMID: 37435949 PMCID: PMC10599640 DOI: 10.1093/ehjacc/zuad081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/05/2023] [Accepted: 07/10/2023] [Indexed: 07/13/2023]
Abstract
AIMS The utility of clinical risk scores regarding the prediction of major adverse cardiac events (MACE) is uncertain. We aimed to directly compare the prognostic performance of five established clinical risk scores as well as an unstructured integrated clinical judgement (ICJ) of the treating emergency department (ED) physician. METHODS AND RESULTS Thirty-day MACE including all-cause death, life-threatening arrhythmia, cardiogenic shock, acute myocardial infarction (including the index event), and unstable angina requiring urgent coronary revascularization were centrally adjudicated by two independent cardiologists in patients presenting to the ED with acute chest discomfort in an international multicentre study. We compared the prognostic performance of the HEART score, GRACE score, T-MACS, TIMI score, and EDACS, as well as the unstructured ICJ of the treating ED physician (visual analogue scale to estimate the probability of acute coronary syndrome, ranging from 0 to 100). Among 4551 eligible patients, 1110/4551 patients (24.4%) had at least one MACE within 30 days. Prognostic accuracy was high and comparable for the HEART score, GRACE score, T-MACS, and ICJ [area under the receiver operating characteristic curve (AUC) 0.85-0.87] but significantly lower and only moderate for the TIMI score (AUC 0.79, P < 0.001) and EDACS (AUC 0.74, P < 0.001), resulting in sensitivities for the rule-out of 30-day MACE of 93-96, 87 (P < 0.001), and 72% (P < 0.001), respectively. CONCLUSION The HEART score, GRACE score, T-MACS, and unstructured ICJ of the treating physician, not the TIMI score or EDACS, performed well for the prediction of 30-day MACE and may be considered for routine clinical use. TRIAL REGISTRATION ClinicalTrials.gov number NCT00470587.
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Affiliation(s)
- Mario Meier
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Joan Elias Walter
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, Triemli Hospital, Zurich, Switzerland
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Australia
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Cardiology and internal Medicine, University Heart Center Leipzig, Leipzig, Germany
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Jan Magni
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Òscar Miró
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Damian Kawecki
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Zabrze, Poland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- University Center of Cardiovascular Science & Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian H Nickel
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Roland Bingisser
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
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Affiliation(s)
- Goaris W A Aarts
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen 6525GA, The Netherlands
| | - Cyril Camaro
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen 6525GA, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen 6525GA, The Netherlands
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7
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Pawlikowski A, Hubbard E, Krauss J, Valle J, Doan J, DeMeester S, Hubbard B. Early emergency department discharge for intermediate heart score patients presenting for chest pain. J Am Coll Emerg Physicians Open 2023; 4:e13037. [PMID: 37692195 PMCID: PMC10492236 DOI: 10.1002/emp2.13037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 09/12/2023] Open
Abstract
Study Objective The use of the HEART score to risk stratify patients for short-term major adverse cardiac events in the emergency department (ED) setting is well established. Although discharge to home for low-risk HEART score patients is widely accepted as safe practice, there are limited outcomes data on moderate-risk HEART score patients discharged to home. We investigated the safety of discharging moderate-risk HEART score patients to home from the ED with established early cardiology follow-up. Methods We performed a retrospective cohort analysis of patients presenting to the ED with chest pain from April 2020 through December 2020. Patients were evaluated in the ED and underwent serial conventional troponin testing and electrocardiogram (ECG). Clinicians calculated a HEART score and employed shared decision-making with moderate-risk patients (score 4-6), offering hospital admission versus discharge home with a formalized process for rapid cardiology follow-up (within 2 business days). We assessed the frequency of acute myocardial infarction or death at 30 days and before cardiology follow-up. Results During our study period, 2939 patient encounters were screened for chest pain. Of these, 333 of 547 eligible moderate-risk HEART score patients were referred for rapid follow-up. The median time to follow-up appointment was 2.9 business days (interquartile range 1.3, 6.5), and 264 (79%) of patients kept their follow-up appointment. One patient (0.3%) suffered death within 30 days, before cardiology follow-up. There were no myocardial infarctions. Conclusions These results suggest that moderate-risk HEART score patients may be considered for discharge from the ED with rapid cardiology follow-up. Formalizing processes to facilitate these early evaluations may represent a viable alternative to hospital admission, without diminishing patient outcomes.
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Affiliation(s)
- Amber Pawlikowski
- St Joseph Mercy Hospital/Michigan Heart and Vascular InstituteAnn ArborMichiganUSA
| | - Elizabeth Hubbard
- Deparment of MedicineNorthwestern Memorial HospitalChicagoIllinoisUSA
| | - Joel Krauss
- St Joseph Mercy Hospital/Michigan Heart and Vascular InstituteAnn ArborMichiganUSA
| | - Javier Valle
- St Joseph Mercy Hospital/Michigan Heart and Vascular InstituteAnn ArborMichiganUSA
- University of Colorado School of MedicineAuroraColoradoUSA
| | - Jessica Doan
- Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Susanne DeMeester
- Department of Emergency MedicineSt Charles Medical CenterSt. Charles Medical CenterBendOregonUSA
| | - Bradley Hubbard
- St Joseph Mercy Hospital/Michigan Heart and Vascular InstituteAnn ArborMichiganUSA
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8
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KAYA AF, OZDIL MH, YILMAZ C, KILIC R, OZBEK M, KAYA H. Non-invasive Evaluation of Electromechanical Transmission in Patients with Hypertensive Response to Exercise Stress Test. Medeni Med J 2023; 38:180-186. [PMID: 37766599 PMCID: PMC10542984 DOI: 10.4274/mmj.galenos.2023.42027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/09/2023] [Indexed: 09/29/2023] Open
Abstract
Objective Excessive hypertensive response to exercise testing is associated with adverse cardiovascular events such as left ventricular hypertrophy and atrial fibrillation (AF). In this study, we examined the relationship between electromechanical delay and excessive hypertensive response to exercise testing. Methods Twenty-five people who had a hypertensive response to the exercise stress test and 28 people who were similar in age and gender with a normal blood pressure response in the exercise stress test as the control group were included in the study. Results There was no statistical difference between the study groups in blood pressure holter values, conventional echocardiography findings, and exercise stress test findings. Lateral PA-TDI time (the time from the beginning of the P wave measured by tissue Doppler imaging to the beginning of the A' wave), left atrial electromechanical delay, and interatrial electromechanical delay were observed to be significantly longer in the hypertensive response group to exercise stress test compared with the control group (74.0±6.3 vs. 68.8±5.7, p=0.003; 24.7±7.0 vs. 19.6±7.1, p=0.013; 36.8±8.5 vs. 30.6±6.6, p=0.003, respectively). Conclusions Early detection of electromechanical delay non-invasively may be useful in this patient group in predicting the development of new AF risk.
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Affiliation(s)
- Ahmet Ferhat KAYA
- Dicle University Hospital, Department of Cardiology, Diyarbakir, Turkey
| | | | | | - Raif KILIC
- Diyarlife Hospital, Clinic of Cardiology, Diyarbakir, Turkey
| | - Mehmet OZBEK
- Dicle University Hospital, Department of Cardiology, Diyarbakir, Turkey
| | - Hasan KAYA
- Dicle University Hospital, Department of Cardiology, Diyarbakir, Turkey
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Patail H, Bali A, Sharma T, Frishman WH, Aronow WS. Review and Key Takeaways of the 2021 Percutaneous Coronary Intervention Guidelines. Cardiol Rev 2023:00045415-990000000-00151. [PMID: 37729589 DOI: 10.1097/crd.0000000000000608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
The 2021 Percutaneous Coronary Intervention guidelines completed by American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions provide a set of guidelines regarding revascularization strategies. With emphasis on equity of care, multidisciplinary heart team use, revascularization for acute coronary syndrome, and stable ischemic heart disease, the guidelines create a thorough framework with recommendations regarding therapeutic strategies. In this comprehensive review, our aim is to summarize the 2021 revascularization guidelines and analyze key points regarding each recommendation.
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Affiliation(s)
- Haris Patail
- From the Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT
| | - Atul Bali
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Tanya Sharma
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - William H Frishman
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
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10
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Huang CT, Chang CH, Chen JY, Ling DA, Lee AF, Wang PH, Wu CK, Ko YC, Hsiao YT, Lien WC, Chang WT, Huang CH. The effect of point-of-care ultrasound on length of stay and mortality in patients with chest pain/dyspnea. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:389-394. [PMID: 37072032 DOI: 10.1055/a-2048-6274] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
PURPOSE This study aims to investigate the effects of point-of-care ultrasound (PoCUS) on length of stay (LOS) and mortality in hemodynamically stable patients with chest pain/dyspnea. MATERIALS AND METHODS The prospective study was conducted from June 2020 to May 2021. A convenience sample of adult non-traumatic patients with chest pain/dyspnea was included and evaluated by PoCUS. The primary outcome was the relationship between the door-to-PoCUS time and LOS/mortality categorized by the ST-segment elevation (STE) and non-STE on the initial electrocardiogram. The diagnostic accuracy of PoCUS was computed, compared to the final diagnosis. RESULTS A total of 465 patients were included. 3 of 18 patients with STE had unexpected cardiac tamponade and 1 had myocarditis with pulmonary edema. PoCUS had a minimal effect on LOS and mortality in patients with STE. In the non-STE group, the shorter door-to-PoCUS time was associated with a shorter LOS (coefficient, 1.26±0.47, p=0.008). After categorizing the timing of PoCUS as 30, 60, 90, and 120 minutes, PoCUS had a positive effect, especially when performed within 90 minutes of arrival, on LOS of less than 360 minutes (OR, 2.42, 95% CI, 1.61-3.64) and patient survival (OR, 3.32, 95% CI, 1.14-9.71). The overall diagnostic performance of PoCUS was 96.6% (95% CI, 94.9-98.2%), but lower efficacy occurred in pulmonary embolism and myocardial infarction. CONCLUSION The use of PoCUS was associated with a shorter LOS and less mortality in patients with non-STE, especially when performed within 90 minutes of arrival. Although the effect on patients with STE was minimal, PoCUS played a role in discovering unexpected diagnoses.
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Affiliation(s)
- Chien-Tai Huang
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Heng Chang
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Jia-Yu Chen
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Dean-An Ling
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - An-Fu Lee
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Pei-Hsiu Wang
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Kai Wu
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Chih Ko
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Tse Hsiao
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Wan-Ching Lien
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Tien Chang
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Hua Huang
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
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11
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Grande Ratti MF, Bluro IM, Castillo F, Zapiola ME, Pedretti AS, Martínez B. [Clinical characteristics and care times in a chest pain unit of the emergency department of an argentine center]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2023; 4:41-47. [PMID: 37780952 PMCID: PMC10538921 DOI: 10.47487/apcyccv.v4i2.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/18/2023] [Indexed: 10/03/2023]
Abstract
Objectives . To report the frequency of precordial pain, describe clinical characteristics, and care times. Methods . Retrospective descriptive study that included consultations in the Chest Pain Unit in 2021 in the emergency department of a private hospital in Argentina. Results There were 1469 admissions for chest pain, yielding a frequency of 1.09% (95%CI 1.04-1.15). They were 52% men, mean age 62 years (SD ±15); 48% had hypertension and 32% dyslipidemia. The median time to initial ECG was 4.3 min (ICR 2.5-7.5); and 26 min (ICR 14-46) to medical evaluation. A total of 206 (14%) were hospitalized with a median of 3 days, 76% were admitted to a closed unit, 9% required non-invasive ventilation/mechanical ventilaction and in-hospital mortality was 2.9%. Those hospitalized presented shorter delay time to medical attention (p<0.01), and greater performance of complementary studies (p<0.01), with no differences in time to ECG (p=0.22). Conclusions Care times were within the stipulated standards, being an important indicator of quality. Nursing was crucial, taking care of the correct triage, ECG on admission, and guaranteeing care until medical evaluation.
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Affiliation(s)
- María Florencia Grande Ratti
- Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.Instituto Universitario Hospital Italiano de Buenos AiresBuenos AiresArgentina
- Área de Investigación en Medicina Interna, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.Área de Investigación en Medicina Interna, Hospital Italiano de Buenos AiresBuenos AiresArgentina
- CONICET (Consejo Nacional de Investigaciones Científicas y Técnicas), Departamento de Medicina, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.CONICET (Consejo Nacional de Investigaciones Científicas y Técnicas)Departamento de MedicinaHospital Italiano de Buenos AiresBuenos AiresArgentina
- Central de Emergencias de Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.Central de Emergencias de AdultosHospital Italiano de Buenos AiresBuenos AiresArgentina
| | - Ignacio Martín Bluro
- Central de Emergencias de Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.Central de Emergencias de AdultosHospital Italiano de Buenos AiresBuenos AiresArgentina
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.Servicio de CardiologíaHospital Italiano de Buenos AiresBuenos AiresArgentina
| | - Fiorella Castillo
- Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.Instituto Universitario Hospital Italiano de Buenos AiresBuenos AiresArgentina
| | - María Elena Zapiola
- Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.Instituto Universitario Hospital Italiano de Buenos AiresBuenos AiresArgentina
| | - Ana Soledad Pedretti
- Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.Instituto Universitario Hospital Italiano de Buenos AiresBuenos AiresArgentina
| | - Bernardo Martínez
- Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.Instituto Universitario Hospital Italiano de Buenos AiresBuenos AiresArgentina
- Central de Emergencias de Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.Central de Emergencias de AdultosHospital Italiano de Buenos AiresBuenos AiresArgentina
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12
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Arzuan M, Iram YA, Matetzky S, Herscovici R, Goldkorn R, Goitein O, Narodetsky M, Mazin I, Beigel R, Fardman A. Sex differences of patients with acute chest pain evaluated through a chest pain unit. J Cardiovasc Med (Hagerstown) 2023; 24:283-288. [PMID: 36957985 DOI: 10.2459/jcm.0000000000001466] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND Although sex disparities between patients with acute myocardial infarction are well known, the data regarding sex differences among symptomatic patients with acute chest pain (ACP) are limited. METHODS We retrospectively evaluated the records of 1000 consecutive patients with ACP and hospitalized in a tertiary medical center chest pain unit (CPU). Patients were divided according to sex. The primary outcome was defined as a composite end point of readmission because of chest pain, incidence of acute coronary syndrome, revascularization, and death at 90 days and 1 year. RESULTS Overall, 673 men and 327 women were included in the current analysis. There was no difference in regard to sex for patients who underwent noninvasive evaluation, (87.8 vs. 87.3%, P = 0.85, for female vs. male, respectively). Among patients who underwent coronary computed tomography angiography, women were less likely to have significant coronary artery disease (CAD) (4.2 vs. 11.3%, P = 0.005). Similarly, women had fewer significant findings (4.4 vs. 7.6%, P = 0.007) on myocardial perfusion imaging. Consequently, fewer women underwent angiography (8 vs. 14%, P = 0.006) and revascularization (2.8 vs. 7.3%, P = 0.004). During follow-up, sex was not associated with the development of the primary composite outcome [odds ratio (OR) 0.91, 95% confidence interval (CI) 0.39-2.09, P-value = 0.82 and OR 1.16, 95% CI 0.65-2.06, P-value = 0.59 for 90-day and 1-year follow-up, respectively]. CONCLUSION Evaluation of patients through a CPU enables comparable noninvasive evaluation, appropriate utilization of invasive assessment with similar outcomes during the short and intermediate follow-up period regardless of patients' sex.
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Affiliation(s)
| | - Yael Abramov Iram
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Shlomi Matetzky
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Romana Herscovici
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ronen Goldkorn
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Orly Goitein
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Michael Narodetsky
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Israel Mazin
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Roy Beigel
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Alexander Fardman
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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13
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Coronary CTA for Acute Chest Pain in the Emergency Department: Comparison of 64-Detector Row Single-Source and Third-Generation Dual-Source Scanners. AJR Am J Roentgenol 2023:1-11. [PMID: 36856300 DOI: 10.2214/ajr.22.28963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Background: When performing coronary CTA in the emergency department (ED), a contemporary scanner with improved temporal resolution may eliminate the need to administer beta blockers for heart rate (HR) control, thereby expediting workup. Objective: To compare ED length-of-stay (LOS), image quality, frequency of nondiagnostic examinations, and other clinical outcomes between patients undergoing coronary CTA in the ED by a single-source CT (SSCT) scanner with HR control versus a dual-source CT (DSCT) scanner without HR control. Methods: This retrospective study included 509 patients (mean age, 52.1±15.1 years; 283 men, 226 women) at low-to-intermediate risk for acute coronary syndrome who underwent coronary CTA for acute chest pain during off hours in a single ED from March 1, 2020 to April 25, 2022. A total of 205 patients initially underwent CTA using a 64-detector SSCT with HR control (oral beta-blocker administration if HR was >65 beats per minute); following scanner replacement on April 26, 2021, 304 patients underwent CTA using a third-generation DSCT without HR control. Groups were compared in terms of ED LOS and CT completion time (time from ordering of CTA to completion of acquisition) using propensity score matching, and additional endpoints including image quality and nondiagnostic examinations based on radiology reports. Results: DSCT group, compared with SSCT group, showed no significant difference in median ED LOS (505 vs 457 minutes; P=.37), but shorter median CT completion time (95 vs 117 minutes; P<.001); based on mediation analysis, 89% of reduction in CT completion time for DSCT was attributed to absence of HR control. DSCT group, compared with SSCT group, showed higher frequency of examinations with good or excellent image quality (87.8% vs 60.0%, P<.001) and lower frequency of nondiagnostic examinations (1.6% vs 6.3%, P=.01), but no significant difference in frequencies of emergent cardiology consultation, invasive angiography, ED disposition, or coronary revascularization (all P>.05). No patient in either group experienced 30-day all-cause mortality or major adverse cardiovascular event. Conclusion: Use of a DSCT scanner for coronary CTA can eliminate need for beta-blocker administration for HR control while decreasing nondiagnostic examinations. Clinical Impact: A DSCT scanner can expedite clinical processes in the ED.
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14
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Tyner RJ, Whittington MD, Patterson VP, Ho M, Pincus S, Wiler JL, Michael SS. Differences in cardiac testing resource utilization using two different risk stratification schemes. Am J Emerg Med 2023; 65:179-184. [PMID: 36641961 DOI: 10.1016/j.ajem.2022.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 12/05/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Assess whether changing an emergency department (ED) chest pain pathway from utilizing the Thrombolysis in Myocardial Infarction (TIMI) score for risk stratification to an approach utilizing the History, EKG, Age, Risk, Troponin (HEART) score was associated with reductions in healthcare resource utilization. METHODS A retrospective, quasi-experimental study using difference-in-differences and interrupted time series specifications evaluated all ED patients with a chest pain encounter from 8/2015 to 7/2019 at a large academic medical center. We included patients age ≥ 18 with negative troponin testing discharged from the ED. Our standardized care pathway utilized TIMI for risk stratification until 09/2017 and HEART thereafter. We evaluated patients undergoing hospital-based cardiac diagnostic testing (CDT), length of stay (LOS), and 30-day Major Adverse Cardiovascular Events (MACE) at the intervention site before and after the pathway change and compared these outcomes to a similar control site within the health system for the difference-in-differences specification. RESULTS During the study period, 6.3% (450 of 7117) of patients in the TIMI cohort and 7.2% (546 of 7623) in the HEART cohort among 400,965 total ED visits underwent CDT. In a multivariable analysis, transition to the HEART pathway was associated with greater odds of receiving CDT (odds ratio 2.88 [95% CI 1.21 to 6.86]), a reduction in LOS of 34 min (95% CI 2.2 to 67.6), and no significant difference in 30-day MACE. CONCLUSION The transition from TIMI to HEART was associated with mixed consequences for healthcare resource utilization, including increased CDT but reduced length of stay.
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Affiliation(s)
- Robin J Tyner
- Department of Emergency Medicine, University of Colorado School of Medicine.
| | - Melanie D Whittington
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus; Navigation Lab, Data Science to Patient Value/ACCORDS, University of Colorado School of Medicine
| | - Vanessa P Patterson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus; Navigation Lab, Data Science to Patient Value/ACCORDS, University of Colorado School of Medicine
| | - Michael Ho
- Navigation Lab, Data Science to Patient Value/ACCORDS, University of Colorado School of Medicine; Division of Cardiology, Department of Medicine, University of Colorado School of Medicine
| | - Sharon Pincus
- Navigation Lab, Data Science to Patient Value/ACCORDS, University of Colorado School of Medicine
| | - Jennifer L Wiler
- Department of Emergency Medicine, University of Colorado School of Medicine; The CU Denver Business School
| | - Sean S Michael
- Department of Emergency Medicine, University of Colorado School of Medicine; The CU Denver Business School
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15
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Bhagat AA, Fordham MJ, Lohani M, Teressa G. Outcomes of Functional Testing Versus Invasive Cardiac Catheterization for the Evaluation of Intermediate Severity Coronary Stenosis Detected on Cardiac Computed Tomography Angiography. Crit Pathw Cardiol 2023; 22:25-30. [PMID: 36812341 DOI: 10.1097/hpc.0000000000000309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION The aim of this study was to evaluate the effectiveness of functional testing in comparison to invasive coronary angiography (ICA) among acute chest pain patients whose first diagnostic modality was a coronary computed tomography angiogram (CCTA) and were found to have intermediate coronary stenosis, defined as 50%-70% luminal stenosis. METHODS We conducted a retrospective review of 4763 acute chest pain patients ≥18 years old who received a CCTA as the initial diagnostic modality. Of these, 118 patients met enrollment criteria and proceeded to either stress test (80/118) or directly to ICA (38/118). The primary outcome was 30-day major adverse cardiac event, consisting of acute myocardial infarction, urgent revascularization, or death. RESULTS There was no difference in 30-day major adverse cardiac event among patients who underwent initial stress testing versus directly referred to ICA (0% vs. 2.6%, P = 0.322) following CCTA. The rate of revascularization without acute myocardial infarction was significantly higher among those who underwent ICA versus stress test [36.8% vs. 3.8%, P < 0.0001; adjusted odds ratio: 9.6, 95% confidence interval, 1.8-49.6]. Patients who underwent ICA had a higher rate of catheterization without revascularization within 30 days of the index admission in comparison to those who underwent initial stress testing (55.3% vs. 12.5%, P < 0.0001; adjusted odds ratio: 26.7, 95% confidence interval, 6.6-109.5). CONCLUSION Among patients with intermediate coronary stenosis on CCTA, a functional stress test compared with ICA may prevent unnecessary revascularization and improve cardiac catheterization yield without negatively affecting the 30-day patient safety profile.
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Affiliation(s)
- Aditi A Bhagat
- From the Division of Cardiology, Stony Brook University, Stony Brook, NY
| | | | - Minisha Lohani
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Getu Teressa
- Department of Medicine, Stony Brook University, Stony Brook, NY
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16
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Camaro C, Aarts GWA, Adang EMM, van Hout R, Brok G, Hoare A, Rodwell L, de Pooter F, de Wit W, Cramer GE, van Kimmenade RRJ, Damman P, Ouwendijk E, Rutten M, Zegers E, van Geuns RJM, Gomes MER, van Royen N. Rule-out of non-ST-segment elevation acute coronary syndrome by a single, pre-hospital troponin measurement: a randomized trial. Eur Heart J 2023; 44:1705-1714. [PMID: 36755110 PMCID: PMC10182886 DOI: 10.1093/eurheartj/ehad056] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/28/2022] [Accepted: 01/25/2023] [Indexed: 02/10/2023] Open
Abstract
AIMS Patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) are routinely transferred to the emergency department (ED). A clinical risk score with point-of-care (POC) troponin measurement might enable ambulance paramedics to identify low-risk patients in whom ED evaluation is unnecessary. The aim was to assess safety and healthcare costs of a pre-hospital rule-out strategy using a POC troponin measurement in low-risk suspected NSTE-ACS patients. METHODS AND RESULTS This investigator-initiated, randomized clinical trial was conducted in five ambulance regions in the Netherlands. Suspected NSTE-ACS patients with HEAR (History, ECG, Age, Risk factors) score ≤3 were randomized to pre-hospital rule-out with POC troponin measurement or direct transfer to the ED. The sample size calculation was based on the primary outcome of 30-day healthcare costs. Secondary outcome was safety, defined as 30-day major adverse cardiac events (MACE), consisting of ACS, unplanned revascularization or all-cause death. : A total of 863 participants were randomized. Healthcare costs were significantly lower in the pre-hospital strategy (€1349 ± €2051 vs. €1960 ± €1808) with a mean difference of €611 [95% confidence interval (CI): 353-869; P < 0.001]. In the total population, MACE were comparable between groups [3.9% (17/434) in pre-hospital strategy vs. 3.7% (16/429) in ED strategy; P = 0.89]. In the ruled-out ACS population, MACE were very low [0.5% (2/419) vs. 1.0% (4/417)], with a risk difference of -0.5% (95% CI -1.6%-0.7%; P = 0.41) in favour of the pre-hospital strategy. CONCLUSION Pre-hospital rule-out of ACS with a POC troponin measurement in low-risk patients significantly reduces healthcare costs while incidence of MACE was low in both strategies. TRIAL REGISTRATION Clinicaltrials.gov identifier NCT05466591 and International Clinical Trials Registry Platform id NTR 7346.
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Affiliation(s)
- Cyril Camaro
- Department of Cardiology, Radboud University Medical Centre, P.O. Box 9101, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Gelderland, The Netherlands
| | - Goaris W A Aarts
- Department of Cardiology, Radboud University Medical Centre, P.O. Box 9101, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Gelderland, The Netherlands
| | - Eddy M M Adang
- Department of Health Evidence, Radboud Institute for Health Sciences, Geert Grooteplein 21, 6525 EZ Nijmegen, Gelderland, The Netherlands
| | - Roger van Hout
- Ambulance Service, Safety region Gelderland-Zuid, Professor Bellefroidstraat 11, 6525 AG Nijmegen, Gelderland, The Netherlands
| | - Gijs Brok
- Ambulance Service, Safety region Gelderland-Zuid, Professor Bellefroidstraat 11, 6525 AG Nijmegen, Gelderland, The Netherlands
| | - Anouk Hoare
- Ambulance Service, Witte Kruis, Ringveste 7A, 3992 DD Houten, Utrecht, The Netherlands
| | - Laura Rodwell
- Department of Health Evidence, Radboud Institute for Health Sciences, Geert Grooteplein 21, 6525 EZ Nijmegen, Gelderland, The Netherlands
| | - Frank de Pooter
- Ambulance Service, Witte Kruis, Ringveste 7A, 3992 DD Houten, Utrecht, The Netherlands
| | - Walter de Wit
- Ambulance Service, Witte Kruis, Ringveste 7A, 3992 DD Houten, Utrecht, The Netherlands
| | - Gilbert E Cramer
- Department of Cardiology, Radboud University Medical Centre, P.O. Box 9101, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Gelderland, The Netherlands
| | - Roland R J van Kimmenade
- Department of Cardiology, Radboud University Medical Centre, P.O. Box 9101, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Gelderland, The Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Centre, P.O. Box 9101, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Gelderland, The Netherlands
| | - Eva Ouwendijk
- General Practitioner Centre Nijmegen and Boxmeer, Weg door Jonkerbos 108, 6532 SZ Nijmegen, Gelderland, The Netherlands
| | - Martijn Rutten
- Scientific Centre for Quality of Healthcare (IQ Healthcare), Radboud University Medical Centre, Kapittelweg 54, 6525 EP Nijmegen, Gelderland, The Netherlands
| | - Erwin Zegers
- Department of Cardiology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, Gelderland, The Netherlands
| | - Robert-Jan M van Geuns
- Department of Cardiology, Radboud University Medical Centre, P.O. Box 9101, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Gelderland, The Netherlands
| | - Marc E R Gomes
- Department of Cardiology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, Gelderland, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Centre, P.O. Box 9101, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Gelderland, The Netherlands
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O'Neill JC, Ashburn NP, Paradee BE, Snavely AC, Stopyra JP, Noe G, Mahler SA. Rural and socioeconomic differences in the effectiveness of the HEART Pathway accelerated diagnostic protocol. Acad Emerg Med 2023; 30:110-123. [PMID: 36527333 PMCID: PMC10009897 DOI: 10.1111/acem.14643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The HEART Pathway is a validated accelerated diagnostic protocol (ADP) for patients with possible acute coronary syndrome (ACS). This study aimed to compare the safety and effectiveness of the HEART Pathway based on patient rurality (rural vs. urban) or socioeconomic status (SES). METHODS We performed a preplanned subgroup analysis of the HEART Pathway Implementation Study. The primary outcomes were death or myocardial infarction (MI) and hospitalization at 30 days. Proportions were compared by SES and rurality with Fisher's exact tests. Logistic regression evaluated for interactions of ADP implementation with SES or rurality and changes in outcomes within subgroups. RESULTS Among 7245 patients with rurality and SES data, 39.9% (2887/7245) were rural and 22.2% were low SES (1607/7245). The HEART Pathway identified patients as low risk in 32.2% (818/2540) of urban versus 28.1% (425/1512) of rural patients (p = 0.007) and 34.0% (311/915) of low SES versus 29.7% (932/3137) high SES patients (p = 0.02). Among low-risk patients, 30-day death or MI occurred in 0.6% (5/818) of urban versus 0.2% (1/425) rural (p = 0.67) and 0.6% (2/311) with low SES versus 0.4% (4/932) high SES (p = 0.64). Following implementation, 30-day hospitalization was reduced by 7.7% in urban patients (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI] 0.66-0.87), 10.6% in low SES patients (aOR 0.68, 95% CI 0.54-0.86), and 4.5% in high SES patients (aOR 0.83, 95% CI 0.73-0.94). However, rural patients had a nonsignificant 3.3% reduction in hospitalizations. CONCLUSIONS HEART Pathway implementation decreased 30-day hospitalizations regardless of SES and for urban patients but not rural patients. The 30-day death or MI rate was similar among low-risk patients.
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Affiliation(s)
- James C O'Neill
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brennan E Paradee
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Greg Noe
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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18
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Sabir R, Umar M, Medarametla V, Sreedhrala A. Impact of an Observation Medicine Educational Intervention on Residents' Confidence, Knowledge, and Attitudes: A Quasi-Experimental Study. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2023; 10:23821205231183220. [PMID: 37362580 PMCID: PMC10286210 DOI: 10.1177/23821205231183220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 05/26/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVES Driven by innovations in healthcare, observation medicine (OM) is expanding as a medical specialty. Despite exponential growth, education on OM remains underemphasized in the internal medicine (IM) residency programs. We assessed the impact of an educational intervention pairing didactic and experiential learning with an interdepartmental approach on IM residents' confidence, knowledge, and attitudes when providing observation care to patients with neuro-cardiovascular diseases in the hospital setting. METHODS Our multifaceted intervention incorporated OM's principles and practice in a flipped classroom with the team-, case-, lecture- and evidence-based learning model. Kirkpatrick's evaluation model was used to assess the educational intervention's effectiveness according to the first three levels, ie, reaction, learning, and behavior, using quantitative surveys. The surveys were completed pre-intervention, and immediately upon completion of the educational intervention. RESULTS Of 55 eligible residents, 55 (100%) participated in this intervention. Fifty (90%) completed the pre-intervention survey, and 21 (38%) completed the immediate post-intervention survey. Kirkpatrick's evaluation framework showed that the intervention had a positive impact on residents' motivational reaction (attention, relevance, confidence, and satisfaction [ARCS], M = 3.8, SD = 0.87), their knowledge of common observation diagnoses (pre = 49%, post = 63%), particularly on cardiac diagnostic workup and approach to patients with transient neurological symptoms (P < .05), and their behavior and self-assessment of core competency domains (pre-mean = 2.69, post-mean = 3.18, P < .001). CONCLUSIONS Our multimodal intervention provides a framework for a structured OM educational experience that can be incorporated into residency training, even without a formal observation unit rotation. The analysis also offers literary data on the current state of OM education in an IM residency program and supports the need to expand OM's educational resources to counteract the growth in hospital observation services. Future research should include an analysis of residents' knowledge and skills from a longitudinal OM experience and advancing the results to residency programs where observation care is as applicable as ours.
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Affiliation(s)
- Riffat Sabir
- Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield, MA, USA
| | - Muhammad Umar
- Department of Hospital Medicine, University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield, MA, USA
| | - Venkatrao Medarametla
- Department of Hospital Medicine, University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield, MA, USA
| | - Aseesh Sreedhrala
- Department of Hospital Medicine, University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield, MA, USA
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19
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Yan N, Wei L, Li Z, Song Y. Establishment of a nomogram model for acute chest pain triage in the chest pain center. Front Cardiovasc Med 2023; 10:930839. [PMID: 37025691 PMCID: PMC10070711 DOI: 10.3389/fcvm.2023.930839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 03/02/2023] [Indexed: 04/08/2023] Open
Abstract
Background Acute myocardial infarction (AMI) is the leading life-threatening disease in the emergency department (ED), so rapid chest pain triage is important. This study aimed to establish a clinical prediction model for the risk stratification of acute chest pain patients based on the Point-of-care (POC) cardiac troponin (cTn) level and other clinical variables. Methods We conducted a post-hoc analysis of the database from 6,019 consecutive patients (excluding prehospital-diagnosed non-cardiac chest pain patients) attending a local chest pain center (CPC) in China between October 2016 and January 2019. The plasma concentration of cardiac troponin I (cTnI) was measured using a POC cTnI (Cardio Triage, Alere) assay. All the eligible patients were randomly divided into training and validation cohorts by a 7:3 ratio. We performed multivariable logistic regression to select variables and build a nomogram based on the significant predictive factors. We evaluated the model's generalization ability of diagnostic accuracy in the validation cohort. Results We analyzed data from 5,397 patients that were included in this research. The median turnaround time (TAT) of POC cTnI was 16 min. The model was constructed with 6 variables: ECG ischemia, POC cTnI level, hypotension, chest pain symptom, Killip class, and sex. The area under the ROC curve (AUC) in the training and validation cohorts was 0.924 and 0.894, respectively. The diagnostic performance was superior to the GRACE score (AUC: 0.737). Conclusion A practical predictive model was created and could be used for rapid and effective triage of acute chest pain patients in the CPC.
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Affiliation(s)
- Na Yan
- Department of Emergency, TEDA International Cardiovascular Hospital, Clinical School of Cardiovascular Disease, Tianjin Medical University, Tianjin, China
| | - Ling Wei
- Department of Emergency, TEDA International Cardiovascular Hospital, Clinical School of Cardiovascular Disease, Tianjin Medical University, Tianjin, China
- Department of Emergency, TEDA Hospital, Tianjin, China
| | - Zhiwei Li
- Department of Pathophysiology, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, China
| | - Yu Song
- Department of Emergency, TEDA International Cardiovascular Hospital, Clinical School of Cardiovascular Disease, Tianjin Medical University, Tianjin, China
- Department of Emergency, TEDA Hospital, Tianjin, China
- Correspondence: Yu Song
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20
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Shaukat Ali A, Finnerty V, Harel F, Marquis-Gravel G, Vadeboncoeur A, Pelletier-Galarneau M. Impact of rubidium imaging availability on management of patients with acute chest pain. J Nucl Cardiol 2022; 29:3281-3290. [PMID: 35199279 PMCID: PMC8865882 DOI: 10.1007/s12350-022-02923-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/21/2022] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Evaluate the impact of 82-Rubidium positron emission tomography (PET) myocardial perfusion imaging (MPI) availability on patient management presenting at the emergency department (ED) with chest pain (CP). METHODS This is a single-center retrospective study of clinical databases. Patients presenting with CP with a non-definitive suspicion of acute coronary syndrome (ACS) at the ED between April 2016 and February 2020 were divided into 2 groups based on PET availability. The proportion of invasive coronary angiography (ICA) without significant coronary artery disease (CAD), length of stay (LoS), and additional downstream testing were evaluated. RESULTS There were 21,242 ED visits for CP without definitive ACS: 5,492 when PET is not available and 15,750 when PET is available. When PET is available, proportion of patients undergoing a MPI study was greater (20.7% vs 17.6%, P<0.0001), proportion of ICA without significant CAD was similar (18.5% vs 21.4%, P=0.24), and median ED LoS was shorter (16.6 vs 18.1 hours, P=0.03). Patients undergoing SPECT MPI had significantly more downstream testing (8.9% vs 6.4%, P=0.003) and a higher rate of coronary angiogram without significant CAD (21.2% vs 14.2%, P=0.09) compared to those who underwent PET MPI. CONCLUSION Availability of PET MPI was associated with an increased number of MPI referral from the ED, similar rates of ICA without significant CAD, decreased LoS, and fewer downstream testing.
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Affiliation(s)
- Akasha Shaukat Ali
- Department of Medical Imaging, Montreal Heart Institute, Montreal, QC H1T 1C8 Canada
| | - Vincent Finnerty
- Department of Medical Imaging, Montreal Heart Institute, Montreal, QC H1T 1C8 Canada
| | - Francois Harel
- Department of Medical Imaging, Montreal Heart Institute, Montreal, QC H1T 1C8 Canada
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21
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Çevrim Ö, Boydak B, Yürüktümen A, Kiyan G, Ersel M, Uz İ, Özçete E, Başol G. The Diagnostic Value of Echocardiography Performed by an Emergency Medicine Physician in the Diagnosis of Acute Coronary Syndrome: A Comparative Study With Cardiologist. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2022. [DOI: 10.1177/87564793221138100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: Early recognition of acute coronary syndromes (ACSs) is crucial in the emergency department. This study was designed to determine the diagnostic value of echocardiography, which was performed by an emergency medicine (EM) physician, to diagnosis ACS. Materials and Methods: This prospective and cross-sectional study was conducted between June 2011 and December 2011. All patients who were admitted with chest pain, to the EM department, and fulfilled the inclusion criteria were enrolled in this study. The focused echocardiography was performed by the EM physician. All echocardiography videos recorded were shown to the cardiologist. The final comments were compared with EM physician’s early findings. Results: Out of 48 patients, four were diagnosed with ACS. Three out of four patients diagnosed with ACS were detected by the EM physician with echocardiography. The EM physician’s prediction value with echocardiography in ACS diagnosis was 75% (95% confidence interval [CI] range 59%–100%), and the negative predictive value was 97% (95% CI range 77,9%-100%). There was no major cardiac event in the patient in whom the EM physician failed to detect a wall motion defect. Conclusion: Echocardiography is a bedside, noninvasive test for diagnosis of ACS. The EM physician who participated in this study was able to recognize ACS with the absence of a segmental wall motion defect, as well as the cardiologist providing the final report.
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Affiliation(s)
- Özgür Çevrim
- Department of Emergency, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Bahar Boydak
- Department of Internal Medicine, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Aslıhan Yürüktümen
- Department of Emergency Medicine, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - G.Selahattin Kiyan
- Department of Emergency Medicine, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Murat Ersel
- Department of Emergency Medicine, Faculty of Medicine, Ege University, İzmir, Turkey
| | - İlhan Uz
- Department of Emergency Medicine, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Enver Özçete
- Department of Emergency Medicine, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Güneş Başol
- Department of Biochemistry, Faculty of Medicine, Ege University, İzmir, Turkey
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22
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Gomez R. Things We Do For No Reason™: Routine repeat electrocardiogram for low-to-intermediate risk chest pain. J Hosp Med 2022; 18:348-351. [PMID: 35996949 DOI: 10.1002/jhm.12937] [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: 10/23/2021] [Revised: 07/21/2022] [Accepted: 07/25/2022] [Indexed: 11/11/2022]
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23
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Mirna M, Schmutzler L, Topf A, Sipos B, Hehenwarter L, Hoppe UC, Lichtenauer M. A Novel Clinical Score for Differential Diagnosis Between Acute Myocarditis and Acute Coronary Syndrome - The SAlzburg MYocarditis (SAMY) Score. Front Med (Lausanne) 2022; 9:875682. [PMID: 35755032 PMCID: PMC9218572 DOI: 10.3389/fmed.2022.875682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/16/2022] [Indexed: 11/17/2022] Open
Abstract
Background Acute myocarditis and acute coronary syndrome (ACS) are important differential diagnoses in patients with new-onset chest pain. To date, no clinical score exists to support the differentiation between these two diseases. The aim of this study was to develop such a score to aid the physician in scenarios where discrimination between myocarditis and ACS appears difficult. Materials and Methods Patients with ACS (n = 233) and acute myocarditis (n = 123) were retrospectively enrolled. Least absolute shrinkage and selection operator (LASSO) regression was conducted to identify parameters associated with the highest or least probability for acute myocarditis. Logistic regression was conducted using the identified parameters and score points for each level of the predictors were calculated. Cutoffs for the prediction of myocarditis were calculated. Validation was conducted in a separate cohort of 90 patients. Results A score for prediction of acute myocarditis was calculated using six parameters [age, previous infection, hyperlipidemia, hypertension, C-reactive protein (CRP), and leukocyte count]. Logistic regression analysis showed a significant association between total score points and the presence of myocarditis (B = 0.9078, p < 0.0001). Cutoff #1 for the prediction of myocarditis was calculated at ≥ 4 (Sens.: 90.3%, Spec.: 93.1%; 46.3% predicted probability for acute myocarditis), cutoff #2 was calculated at ≥ 7 (Sens.: 73.1%, Spec.: > 99.9%; 92.9% pred. prob.). Validation showed good discrimination [area under the curve (AUC) = 0.935] and calibration of the score. Conclusion Our clinical score showed good discrimination and calibration for differentiating patients with acute myocarditis and ACS. Thus, it could support the differential diagnosis between these two disease entities and could facilitate clinical decisions in affected patients.
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Affiliation(s)
- Moritz Mirna
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Lukas Schmutzler
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Albert Topf
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Brigitte Sipos
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Lukas Hehenwarter
- Department of Nuclear Medicine and Endocrinology, Paracelsus Medical University, Salzburg, Austria
| | - Uta C Hoppe
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Michael Lichtenauer
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
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Abstract
Pain is a complex term that describes various sensations that create discomfort in various ways or types inside the human body. Generally, pain has consequences that range from mild to severe in different organs of the body and will depend on the way it is caused, which could be an injury, illness or medical procedures including testing, surgeries or therapies, etc. With recent advances in artificial-intelligence (AI) systems associated in biomedical and healthcare settings, the contiguity of physician, clinician and patient has shortened. AI, however, has more scope to interpret the pain associated in patients with various conditions by using any physiological or behavioral changes. Facial expressions are considered to give much information that relates with emotions and pain, so clinicians consider these changes with high importance for assessing pain. This has been achieved in recent times with different machine-learning and deep-learning models. To accentuate the future scope and importance of AI in medical field, this study reviews the explainable AI (XAI) as increased attention is given to an automatic assessment of pain. This review discusses how these approaches are applied for different pain types.
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25
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McCord J, Gibbs J, Hudson M, Moyer M, Jacobsen G, Murtagh G, Nowak R. Machine Learning to Assess for Acute Myocardial Infarction Within 30 Minutes. Crit Pathw Cardiol 2022; 21:67-72. [PMID: 35190507 DOI: 10.1097/hpc.0000000000000281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Variations in high-sensitivity cardiac troponin I by age and sex along with various sampling times can make the evaluation for acute myocardial infarction (AMI) challenging. Machine learning integrates these variables to allow a more accurate evaluation for possible AMI. The goal was to test the diagnostic and prognostic utility of a machine learning algorithm in the evaluation of possible AMI. We applied a machine learning algorithm (myocardial-ischemic-injury-index [MI3]) that incorporates age, sex, and high-sensitivity cardiac troponin I levels at time 0 and 30 minutes in 529 patients evaluated for possible AMI in a single urban emergency department. MI3 generates an index value from 0 to 100 reflecting the likelihood of AMI. Patients were followed at 30-45 days for major adverse cardiac events (MACEs). There were 42 (7.9%) patients that had an AMI. Patients were divided into 3 groups by the MI3 score: low-risk (≤ 3.13), intermediate-risk (> 3.13-51.0), and high-risk (> 51.0). The sensitivity for AMI was 100% with a MI3 value ≤ 3.13 and 353 (67%) ruled-out for AMI at 30 minutes. At 30-45 days, there were 2 (0.6%) MACEs (2 noncardiac deaths) in the low-risk group, in the intermediate-risk group 4 (3.0%) MACEs (3 AMIs, 1 cardiac death), and in the high-risk group 4 (9.1%) MACEs (4 AMIs, 2 cardiac deaths). The MI3 algorithm had 100% sensitivity for AMI at 30 minutes and identified a low-risk cohort who may be considered for early discharge.
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Affiliation(s)
- James McCord
- From the Heart and Vascular Institute, Henry Ford Hospital, Detroit, MI
| | - Joseph Gibbs
- From the Heart and Vascular Institute, Henry Ford Hospital, Detroit, MI
| | - Michael Hudson
- From the Heart and Vascular Institute, Henry Ford Hospital, Detroit, MI
| | - Michele Moyer
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
| | - Gordon Jacobsen
- Biostatistics, Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
| | | | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 623] [Impact Index Per Article: 311.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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27
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 706] [Impact Index Per Article: 353.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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28
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Lopez DM, Divakaran S, Gupta A, Bajaj NS, Osborne MT, Zhou W, Hainer J, Bibbo CF, Skali H, Dorbala S, Taqueti VR, Blankstein R, Di Carli MF. Role of Exercise Treadmill Testing in the Assessment of Coronary Microvascular Disease. JACC Cardiovasc Imaging 2022; 15:312-321. [PMID: 34419395 PMCID: PMC8831663 DOI: 10.1016/j.jcmg.2021.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The authors aimed to study the sensitivity and specificity of exercise treadmill testing (ETT) in the diagnosis of coronary microvascular disease (CMD), as well as the prognostic implications of ETT results in patients with CMD. BACKGROUND ETT is validated to evaluate for flow-limiting coronary artery disease (CAD), however, little is known about its use for evaluating CMD. METHODS We retrospectively studied 249 consecutive patients between 2006 and 2016 who underwent ETT and positron emission tomography within 12 months. Patients with obstructive CAD or left ventricular systolic dysfunction were excluded. CMD was defined as a coronary flow reserve <2. Patients were followed for the occurrence of a first major adverse event (composite of death or hospitalization for myocardial infarction or heart failure). RESULTS The sensitivity and specificity of a positive ETT to detect CMD were 34.7% (95% CI: 25.4%-45.0%) and 64.9% (95% CI: 56.7%-72.5%), respectively. The specificity of a positive ETT to detect CMD increased to 86.8% (95% CI: 80.3%-91.7%) when only classifying studies with ischemic electrocardiogram changes that lasted at least 1 minute into recovery as positive, although at a cost of lower sensitivity (15.3%; 95% CI: 8.8%-24.0%). Over a median follow-up of 6.9 years (IQR: 5.1-8.2 years), 30 (12.1%) patients met the composite endpoint, including 13 (13.3%) with CMD (n = 98). In patients with CMD, ETT result was not associated with the composite endpoint (P = 0.076). CONCLUSIONS Our data suggest limited sensitivity of ETT to detect CMD. However, a positive ETT with ischemic changes that persist at least 1 minute into recovery in the absence of obstructive CAD should raise suspicion for the presence of CMD given a high specificity. Further study is needed with larger patient sample sizes to assess the association between ETT results and outcomes in patients with CMD.
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Affiliation(s)
- Diana M. Lopez
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA;,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sanjay Divakaran
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA;,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ankur Gupta
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Navkaranbir S. Bajaj
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael T. Osborne
- Cardiovascular Imaging Research Center, Departments of Medicine and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wunan Zhou
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Courtney F. Bibbo
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hicham Skali
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA;,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Viviany R. Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA;,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcelo F. Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA;,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Ma C, Liu X, Ma L. A New Risk Score for Patients With Acute Chest Pain and Normal High Sensitivity Troponin. Front Med (Lausanne) 2022; 8:728339. [PMID: 35059410 PMCID: PMC8764281 DOI: 10.3389/fmed.2021.728339] [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: 06/21/2021] [Accepted: 10/28/2021] [Indexed: 11/25/2022] Open
Abstract
Objective: To investigate a new risk score for patients who suffered from acute chest pain with normal high-sensitivity troponin I (hs-TnI) levels. Methods: In this study, patients with acute chest pain who were admitted to the emergency department (ED) of our hospital had been recruited. Hs-TnI was measured in serum samples drawn on admission to the ED. The end point was the occurrence of major adverse cardiac events (MACE) within 3 months. Predictor variables were selected by logistic regression analysis, and external validity was assessed in this study. Furthermore, validation was performed in an independent cohort, i.e., 352 patients (validation cohort). Results: A total of 724 patients were included in the derivation cohort. The results showed that four predictor variables were significant in the regression analysis—male, a history of chest pain, 60 years of age or older and with three or more coronary artery disease (CAD) risk factors. A total of 105 patients in the validation cohort had serious adverse cardiac events. The validation cohort showed a homogenous pattern with the derivation cohort when patients were stratified by score. The area under the curve (AUC) of the receiver operating characteristic (ROC) in the derivation cohort was 0.80 (95% CI: 0.76–0.83), while in the validation cohort, it was 0.79 (95% CI: 0.75–0.82). Conclusion: A new risk score was developed for acute chest pain patients without known CAD and ST-segment deviation and with normal hs-TnI and may aid MACE risk assessment and patient triage in the ED.
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Affiliation(s)
- Chunpeng Ma
- Department of Cardiology, The First Hospital of Qinhuangdao, Qinhuangdao, China
| | - Xiaoli Liu
- Department of Endocrinology, The First Hospital of Qinhuangdao, Qinhuangdao, China
| | - Lixiang Ma
- Department of Cardiology, The First Hospital of Qinhuangdao, Qinhuangdao, China
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr 2022; 16:54-122. [PMID: 34955448 DOI: 10.1016/j.jcct.2021.11.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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31
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Wang GM. The combination of creatine kinase-myocardial band isoenzyme and point-of-care cardiac troponin/contemporary cardiac troponin for the early diagnosis of acute myocardial infarction. World J Emerg Med 2022; 13:163-168. [DOI: 10.5847/wjem.j.1920-8642.2022.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 12/20/2021] [Indexed: 11/19/2022] Open
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32
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Soeiro ADM, Biselli B, Leal TC, Bossa AS, César MC, Jallad S, Goldstein PG, Guimarães PO, Serrano CV, Nomura CH, Nakamura D, Rochitte CE, Soares PR, Oliveira MTD. Desempenho Diagnóstico da Angiotomografia Computadorizada e da Avaliação Seriada de Troponina Cardíaca Sensível em Pacientes com Dor Torácica e Risco Intermediário para Eventos Cardiovasculares. Arq Bras Cardiol 2021; 118:894-902. [PMID: 35137790 PMCID: PMC9368885 DOI: 10.36660/abc.20210006] [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: 01/05/2021] [Accepted: 06/16/2021] [Indexed: 11/21/2022] Open
Abstract
Fundamento A angiotomografia coronária (ATC) tem sido usada para avaliação de dor torácica principalmente em pacientes de baixo risco, e poucos dados existem com pacientes em risco intermediário. Objetivo Avaliar o desempenho de medidas seriadas de troponinas sensíveis e de ATC em pacientes de risco intermediário. Métodos Um total de 100 pacientes com dor torácica, TIMI score 3 ou 4 e troponina negativa foram prospectivamente incluídos. Todos os pacientes foram submetidos à ATC, e aqueles com obstruções ≥ 50% foram encaminhados à cineangiocoronariografia. Pacientes com lesões < 50% recebiam alta hospitalar, receberam alta e foram contatados 30 dias depois por telefonema para avaliação dos desfechos clínicos. Os desfechos foram hospitalização, morte, e infarto agudo do miocárdio em 30 dias. A comparação entre os métodos foi realizada pelo teste de concordância kappa. O desempenho das medidas de troponina e da ATC na detecção de lesões coronárias significativas e desfechos clínicos foi calculado. Os resultados foram considerados estatisticamente significativos quando p <0,05. Resultados Estenose coronária ≥ 50% na ATC foi encontrada em 38% dos pacientes e lesões coronárias significativas na angiografia coronária foram encontradas em 31 pacientes. Dois eventos clínicos foram observados. A análise de concordância Kappa mostrou baixa concordância entre as medidas de troponina e ATC na detecção de lesões coronárias significativas (kappa = 0,022, p = 0,78). O desempenho da ATC para detectar lesões coronárias significativas na angiografia coronária ou para prever eventos clínicos em 30 dias foi melhor que as medidas de troponina sensível (acurácia de 91% versus 60%). Conclusão ATC teve melhor desempenho que as medidas seriadas de troponina na detecção de doença coronariana significativa em pacientes com dor torácica e risco intermediário para eventos cardiovasculares.
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Zaboli A, Ausserhofer D, Sibilio S, Toccolini E, Bonora A, Giudiceandrea A, Rella E, Paulmichl R, Pfeifer N, Turcato G. Effect of the Emergency Department Assessment of Chest Pain Score on the Triage Performance in Patients With Chest Pain. Am J Cardiol 2021; 161:12-18. [PMID: 34635312 PMCID: PMC9336201 DOI: 10.1016/j.amjcard.2021.08.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/29/2021] [Accepted: 08/31/2021] [Indexed: 12/01/2022]
Abstract
The sensitivity of triage systems in identifying acute cardiovascular events in patients presented to the emergency department with chest pain is not optimal. Recently, a clinical score, the Emergency Department Assessment of Chest Pain Score (EDACS), has been proposed for a rapid assessment without additional instruments. To evaluate whether the integration of EDACS into triage evaluation of patients with chest pain can improve the triage's predictive validity for an acute cardiovascular event, a single-center prospective observational study was conducted. This study involved all patients who needed a triage admission for chest pain between January 1, 2020, and December 31, 2020. All enrolled patients first underwent a standard triage assessment and then the EDACS was calculated. The primary outcome of the study was the presence of an acute cardiovascular event. The discriminatory ability of EDACS in triage compared with standard triage assessment was evaluated by comparing the areas under the receiver operating characteristic curve, decision curve analysis, and net reclassification improvement. The study involved 1,596 patients, of that 7.3% presented the study outcome. The discriminatory ability of triage presented an area under the receiver operating characteristic curve of 0.688 that increased to 0.818 after the application of EDACS in the triage assessment. EDACS improved the baseline assessment of priority assigned in triage, with a net reclassification improvement of 33.6% (p <0.001), and the decision curve analyses demonstrated that EDACS in triage resulted in a clear net clinical benefit. In conclusion, the results of the study suggest that EDACS has a good discriminatory capacity for acute cardiovascular events and that its implementation in routine triage may improve triage performance in patients with chest pain.
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34
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:e187-e285. [PMID: 34756653 DOI: 10.1016/j.jacc.2021.07.053] [Citation(s) in RCA: 303] [Impact Index Per Article: 101.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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35
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 136] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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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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Mark DG, Huang J, Ballard DW, Kene MV, Sax DR, Chettipally UK, Lin JS, Bouvet SC, Cotton DM, Anderson ML, McLachlan ID, Simon LE, Shan J, Rauchwerger AS, Vinson DR, Reed ME. Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study. J Am Heart Assoc 2021; 10:e022539. [PMID: 34743565 PMCID: PMC8751925 DOI: 10.1161/jaha.121.022539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA-ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA-ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48-month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7-day objective cardiac testing). Secondary outcomes were 30-day objective cardiac testing, 60-day major adverse cardiac events (MACE), and 60-day MACE-CR (MACE excluding coronary revascularization). Difference-in-differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30-day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60-day MACE risk (-2.5%, 95% CI -3.7 to -1.2%, P<0.001) and increased among patients with non-low (>2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, P=0.014), without significant overall change (-1.0%, 95% CI -2.1 to 0.1%, P=0.079). There were no statistically significant differences in index visit resource utilization, 60-day MACE or 60-day MACE-CR. Conclusions Implementation of RISTRA-ACS was associated with better allocation of 30-day objective cardiac testing and no change in index visit resource utilization or 60-day MACE. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.
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Affiliation(s)
- Dustin G Mark
- Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Department of Critical Care Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Division of Research Kaiser Permanente Northern California Oakland CA
| | - Jie Huang
- Division of Research Kaiser Permanente Northern California Oakland CA
| | - Dustin W Ballard
- Division of Research Kaiser Permanente Northern California Oakland CA.,Department of Emergency Medicine Kaiser Permanente San Rafael Medical Center San Rafael CA
| | - Mamata V Kene
- Department of Emergency Medicine Kaiser Permanente San Leandro Medical Center San Leandro CA
| | - Dana R Sax
- Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Division of Research Kaiser Permanente Northern California Oakland CA
| | - Uli K Chettipally
- Department of Emergency Medicine Kaiser Permanente South San Francisco Medical Center South San Francisco CA
| | - James S Lin
- Department of Emergency Medicine Kaiser Permanente Santa Clara Medical Center Santa Clara CA
| | - Sean C Bouvet
- Department of Emergency Medicine Kaiser Permanente Walnut Creek Medical Center Walnut Creek CA
| | - Dale M Cotton
- Department of Emergency Medicine Kaiser Permanente South Sacramento Medical Center Sacramento CA
| | - Megan L Anderson
- Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA
| | - Ian D McLachlan
- Department of Emergency Medicine Kaiser Permanente San Francisco Medical Center San Francisco CA
| | - Laura E Simon
- University of California San Diego School of Medicine San Diego CA
| | - Judy Shan
- Division of Research Kaiser Permanente Northern California Oakland CA
| | | | - David R Vinson
- Division of Research Kaiser Permanente Northern California Oakland CA.,Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA
| | - Mary E Reed
- Division of Research Kaiser Permanente Northern California Oakland CA
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38
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Olsson P, Khoshnood A, Mokhtari A, Ekelund U. Glucose and high-sensitivity troponin T predict a low risk of major adverse cardiac events in emergency department chest pain patients. SCAND CARDIOVASC J 2021; 55:354-361. [PMID: 34617492 DOI: 10.1080/14017431.2021.1987512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background. Glucose is emerging as a biomarker for early and safe rule-out of acute myocardial infarction in emergency department (ED) chest pain patients. We evaluated the diagnostic accuracy of dual testing with high sensitivity TnT (hs-cTnT) and glucose for prediction of major adverse cardiac events (MACE) within 30 days. Methods. This was a secondary analysis of a single-center prospective observational study of 1167 ED chest-pain patients with hs-cTnT and glucose testing at presentation (0 h), and hs-cTnT 1 h later. We tested the addition of glucose <5.6 mmol/L to three MACE rule-out strategies: hs-cTnT <5 ng/L, ≤14 ng/L or a 0 h/1h algorithm, i.e. initial hs-cTnT <12 ng/L with a 1 h change of <3 ng/L. We also tested the addition of glucose ≥11mmol/L to three rule-in strategies: hs-cTnT ≥52 ng/L, a 1 h change ≥5 ng/L or hs-cTnT >14 ng/L. The outcomes were 30-day MACE and 30-day MACE without UA. Results. Two dual-testing approaches reached our target NPV for rule-out: A 0 h hs-cTnT ≤14 ng/L and glucose <5.6 mmol/L identified 252 patients (24.4%) with a 98.8% NPV for 30-day MACE and 99.6% for MACE without UA. The 0 h/1h hs-cTnT algorithm combined with glucose identified 240 patients (23.2%) with a 99.2% NPV for 30-day MACE and 100.0% for MACE without UA. No dual rule-in strategy performed better than using hs-cTnT alone. Conclusions. A combination of hs-cTnT and blood glucose at presentation can be used to identify almost ¼ of ED chest pain patients with a very low risk of 30-day MACE where further testing is not needed. Adding glucose did not improve the rule-in of 30-day MACE.
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Affiliation(s)
- Pontus Olsson
- Department of Internal and Emergency Medicine, Skåne University Hospital, Lund University, Lund, Sweden
| | - Ardavan Khoshnood
- Department of Internal and Emergency Medicine, Skåne University Hospital, Lund University, Lund, Sweden
| | - Arash Mokhtari
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Ulf Ekelund
- Department of Internal and Emergency Medicine, Skåne University Hospital, Lund University, Lund, Sweden
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Liu WT, Lin CS, Tsao TP, Lee CC, Cheng CC, Chen JT, Tsai CS, Lin WS, Lin C. A Deep-Learning Algorithm-Enhanced System Integrating Electrocardiograms and Chest X-rays for Diagnosing Aortic Dissection. Can J Cardiol 2021; 38:160-168. [PMID: 34619339 DOI: 10.1016/j.cjca.2021.09.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/10/2021] [Accepted: 09/27/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Chest pain is the most common symptom of aortic dissection (AD), but it is often confused with other prevalent cardiopulmonary diseases. We aimed to develop deep-learning models (DLMs) with electrocardiography (ECG) and chest x-ray (CXR) features to detect AD and evaluate their performance. METHODS This study included 43,473 patients in the emergency department (ED) between July 2012 and December 2019 for retrospective DLM development. A development cohort including 49,071 ED records (120 AD type A and 64 AD type B) was used to train DLMs for ECG and CXR, and 9904 independent ED records (40 AD type A and 34 AD type B) were used to validate DLM performance. Human-machine competitions of ECG and CXR were conducted. Patient characteristics and laboratory results were used to enhance the diagnostic accuracy. The DLM-enabled AD diagnostic process was prospectively evaluated in 25,885 ED visits. RESULTS The area under the curves (AUCs) of the ECG and CXR models were 0.918 and 0.857 for detecting AD in a human-machine competition, respectively, which were better than those of the participating physicians. In the validation cohort, the AUCs of the integrated model were 0.882, 0.960, and 0.813 in all AD, AD type A, and AD type B patients, respectively, with a sensitivity of 100.0% and a specificity of 81.7% for AD type A. In patients with chest pain and D-dimer tests, the DLM could predict more precisely, achieving a positive predictive value of 62.5% in the prospective evaluation. CONCLUSIONS DLMs may serve as decision-supporting tools for identification of AD and facilitate differential diagnosis in patients with acute chest pain.
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Affiliation(s)
- Wei-Ting Liu
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tien-Ping Tsao
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Division of Cardiology, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Chia-Cheng Lee
- Division of Colorectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Cheng-Chung Cheng
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jiann-Torng Chen
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Sung Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Shiang Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin Lin
- School of Medicine, National Defense Medical Center, Taipei, Taiwan.
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Cubedo J, Padró T, Vilahur G, Crea F, Storey RF, Lopez Sendon JL, Kaski JC, Sionis A, Sans-Rosello J, Fernández-Peregrina E, Gallinat A, Badimon L. Glycosylated apolipoprotein J in cardiac ischaemia: molecular processing and circulating levels in patients with acute ischaemic events. Eur Heart J 2021; 43:153-163. [PMID: 34580705 DOI: 10.1093/eurheartj/ehab691] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/16/2021] [Accepted: 09/15/2021] [Indexed: 11/12/2022] Open
Abstract
AIM Using proteomics, we previously found that serum levels of glycosylated (Glyc) forms of apolipoprotein J (ApoJ), a cytoprotective and anti-oxidant protein, decrease in the early phase of acute myocardial infarction (AMI). We aimed to investigate: (i) ApoJ-Glyc intracellular distribution and secretion during ischaemia; (ii) the early changes in circulating ApoJ-Glyc during AMI; and (iii) associations between ApoJ-Glyc and residual ischaemic risk post-AMI. METHODS AND RESULTS Glycosylated apolipoprotein J was investigated in: (i) cells from different organ/tissue origin; (ii) a pig model of AMI; (iii) de novo AMI patients (n = 38) at admission within the first 6 h of chest pain onset and without troponin T elevation at presentation (early AMI); (iv) ST-elevation myocardial infarction patients (n = 212) who were followed up for 6 months; and (v) a control group without any overt cardiovascular disease (n = 144). Inducing simulated ischaemia in isolated cardiac cells resulted in an increased intracellular accumulation of non-glycosylated ApoJ forms. A significant decrease in ApoJ-Glyc circulating levels was seen 15 min after ischaemia onset in pigs. Glycosylated apolipoprotein J levels showed a 45% decrease in early AMI patients compared with non-ischaemic patients (P < 0.0001), discriminating the presence of the ischaemic event (area under the curve: 0.934; P < 0.0001). ST-elevation myocardial infarction patients with lower ApoJ-Glyc levels at admission showed a higher rate of recurrent ischaemic events and mortality after 6-month follow-up (P = 0.008). CONCLUSIONS These results indicate that ischaemia induces an intracellular accumulation of non-glycosylated ApoJ and a reduction in ApoJ-Glyc secretion. Glycosylated apolipoprotein J circulating levels are reduced very early after ischaemia onset. Its continuous decrease indicates a worsening in the evolution of the cardiac event, likely identifying patients with sustained ischaemia after AMI.
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Affiliation(s)
- Judit Cubedo
- Cardiovascular Program-ICCC-IR, Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain
| | - Teresa Padró
- Cardiovascular Program-ICCC-IR, Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CiberCV), Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain
| | - Gemma Vilahur
- Cardiovascular Program-ICCC-IR, Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CiberCV), Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain
| | - Filippo Crea
- Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, Roma 00168, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Via Giuseppe Moscati, 31, Roma 00168, Italy
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK
| | | | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London SW17 0RE, UK
| | - Alessandro Sionis
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CiberCV), Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain.,Cardiology Department, Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain
| | - Jordi Sans-Rosello
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CiberCV), Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain.,Cardiology Department, Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain
| | | | - Alex Gallinat
- Cardiovascular Program-ICCC-IR, Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain
| | - Lina Badimon
- Cardiovascular Program-ICCC-IR, Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CiberCV), Hospital Santa Creu i Sant Pau, c/Sant Antoni MaClaret 167, 08025 Barcelona, Spain.,Autonomous University of Barcelona, Bellaterra 08193, Spain
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Aurora L, McCord J, Nowak R, Giannitsis E, Christenson R, DeFilippi C, Lindahl B, Christ M, Body R, Jacobsen G, Mueller C. Prognostic Utility of a Modified HEART Score When Different Troponin Cut Points Are Used. Crit Pathw Cardiol 2021; 20:134-139. [PMID: 33988541 DOI: 10.1097/hpc.0000000000000262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although the recommended cut point for cardiac troponin (cTn) is the 99th percentile, many institutions use cut points that are multiples higher than the 99th percentile for diagnosing acute myocardial infarction (AMI). Prior studies have shown that patients with a HEART score (HS) ≤ 3 and normal serial cTn values (modified HS) are at low risk for adverse events. This study aimed to evaluate the prognostic utility of the HS when various cTn cut points are used. METHODS This was a substudy of High Sensitivity Cardiac Troponin T assay for RAPID Rule-out of Acute Myocardial Infarction (TRAPID-AMI), a multicenter, international trial evaluating a rapid rule-out AMI study using high-sensitivity cardiac troponin T (hs-cTnT). One-thousand two-hundred eighty-two patients were evaluated for AMI from 12 centers in Europe, United States, and Australia from 2011 to 2013. Blood samples of hs-cTnT were collected at presentation and 2 hours, and each patient had a HS calculated. The US Food and Drug Administration approved 99th percentile for hs-cTnT (19 ng/L) was used. RESULTS There were 213 (17%) AMIs. Within 30 days, there were an additional 2 AMIs and 8 deaths. The adverse event rates at 30 days (death/AMI) for a HS ≤ 3 and nonelevated hs-cTnT over 2 hours using increasing hs-cTnT cut points ranged from 0.6% to 5.1%. CONCLUSIONS Using the recommended 99th percentile cut point for hs-cTnT, the combination of a HS ≤ 3 with nonelevated hs-cTnT values over 2 hours identifies a low-risk cohort who can be considered for discharge from the emergency department without further testing. The prognostic utility of this strategy is greatly lessened as higher hs-cTnT cut points are used.
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Affiliation(s)
- Lindsey Aurora
- From the Heart and Vascular Institute, Henry Ford Health System, Detroit, MI
| | - James McCord
- From the Heart and Vascular Institute, Henry Ford Health System, Detroit, MI
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
| | - Evangelos Giannitsis
- Depar Medizinische Klinik III, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Robert Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
| | | | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Michael Christ
- Department of Emergency Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Richard Body
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Gordon Jacobsen
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
| | - Christian Mueller
- Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
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Stopyra JP, Snavely AC, Ashburn NP, Nelson R, McMurray EL, Hunt MR, Miller CD, Mahler SA. EMS blood collection from patients with acute chest pain reduces emergency department length of stay. Am J Emerg Med 2021; 47:248-252. [PMID: 33964547 PMCID: PMC9052866 DOI: 10.1016/j.ajem.2021.04.073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/16/2021] [Accepted: 04/23/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Expediting the measurement of serum troponin by leveraging EMS blood collection could reduce the diagnostic time for patients with acute chest pain and help address Emergency Department (ED) overcrowding. However, this practice has not been examined among an ED chest pain patient population in the United States. METHODS A prospective observational cohort study of adults with non-traumatic chest pain without ST-segment elevation myocardial infarction was conducted in three EMS agencies between 12/2016-4/2018. During transport, paramedics obtained a patient blood sample that was sent directly to the hospital core lab for troponin measurement. On ED arrival HEART Pathway assessments were completed by ED providers as part of standard care. ED providers were blinded to troponin results from EMS blood samples. To evaluate the potential impact on length of stay (LOS), the time difference between EMS blood draw and first clinical ED draw was calculated. To determine the safety of using troponin measures from EMS blood samples, the diagnostic performance of the HEART Pathway for 30-day major adverse cardiac events (MACE: composite of cardiac death, myocardial infarction (MI), coronary revascularization) was determined using EMS troponin plus arrival ED troponin and EMS troponin plus a serial 3-h ED troponin. RESULTS The use of EMS blood samples for troponin measures among 401 patients presenting with acute chest pain resulted in a mean potential reduction in LOS of 72.5 ± SD 35.7 min. MACE at 30 days occurred in 21.0% (84/401), with 1 cardiac death, 78 MIs, and 5 revascularizations without MI. Use of the HEART Pathway with EMS and ED arrival troponin measures yielded a NPV of 98.0% (95% CI: 89.6-100). NPV improved to 100% (95% CI: 92.9-100) when using the EMS and 3-h ED troponin measures. CONCLUSIONS EMS blood collection used for core lab ED troponin measures could significantly reduce ED LOS and appears safe when integrated into the HEART Pathway.
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Affiliation(s)
- Jason P. Stopyra
- Corresponding author at: Department of Emergency Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA., (J.P. Stopyra)
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Zhang M, Huang L, Yang J, Xu W, Su H, Cao J, Wang Q, Pu J, Qian K. Ultra-Fast Label-Free Serum Metabolic Diagnosis of Coronary Heart Disease via a Deep Stabilizer. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2021; 8:e2101333. [PMID: 34323397 PMCID: PMC8456274 DOI: 10.1002/advs.202101333] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/19/2021] [Indexed: 05/07/2023]
Abstract
Although mass spectrometry (MS) of metabolites has the potential to provide real-time monitoring of patient status for diagnostic purposes, the diagnostic application of MS is limited due to sample treatment and data quality/reproducibility. Here, the generation of a deep stabilizer for ultra-fast, label-free MS detection and the application of this method for serum metabolic diagnosis of coronary heart disease (CHD) are reported. Nanoparticle-assisted laser desorption/ionization-MS is used to achieve direct metabolic analysis of trace unprocessed serum in seconds. Furthermore, a deep stabilizer is constructed to map native MS results to high-quality results obtained by established methods. Finally, using the newly developed protocol and diagnosis variation characteristic surface to characterize sensitivity/specificity and variation, CHD is diagnosed with advanced accuracy in a high-throughput/speed manner. This work advances design of metabolic analysis tools for disease detection as it provides a direct label-free, ultra-fast, and stabilized platform for future protocol development in clinics.
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Affiliation(s)
- Mengji Zhang
- State Key Laboratory for Oncogenes and Related GenesSchool of Biomedical EngineeringInstitute of Medical Robotics and Med‐X Research InstituteShanghai Jiao Tong UniversityShanghai200030P. R. China
- State Key Laboratory for Oncogenes and Related GenesDivision of CardiologyRenji HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghai Cancer Institute160 Pujian RoadShanghai200127P. R. China
| | - Lin Huang
- State Key Laboratory for Oncogenes and Related GenesSchool of Biomedical EngineeringInstitute of Medical Robotics and Med‐X Research InstituteShanghai Jiao Tong UniversityShanghai200030P. R. China
- State Key Laboratory for Oncogenes and Related GenesDivision of CardiologyRenji HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghai Cancer Institute160 Pujian RoadShanghai200127P. R. China
| | - Jing Yang
- State Key Laboratory for Oncogenes and Related GenesSchool of Biomedical EngineeringInstitute of Medical Robotics and Med‐X Research InstituteShanghai Jiao Tong UniversityShanghai200030P. R. China
- State Key Laboratory for Oncogenes and Related GenesDivision of CardiologyRenji HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghai Cancer Institute160 Pujian RoadShanghai200127P. R. China
| | - Wei Xu
- State Key Laboratory for Oncogenes and Related GenesSchool of Biomedical EngineeringInstitute of Medical Robotics and Med‐X Research InstituteShanghai Jiao Tong UniversityShanghai200030P. R. China
- State Key Laboratory for Oncogenes and Related GenesDivision of CardiologyRenji HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghai Cancer Institute160 Pujian RoadShanghai200127P. R. China
| | - Haiyang Su
- State Key Laboratory for Oncogenes and Related GenesSchool of Biomedical EngineeringInstitute of Medical Robotics and Med‐X Research InstituteShanghai Jiao Tong UniversityShanghai200030P. R. China
- State Key Laboratory for Oncogenes and Related GenesDivision of CardiologyRenji HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghai Cancer Institute160 Pujian RoadShanghai200127P. R. China
| | - Jing Cao
- State Key Laboratory for Oncogenes and Related GenesSchool of Biomedical EngineeringInstitute of Medical Robotics and Med‐X Research InstituteShanghai Jiao Tong UniversityShanghai200030P. R. China
- State Key Laboratory for Oncogenes and Related GenesDivision of CardiologyRenji HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghai Cancer Institute160 Pujian RoadShanghai200127P. R. China
| | - Qian Wang
- State Key Laboratory for Oncogenes and Related GenesSchool of Biomedical EngineeringInstitute of Medical Robotics and Med‐X Research InstituteShanghai Jiao Tong UniversityShanghai200030P. R. China
- State Key Laboratory for Oncogenes and Related GenesDivision of CardiologyRenji HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghai Cancer Institute160 Pujian RoadShanghai200127P. R. China
| | - Jun Pu
- State Key Laboratory for Oncogenes and Related GenesDivision of CardiologyRenji HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghai Cancer Institute160 Pujian RoadShanghai200127P. R. China
| | - Kun Qian
- State Key Laboratory for Oncogenes and Related GenesSchool of Biomedical EngineeringInstitute of Medical Robotics and Med‐X Research InstituteShanghai Jiao Tong UniversityShanghai200030P. R. China
- State Key Laboratory for Oncogenes and Related GenesDivision of CardiologyRenji HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghai Cancer Institute160 Pujian RoadShanghai200127P. R. China
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Chest pain and acute coronary syndrome in octogenarians admitted to the Emergency Department. Aging Clin Exp Res 2021; 33:2213-2221. [PMID: 33099674 DOI: 10.1007/s40520-020-01737-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Although chest pain and acute coronary syndrome (ACS) are among the most common complaints in the Emergency Departments (ED), little is known about this topic in the octogenarian population. OBJECTIVES This study aimed to describe the clinical presentation and to evaluate survival time according to the ACS type in a group of 80-year-old or over patients admitted for chest pain to an ED. METHODS Patients were classified according to the discharge diagnosis. A multivariable Cox regression analysis was done to assess the association between ACS type and mortality with the non-ACS chest pain group as the reference category. RESULTS ACS was diagnosed in 170 of the 391 patients analyzed and 51% of ACS patients were female. Within the ACS patients, 18.8% presented STEMI, 57% NSTEMI, and 24% unstable angina (UA). Most of the patients were treated conservatively. In the adjusted analysis, the incidence of death at 40 months of follow-up was higher in patients with STEMI (HR 3.24; CI 1.59-6.56) than NSTEMI (HR 2.53; CI 1.56-4.11). There was no difference between patients with UA and the non-ACS group (HR 0.64; CI 0.26-1.58), and myocardial revascularization was associated with reduced mortality risk (HR 0.45; CI 0.22-0.92). CONCLUSIONS A high prevalence of ACS was found among octogenarians admitted to the ED with chest pain, and the ACS type behaved as an independent predictor of mortality. Patients with UA diagnosis had a similar prognosis to patients with non-ACS chest pain, but this needs to be demonstrated by a prospective study.
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Prognostic Value of Coronary Artery Disease-Reporting and Data System Score for Major Adverse Cardiac Events in Patients Attending the Emergency Department With Acute Chest Pain. J Comput Assist Tomogr 2021; 45:395-402. [PMID: 34297510 DOI: 10.1097/rct.0000000000001153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to compare the prognostic performance of Coronary Artery Disease (CAD)-Reporting and Data System (CAD-RADS) score with those of clinical risk factors and the extent of CAD classification for predicting major adverse cardiac events in emergency department patients. METHODS A total of 779 patients with acute chest pain at low to intermediate risk for CAD underwent cardiac computed tomography angiography. The primary end point was early and late major adverse cardiac events. We developed the following models: model 1, clinical risk factors; model 2, clinical risk factors and CAD-RADS scores; model 3, clinical risk factors and extent of CAD. RESULTS The C-statistics revealed that both CAD-RADS score and CAD extent improved risk stratification over the clinical risk factors (C-index for early events: C-index: 0.901 vs 0.814 and 0.911 vs 0.814; C-index for late events: 0.897 vs 0.808 and 0.905 vs 0.808; all P < 0.05). CONCLUSIONS The CAD-RADS score had additional risk prediction benefits over clinical risk factors for emergency department patients.
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Clergue-Duval V, Nicolas-Sacy L, Karsinti E, Zerdazi EH, Laplanche JL, Brousse G, Marees AT, Derks EM, Henry P, Bellivier F, Vorspan F, Bloch V. Risk and Protective Factors of Lifetime Cocaine-Associated Chest Pain. Front Psychiatry 2021; 12:704276. [PMID: 34366936 PMCID: PMC8335401 DOI: 10.3389/fpsyt.2021.704276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/25/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Cocaine users often present with repetitive events of cocaine-associated chest pain (CACP), clinically resembling acute coronary syndromes. The aim of the study is to describe the specific risk factors for CACP. Method: Cocaine users (n = 316) were recruited for a multicenter cross-sectional study. Lifetime CACP history, sociodemographic factors, and lifetime use of cocaine and other substances were assessed. Thirty single nucleotide polymorphisms (SNPs) of NOS3, ROCK2, EDN1, GUCY1A3, and ALDH2 genes, suggested by the literature on coronary spasms, were selected. The associations with CACP history were tested using the chi-square test, Student's t-test and logistic regression. Results: Among the 316 subjects [78.5% men, mean age 37.5 years, (standard-deviation ±8.7)], 190 (60.1%) were daily cocaine users and 103 (32.6%) reported a lifetime CACP history. Among those with a lifetime CACP history, the median was 10 events per individual. In multivariate analysis, lifetime CACP history was associated with daily cocaine use [odds-ratio (OR) 3.24; 95% confidence intervals (1.29-9.33)], rapid route of cocaine use [OR 2.33 (1.20-4.64) vs. intranasal use], and lifetime amphetamine use [daily amphetamine use: OR 2.80 (1.25-6.32) and non-daily amphetamine use: OR 2.14 (1.15-4.04) vs. never used]. Patients with lifetime opioid maintenance treatment (OMT) reported significantly less lifetime CACP history [OR 0.35 (0.16-0.76)]. None of the selected SNPs was associated with CACP history after multiple testing corrections. Conclusions: Clinical variables describing the intensity of stimulant use were positively associated with lifetime CACP history, while OMT was negatively associated with it. Specific harm reduction strategies can target these risk factors.
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Affiliation(s)
- Virgile Clergue-Duval
- APHP, Département de Psychiatrie et de Médecine Addictologique, Site Lariboisière Fernand-Widal, Groupe hospitalier universitaire APHP Nord - Université de Paris, Paris, France
- Inserm UMRS-1144 Optimisation Thérapeutique en Neuropsychopharmacologie, Université de Paris, Paris, France
- Fédération Hospitalo-Universitaire NOR-SUD Network of Research in Substance Use Disorders, Ile-de-France, France
- Faculté de Médecine, Université de Paris, Paris, France
| | - Louise Nicolas-Sacy
- APHP, Pharmacie, Site Lariboisière Fernand-Widal, Groupe Hospitalier Universitaire APHP Nord - Université de Paris, Paris, France
| | - Emily Karsinti
- APHP, Département de Psychiatrie et de Médecine Addictologique, Site Lariboisière Fernand-Widal, Groupe hospitalier universitaire APHP Nord - Université de Paris, Paris, France
- Inserm UMRS-1144 Optimisation Thérapeutique en Neuropsychopharmacologie, Université de Paris, Paris, France
- Fédération Hospitalo-Universitaire NOR-SUD Network of Research in Substance Use Disorders, Ile-de-France, France
- Laboratoire ClipsyD, Université Paris Nanterre, Nanterre, France
| | - El-Hadi Zerdazi
- Inserm UMRS-1144 Optimisation Thérapeutique en Neuropsychopharmacologie, Université de Paris, Paris, France
- APHP, Service d'addictologie, DMU IMPACT, GHU Mondor, Hôpital Emile ROUX, Limeil Brévannes, France
| | - Jean-Louis Laplanche
- Inserm UMRS-1144 Optimisation Thérapeutique en Neuropsychopharmacologie, Université de Paris, Paris, France
- APHP, Département de Biochimie et Biologie Moléculaire, Site Lariboisière Fernand-Widal, Groupe Hospitalier Universitaire APHP Nord - Université de Paris, Paris, France
- Faculté de Pharmacie, Université de Paris, Paris, France
| | - Georges Brousse
- Service de psychiatrie-addictologie, CHU de Clermont-Ferrand, Université Clermont-Auvergne, Clermont-Ferrand, France
| | - Andries T. Marees
- Department of Economics, School of Business and Economics, VU University Amsterdam, Amsterdam, Netherlands
| | - Eske M. Derks
- Queensland Institute of Medical Research Berghofer, Translational Neurogenomics Group, Brisbane, QLD, Australia
| | - Patrick Henry
- Faculté de Médecine, Université de Paris, Paris, France
- APHP, Département de Cardiologie, Site Lariboisière Fernand-Widal, Groupe Hospitalier Universitaire APHP Nord - Université de Paris, Paris, France
| | - Frank Bellivier
- APHP, Département de Psychiatrie et de Médecine Addictologique, Site Lariboisière Fernand-Widal, Groupe hospitalier universitaire APHP Nord - Université de Paris, Paris, France
- Inserm UMRS-1144 Optimisation Thérapeutique en Neuropsychopharmacologie, Université de Paris, Paris, France
- Fédération Hospitalo-Universitaire NOR-SUD Network of Research in Substance Use Disorders, Ile-de-France, France
- Faculté de Médecine, Université de Paris, Paris, France
| | - Florence Vorspan
- APHP, Département de Psychiatrie et de Médecine Addictologique, Site Lariboisière Fernand-Widal, Groupe hospitalier universitaire APHP Nord - Université de Paris, Paris, France
- Inserm UMRS-1144 Optimisation Thérapeutique en Neuropsychopharmacologie, Université de Paris, Paris, France
- Fédération Hospitalo-Universitaire NOR-SUD Network of Research in Substance Use Disorders, Ile-de-France, France
- Faculté de Médecine, Université de Paris, Paris, France
| | - Vanessa Bloch
- Inserm UMRS-1144 Optimisation Thérapeutique en Neuropsychopharmacologie, Université de Paris, Paris, France
- Fédération Hospitalo-Universitaire NOR-SUD Network of Research in Substance Use Disorders, Ile-de-France, France
- APHP, Pharmacie, Site Lariboisière Fernand-Widal, Groupe Hospitalier Universitaire APHP Nord - Université de Paris, Paris, France
- Faculté de Pharmacie, Université de Paris, Paris, France
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Nicolau JC, Feitosa Filho GS, Petriz JL, Furtado RHDM, Précoma DB, Lemke W, Lopes RD, Timerman A, Marin Neto JA, Bezerra Neto L, Gomes BFDO, Santos ECL, Piegas LS, Soeiro ADM, Negri AJDA, Franci A, Markman Filho B, Baccaro BM, Montenegro CEL, Rochitte CE, Barbosa CJDG, Virgens CMBD, Stefanini E, Manenti ERF, Lima FG, Monteiro Júnior FDC, Correa Filho H, Pena HPM, Pinto IMF, Falcão JLDAA, Sena JP, Peixoto JM, Souza JAD, Silva LSD, Maia LN, Ohe LN, Baracioli LM, Dallan LADO, Dallan LAP, Mattos LAPE, Bodanese LC, Ritt LEF, Canesin MF, Rivas MBDS, Franken M, Magalhães MJG, Oliveira Júnior MTD, Filgueiras Filho NM, Dutra OP, Coelho OR, Leães PE, Rossi PRF, Soares PR, Lemos Neto PA, Farsky PS, Cavalcanti RRC, Alves RJ, Kalil RAK, Esporcatte R, Marino RL, Giraldez RRCV, Meneghelo RS, Lima RDSL, Ramos RF, Falcão SNDRS, Dalçóquio TF, Lemke VDMG, Chalela WA, Mathias Júnior W. Brazilian Society of Cardiology Guidelines on Unstable Angina and Acute Myocardial Infarction without ST-Segment Elevation - 2021. Arq Bras Cardiol 2021; 117:181-264. [PMID: 34320090 PMCID: PMC8294740 DOI: 10.36660/abc.20210180] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- José Carlos Nicolau
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Gilson Soares Feitosa Filho
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Centro Universitário de Tecnologia e Ciência (UniFTC), Salvador, BA - Brasil
| | - João Luiz Petriz
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
| | | | | | - Walmor Lemke
- Clínica Cardiocare, Curitiba, PR - Brasil
- Hospital das Nações, Curitiba, PR - Brasil
| | | | - Ari Timerman
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | - José A Marin Neto
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, SP - Brasil
| | | | - Bruno Ferraz de Oliveira Gomes
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | | | | | - Carlos Eduardo Rochitte
- Hospital do Coração (HCor), São Paulo, SP - Brasil
- Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Edson Stefanini
- Escola Paulista de Medicina da Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
| | | | - Felipe Gallego Lima
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | - José Maria Peixoto
- Universidade José do Rosário Vellano (UNIFENAS), Belo Horizonte, MG - Brasil
| | - Juliana Ascenção de Souza
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Lilia Nigro Maia
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP - Brasil
| | | | - Luciano Moreira Baracioli
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luís Alberto de Oliveira Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luis Augusto Palma Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Luiz Carlos Bodanese
- Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | | | - Marcelo Bueno da Silva Rivas
- Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Múcio Tavares de Oliveira Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Nivaldo Menezes Filgueiras Filho
- Universidade do Estado da Bahia (UNEB), Salvador, BA - Brasil
- Universidade Salvador (UNIFACS), Salvador, BA - Brasil
- Hospital EMEC, Salvador, BA - Brasil
| | - Oscar Pereira Dutra
- Instituto de Cardiologia - Fundação Universitária de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | - Otávio Rizzi Coelho
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
| | | | | | - Paulo Rogério Soares
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | - Roberto Esporcatte
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Talia Falcão Dalçóquio
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - William Azem Chalela
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Wilson Mathias Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
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48
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Musey PI, Bellolio F, Upadhye S, Chang AM, Diercks DB, Gottlieb M, Hess EP, Kontos MC, Mumma BE, Probst MA, Stahl JH, Stopyra JP, Kline JA, Carpenter CR. Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department. Acad Emerg Med 2021; 28:718-744. [PMID: 34228849 DOI: 10.1111/acem.14296] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/21/2021] [Accepted: 05/12/2021] [Indexed: 12/15/2022]
Abstract
This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low-risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low-risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non-obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high-sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.
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Affiliation(s)
- Paul I. Musey
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN USA
| | | | - Suneel Upadhye
- Division of Emergency Medicine McMaster University Hamilton Canada
| | - Anna Marie Chang
- Department of Emergency Medicine Thomas Jefferson University Philadelphia PA USA
| | - Deborah B. Diercks
- Department of Emergency Medicine UT Southwestern Medical Center Dallas TX USA
| | - Michael Gottlieb
- Department of Emergency Medicine Rush Medical Center Chicago IL USA
| | - Erik P. Hess
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN USA
| | - Michael C. Kontos
- Department of Internal Medicine Virginia Commonwealth University Richmond VA USA
| | - Bryn E. Mumma
- Department of Emergency Medicine UC Davis School of Medicine Sacramento CA USA
| | - Marc A. Probst
- Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NY USA
| | | | - Jason P. Stopyra
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐SalemNC USA
| | - Jeffrey A. Kline
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN USA
| | - Christopher R. Carpenter
- Department of Emergency Medicine and Emergency Care Research Core Washington University School of Medicine St. Louis MO USA
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49
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Chou SC, Hong AS, Weiner SG, Wharam JF. Impact of High-Deductible Health Plans on Emergency Department Patients With Nonspecific Chest Pain and Their Subsequent Care. Circulation 2021; 144:336-349. [PMID: 34176279 PMCID: PMC8323713 DOI: 10.1161/circulationaha.120.052501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Supplemental Digital Content is available in the text. Timely evaluation of acute chest pain is necessary, although most evaluations will not find significant coronary disease. With employers increasingly adopting high-deductible health plans (HDHP), how HDHPs impact subsequent care after an emergency department (ED) diagnosis of nonspecific chest pain is unclear.
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Affiliation(s)
- Shih-Chuan Chou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA (S.-C.C., S.G.W.)
| | - Arthur S Hong
- Departments of Internal Medicine and Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas (A.S.H.)
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA (S.-C.C., S.G.W.)
| | - J Frank Wharam
- Department of Population Medicine, Harvard Medical School, Boston, MA (J.F.W.).,Harvard Pilgrim Health Care Institute, Boston, MA (J.F.W.)
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50
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Meng H, Ruan J, Tian X, Li L, Chen W, Meng F. High retinoic acid receptor-related orphan receptor A gene expression in peripheral blood leukocytes may be related to acute myocardial infarction. J Int Med Res 2021; 49:3000605211019663. [PMID: 34101510 PMCID: PMC8191083 DOI: 10.1177/03000605211019663] [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] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE This study aimed to investigate whether differential expression of the retinoic acid receptor-related orphan receptor A (RORA) gene is related to occurrence of acute myocardial infarction (AMI). METHODS This was a retrospective study. White blood cells of 93 patients with acute myocardial infarction and 74 patients with stable coronary artery disease were collected. Reverse transcription quantitative polymerase chain reaction and western blotting were used to measure RORA mRNA and protein expression, respectively. RESULTS RORA mRNA expression levels in peripheral blood leukocytes in patients with AMI were 1.57 times higher than those in patients with stable coronary artery disease. Protein RORA levels in peripheral blood of patients with AMI were increased. Binary logistic regression analysis showed that high expression of RORA was an independent risk factor for AMI, and it increased the risk of AMI by 2.990 times. CONCLUSION RORA expression levels in patients with AMI is significantly higher than that in patients with stable coronary artery disease. High expression of RORA is related to AMI and it may be an independent risk factor for AMI.
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Affiliation(s)
- Heyu Meng
- Department of Cardiology, Third Hospital of Jilin University, Jilin Provincial Cardiovascular Research Institute, Jilin, China
| | - Jianjun Ruan
- Department of Cardiology, Third Hospital of Jilin University, Jilin Provincial Cardiovascular Research Institute, Jilin, China
| | - Xiaomin Tian
- Department of Cardiology, Third Hospital of Jilin University, Jilin Provincial Cardiovascular Research Institute, Jilin, China
| | - Lihong Li
- Department of Cardiology, Third Hospital of Jilin University, Jilin Provincial Cardiovascular Research Institute, Jilin, China
| | - Weiwei Chen
- Department of Cardiology, Third Hospital of Jilin University, Jilin Provincial Cardiovascular Research Institute, Jilin, China
| | - Fanbo Meng
- Department of Cardiology, Third Hospital of Jilin University, Jilin Provincial Cardiovascular Research Institute, Jilin, China
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