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Yamashita S, Saitoh T, Iguchi K, Suwa K, Ohtani H, Saotome M, Maekawa Y. Electrocardiogram Electrode Positioning on the Back During Echocardiography: An Exploratory Cross-Sectional Study. Cureus 2024; 16:e57967. [PMID: 38738079 PMCID: PMC11086598 DOI: 10.7759/cureus.57967] [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] [Accepted: 04/09/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND ECG interpretation is sometimes difficult due to baseline fluctuations and electrode detachments when placed on the subjects' front side, leading to misinterpretation of the rhythms and phases of the cardiac cycle. We aimed to compare the differences in the wave amplitudes and respiratory variations between conventional ECG electrode positioning on the front side of patients and an alternative position on the backs of patients. METHODS Echocardiography was performed in 85 patients lying in the left lateral position. We attached the red electrode to the right clavicle, the yellow to the left clavicle, and the green to the left lateral abdomen on the front side of the patients; on the back, we attached the electrode to the right clavicle, the right upper posterior iliac spine, and the left upper posterior iliac spine. RESULTS The ECG monitor amplitudes were greater on the front side compared to the back side, but the BF-breath values were smaller on the back side (6.0 pixels) compared to the front side (10.5 pixels, p<0.05). The P wave amplitude divided by the BF-breath on the back side was greater than that seen on the front side (2.8 vs. 1.8, p<0.05), whereas the QRS amplitude divided by the BF-breath was 15.0 and 16.3, respectively (p=ns). CONCLUSION As an alternative to front-side ECG monitoring, electrodes placed on the back can help avoid misinterpretation of the ECG rhythms and the phases of the cardiac cycle due to respiration during echocardiography.
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Affiliation(s)
- Satoshi Yamashita
- Department of Cardiology, Hamamatsu University School of Medicine, Hamamatsu, JPN
| | - Takeji Saitoh
- Next Generation Creative Education Center for Medicine, Engineering, and Informatics, Hamamatsu University School of Medicine, Hamamatsu, JPN
| | - Keisuke Iguchi
- Department of Cardiology, Hamamatsu University School of Medicine, Hamamatsu, JPN
| | - Kenichiro Suwa
- Department of Cardiology, Hamamatsu University School of Medicine, Hamamatsu, JPN
| | - Hayato Ohtani
- Department of Cardiology, Hamamatsu University School of Medicine, Hamamatsu, JPN
| | - Masao Saotome
- Department of Cardiology, Hamamatsu University School of Medicine, Hamamatsu, JPN
| | - Yuichiro Maekawa
- Department of Cardiology, Hamamatsu University School of Medicine, Hamamatsu, JPN
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2
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Chang H, Yu JY, Lee GH, Heo S, Lee SU, Hwang SY, Yoon H, Cha WC, Shin TG, Sim MS, Jo IJ, Kim T. Clinical support system for triage based on federated learning for the Korea triage and acuity scale. Heliyon 2023; 9:e19210. [PMID: 37654468 PMCID: PMC10465866 DOI: 10.1016/j.heliyon.2023.e19210] [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: 05/08/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 09/02/2023] Open
Abstract
Background and aims This study developed a clinical support system based on federated learning to predict the need for a revised Korea Triage Acuity Scale (KTAS) to facilitate triage. Methods This was a retrospective study that used data from 11,952,887 patients in the Korean National Emergency Department Information System (NEDIS) from 2016 to 2018 for model development. Separate cohorts were created based on the emergency medical center level in the NEDIS: regional emergency medical center (REMC), local emergency medical center (LEMC), and local emergency medical institution (LEMI). External and temporal validation used data from emergency department (ED) of the study site from 2019 to 2021. Patient features obtained during the triage process and the initial KTAS scores were used to develop the prediction model. Federated learning was used to rectify the disparity in data quality between EDs. The patient's demographic information, vital signs in triage, mental status, arrival information, and initial KTAS were included in the input feature. Results 3,626,154 patients' visits were included in the regional emergency medical center cohort; 8,278,081 patients' visits were included in the local emergency medical center cohort; and 48,652 patients' visits were included in the local emergency medical institution cohort. The study site cohort, which is used for external and temporal validation, included 135,780 patients visits. Among the patients in the REMC and study site cohorts, KTAS level 3 patients accounted for the highest proportion at 42.4% and 45.1%, respectively, whereas in the LEMC and LEMI cohorts, KTAS level 4 patients accounted for the highest proportion. The area under the receiver operating characteristic curve for the prediction model was 0.786, 0.750, and 0.770 in the external and temporal validation. Patients with revised KTAS scores had a higher admission rate and ED mortality rate than those with unaltered KTAS scores. Conclusions This novel system might accurately predict the likelihood of KTAS acuity revision and support clinician-based triage.
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Affiliation(s)
- Hansol Chang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Jae Yong Yu
- Department of Biomedical System Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Geun Hyeong Lee
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
- Department of Intelligent Precision Healthcare Convergence, Sungkyunkwan University, Suwon 16419, South Korea
| | - Sejin Heo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Se Uk Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Hee Yoon
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Won Chul Cha
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
- Digital Innovation Center, Samsung Medical Center, Seoul, Korea. 81 Irwon-ro Gangnam-gu, Seoul 06351, South Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Min Seob Sim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Ik Joon Jo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
| | - Taerim Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, 115 Irwon-ro Gangnam-gu, Seoul, 06355, South Korea
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3
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Lee DS, Straus SE, Austin PC, Mohamed S, Taljaard M, Chong A, Fang J, Prasad T, Farkouh ME, Schull MJ, Mak S, Ross HJ. Rationale and design of the comparison of outcomes and access to care for heart failure (COACH) trial: A stepped wedge cluster randomized trial. Am Heart J 2021; 240:1-10. [PMID: 33984316 DOI: 10.1016/j.ahj.2021.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 05/04/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Heart failure (HF) is an ambulatory care sensitive condition and a leading reason for emergency department (ED) visits and hospitalizations. Improved decision-making and care may enhance safety and efficiency for patients presenting to the ED with acute HF. OBJECTIVES We will evaluate an intervention comprised of 2 complementary components: (1) the Emergency Heart Failure Mortality Risk Grade simultaneous 7- and 30-day (EHMRG30-ST) risk scores, which will inform admission-discharge decisions, and (2) a rapid outpatient follow-up (RAPID-HF) clinic for low-to-intermediate risk patients on cardiovascular readmissions or death. STUDY DESIGN Stepped wedge cluster randomized trial with cross-sectional measurement at 10 acute care hospitals in Ontario, Canada. Patients presenting during control and intervention periods are eligible if they have a primary ED diagnosis of HF. In the intervention periods, access to the EHMRG30-ST web calculator will become available to hospitals' internet protocol (IP) addresses, and referral to the RAPID-HF clinic will be facilitated by a study nurse navigator. Patients with a high risk EHMRG30-ST score will be admitted to hospital. The RAPID-HF clinic will accept referrals for patients: (1) with low risk 7- and 30-day EHMRG30-ST scores who are discharged directly from the ED, or (2) intermediate risk patients with hospital length of stay < 72 hours. The RAPID-HF clinic, staffed by a nurse-clinician and cardiologist, will provide care during the 30-day transition after hospital separation. CONCLUSION This trial will determine whether novel risk stratification coupled with rapid ambulatory care achieves better outcomes than conventional decision-making and care for patients with HF.
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Affiliation(s)
- Douglas S Lee
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Canada; Peter Munk Cardiac Centre of the University Health Network, Toronto, Canada; Ted Rogers Centre for Heart Research, Toronto, Canada; University of Toronto, Toronto, Canada.
| | - Sharon E Straus
- University of Toronto, Toronto, Canada; Li Ka Shing Knowledge Institute and Unity Health, Toronto, Canada
| | - Peter C Austin
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Canada; University of Toronto, Toronto, Canada
| | - Shanas Mohamed
- Peter Munk Cardiac Centre of the University Health Network, Toronto, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Alice Chong
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Canada
| | - Jiming Fang
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Canada
| | - Treesa Prasad
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Canada
| | - Michael E Farkouh
- Peter Munk Cardiac Centre of the University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada
| | - Michael J Schull
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Canada; University of Toronto, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Susanna Mak
- University of Toronto, Toronto, Canada; Sinai Health, Toronto, Canada
| | - Heather J Ross
- Peter Munk Cardiac Centre of the University Health Network, Toronto, Canada; Ted Rogers Centre for Heart Research, Toronto, Canada; University of Toronto, Toronto, Canada
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4
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Miró Ò, Rossello X, Platz E, Masip J, Gualandro DM, Peacock WF, Price S, Cullen L, DiSomma S, de Oliveira MT, McMurray JJ, Martín-Sánchez FJ, Maisel AS, Vrints C, Cowie MR, Bueno H, Mebazaa A, Mueller C. Risk stratification scores for patients with acute heart failure in the Emergency Department: A systematic review. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 9:375-398. [PMID: 33191763 DOI: 10.1177/2048872620930889] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIMS This study aimed to systematically identify and summarise all risk scores evaluated in the emergency department setting to stratify acute heart failure patients. METHODS AND RESULTS A systematic review of PubMed and Web of Science was conducted including all multicentre studies reporting the use of risk predictive models in emergency department acute heart failure patients. Exclusion criteria were: (a) non-original articles; (b) prognostic models without predictive purposes; and (c) risk models without consecutive patient inclusion or exclusively tested in patients admitted to a hospital ward. We identified 28 studies reporting findings on 19 scores: 13 were originally derived in the emergency department (eight exclusively using acute heart failure patients), and six in emergency department and hospitalised patients. The outcome most frequently predicted was 30-day mortality. The performance of the scores tended to be higher for outcomes occurring closer to the index acute heart failure event. The eight scores developed using acute heart failure patients only in the emergency department contained between 4-13 predictors (age, oxygen saturation and creatinine/urea included in six scores). Five scores (Emergency Heart Failure Mortality Risk Grade, Emergency Heart Failure Mortality Risk Grade 30 Day mortality ST depression, Epidemiology of Acute Heart Failure in Emergency department 3 Day, Acute Heart Failure Risk Score, and Multiple Estimation of risk based on Emergency department Spanish Score In patients with Acute Heart Failure) have been externally validated in the same country, and two (Emergency Heart Failure Mortality Risk Grade and Multiple Estimation of risk based on Emergency department Spanish Score In patients with Acute Heart Failure) further internationally validated. The c-statistic for Emergency Heart Failure Mortality Risk Grade to predict seven-day mortality was between 0.74-0.81 and for Multiple Estimation of risk based on Emergency department Spanish Score In patients with Acute Heart Failure to predict 30-day mortality was 0.80-0.84. CONCLUSIONS There are several scales for risk stratification of emergency department acute heart failure patients. Two of them are accurate, have been adequately validated and may be useful in clinical decision-making in the emergency department i.e. about whether to admit or discharge.
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Affiliation(s)
- Òscar Miró
- Emergency Department, University of Barcelona, Spain
| | - Xavier Rossello
- Cardiology Department, Hospital Universitari Son Espases, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain.,Grupo de Fisiopatologia y Terapeutica Cardiovascular, Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
| | - Elke Platz
- Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, USA
| | - Josep Masip
- Intensive Care Department, University of Barcelona, Spain.,Cardiology Department, Hospital Sanitas CIMA, Spain
| | - Danielle M Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,Heart Institute (INCOR), University of Sao Paulo Medical School, Brazil
| | - W Frank Peacock
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, USA
| | - Susanna Price
- Royal Brompton and Harefield NHS Foundation Trust, Imperial College, UK
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Australia
| | - Salvatore DiSomma
- Royal Brompton and Harefield NHS Foundation Trust, Imperial College, UK
| | | | - John Jv McMurray
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Australia
| | - Francisco J Martín-Sánchez
- Department of Emergency Medicine, Hospital Clínico San Carlos, Spain.,Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Universidad Complutense de Madrid, Spain
| | - Alan S Maisel
- Coronary Care Unit and Heart Failure Program, Veteran Affairs (VA) San Diego, USA
| | | | - Martin R Cowie
- Royal Brompton and Harefield NHS Foundation Trust, Imperial College, UK
| | - Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain.,Department of Cardiology and Cardiovascular Research Area, Universidad Complutense de Madrid, Spain
| | - Alexandre Mebazaa
- University Paris Diderot, France.,APHP Hôpitaux Universitaires Saint Louis Lariboisière, France
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
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5
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Intensity of Guideline-Directed Medical Therapy for Coronary Heart Disease and Ischemic Heart Failure Outcomes. Am J Med 2021; 134:672-681.e4. [PMID: 33181105 DOI: 10.1016/j.amjmed.2020.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/11/2020] [Accepted: 10/12/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE The impact of guideline-directed medical therapy for coronary heart disease in those hospitalized with acute heart failure is unknown. METHODS We studied guideline-directed medical therapies for coronary disease: angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), beta-adrenoreceptor antagonists, antiplatelet agents or anticoagulants, and statins. Using inverse probability of treatment weighting the propensity score, we examined associations of guideline-directed medical therapy intensity (categorized as low [0-1], high [2-3], or very high [4] number of drugs) with mortality in 1873 patients with angina, troponin elevation, or prior myocardial infarction. RESULTS At discharge, 0-1, 2-3, and 4 medications were prescribed in 467 (25%), 705 (38%), and 701 (37%) patients, respectively. Relative to those prescribed 0-1 drugs (reference), all-cause mortality was lower with 2-3 (hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.28-0.84, P = 0.009) or all 4 drug classes (HR 0.56, 95% CI 0.33-0.96, P = 0.034) over 181-365 days, with similar reductions present from 0-180 days. In those with heart failure with preserved ejection fraction, mortality trended lower with 2-3 drug classes (HR 0.43, 95% CI 0.18-1.02, P = 0.054) and was significantly reduced with 4 drugs (HR 0.32, 95%CI 0.12-0.84, P = 0.021) during 0-180 day follow-up. In heart failure with reduced ejection fraction, all-cause mortality was reduced during both 0-180 and 181-365 days when discharged on 2-3 (HR 0.30 for 181-365 days, 95%CI 0.14-0.64, P = 0.002) or all 4 drug classes (HR 0.43, 95%CI 0.19-0.95, P = 0.038). CONCLUSIONS Increasing guideline-directed medical therapy intensity for coronary heart disease resulted in lower mortality in patients with acute ischemic heart failure with both preserved and reduced ejection fractions.
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6
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Wessman T, Tofik R, Ruge T, Melander O. Socioeconomic and Clinical Predictors of Mortality in Patients with Acute Dyspnea. Open Access Emerg Med 2021; 13:107-116. [PMID: 33790664 PMCID: PMC8008092 DOI: 10.2147/oaem.s277448] [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] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/23/2020] [Indexed: 11/23/2022] Open
Abstract
Background Factors predicting long-term prognosis in patients with acute dyspnea may guide both acute management and follow-up. The aim of this study was to identify socioeconomic and clinical risk factors for all-cause mortality among acute dyspnea patients admitted to an Emergency Department. Methods We included 798 patients with acute dyspnea admitted to the ED of Skåne University Hospital, Malmö, Sweden from 2013 to 2016. Exposures were living in the immigrant-dense urban part of Malmö (IDUD), country of birth, annual income, comorbidities, smoking habits, medical triage priority and severity of dyspnea. Mean follow-up time was 2.2 years. Exposures were related to risk of all-cause mortality using Cox proportional hazard model. Results During follow-up 40% died. In models adjusted for age and gender, low annual income, previous or ongoing smoking, certain comorbidities, high medical triage priority and severe dyspnea were all significantly associated with increased mortality. After adjusting for age, gender and all significant exposures, the lowest quintile of income, ongoing or previous smoking, history of serious infection, anemia, hip fracture, high medical triage priority and severe dyspnea significantly and independently predicted mortality. In contrast, neither country of birth nor living in IDUD predicted a mortality risk. Conclusion Apart from several clinical risk factors, low annual income predicts two-year mortality risk in patients with acute dyspnea. This is not the case for country of birth and living in IDUD. Our results underline the wide range of mortality risk factors in acute dyspnea patients. Knowledge of patients' annual income as well as certain clinical features may aid risk stratification and determining the need of follow-up both in hospital and after discharge from an ED.
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Affiliation(s)
- Torgny Wessman
- Department of Emergency Medicine, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Rafid Tofik
- Department of Emergency Medicine, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Thoralph Ruge
- Department of Emergency Medicine, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Olle Melander
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
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Freitas C, Wang X, Ge Y, Ross HJ, Austin PC, Pang PS, Ko DT, Farkouh ME, Stukel TA, McMurray JJ, Lee DS. Comparison of Troponin Elevation, Prior Myocardial Infarction, and Chest Pain in Acute Ischemic Heart Failure. CJC Open 2020; 2:135-144. [PMID: 32462127 PMCID: PMC7242506 DOI: 10.1016/j.cjco.2020.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/19/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients with heart failure (HF) with concomitant ischemic heart disease (IHD) have not been well characterized. We examined survival of patients with ischemic HF syndrome (IHFS), defined as presentation with acute HF and concomitant features suggestive of IHD. METHODS Patients were included if they presented with acute HF to hospitals in Ontario, Canada. IHD was defined by any of the following criteria: angina/chest pain, prior myocardial infarction (MI), or troponin elevation that was above the upper limit of normal (mild) or suggestive of cardiac injury. Deaths were determined after hospital presentation. RESULTS Of 5353 patients presenting with acute HF, 4088 (76.4%) exhibited features of IHFS. Patients with IHFS demonstrated a higher rate of 30-day (hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.33-2.68) and 1-year death (HR, 1.16, 95% CI, 1.00-1.35) compared with those with nonischemic HF. Troponin elevation demonstrated the strongest association with mortality. Mildly elevated troponin was associated with increased hazard over 30-day (HR, 1.77; 95% CI, 1.12-2.81) and 1-year (HR, 1.63; 95% CI, 1.38-1.93) mortality. Troponins indicative of cardiac injury were associated with increased hazard of death over 30 days (HR, 2.33; 95% CI, 1.63-3.33) and 1 year (HR, 1.40; 95% CI, 1.21-1.61). The association between elevated troponin and higher mortality at 30 days was similar in left ventricular ejection fraction subcategories of HF with reduced ejection fraction, HF with mildly reduced ejection fraction, or HF with preserved ejection fraction (P interaction = 0.588). After multivariable adjustment, prior MI and angina were not associated with higher mortality risk. CONCLUSIONS In acute HF, elevated troponin, but not prior MI or angina, was associated with a higher risk of 30-day and 1-year mortality irrespective of left ventricular ejection fraction.
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Affiliation(s)
- Cassandra Freitas
- University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | | | - Yin Ge
- University of Toronto, Toronto, Ontario, Canada
| | - Heather J. Ross
- University Health Network, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, Toronto, Ontario, Canada
- Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada
| | - Peter C. Austin
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Peter S. Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dennis T. Ko
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michael E. Farkouh
- University Health Network, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, Toronto, Ontario, Canada
- Heart & Stroke Richard Lewar Centre of Excellence in Cardiovascular Research, Toronto, Ontario, Canada
| | - Therese A. Stukel
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Douglas S. Lee
- University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, Toronto, Ontario, Canada
- Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada
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8
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Pouyamehr A, Mirhaghi A, Sharifi MD, Eshraghi A. Comparison between Emergency Severity Index and Heart Failure Triage Scale in heart failure patients: A randomized clinical trial. World J Emerg Med 2019; 10:215-221. [PMID: 31534595 DOI: 10.5847/wjem.j.1920-8642.2019.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND It is not clear whether Emergency Severity Index (ESI) is valid to triage heart failure (HF) patients and if HF patients benefit more from a customized triage scale or not. The aim of study is to compare the effect of Heart Failure Triage Scale (HFTS) and ESI on mistriage among patients with HF who present to the emergency department (ED). METHODS A randomized clinical trial was conducted from April to June 2017. HF patients with dyspnea were randomly assigned to HFTS or ESI groups. Triage level, used resources and time to electrocardiogram (ECG) were compared between both groups among HF patients who were admitted to coronary care unit (CCU), cardiac unit (CU) and discharged patients from the ED. Content validity was examined using Kappa designating agreement on relevance (K*). Reliability of both scale was evaluated using inter-observer agreement (Kappa). RESULTS Seventy-three and 74 HF patients were assigned to HFTS and ESI groups respectively. Time to ECG in HFTS group was significantly shorter than that of ESI group (2.05 vs. 16.82 minutes). Triage level between HFTS and ESI groups was significantly different among patients admitted to CCU (1.0 vs. 2.8), cardiac unit (2.26 vs. 3.06) and discharged patients from the ED (3.53 vs. 2.86). Used resources in HFTS group was significantly different among triage levels (H=25.89; df=3; P<0.001). CONCLUSION HFTS is associated with less mistriage than ESI for triaging HF patients. It is recommended to make use of HFTS to triage HF patients in the ED.
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Affiliation(s)
- Ahmad Pouyamehr
- Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Mirhaghi
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Davood Sharifi
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Eshraghi
- Department of Cardiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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9
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Hinson JS, Martinez DA, Cabral S, George K, Whalen M, Hansoti B, Levin S. Triage Performance in Emergency Medicine: A Systematic Review. Ann Emerg Med 2018; 74:140-152. [PMID: 30470513 DOI: 10.1016/j.annemergmed.2018.09.022] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/11/2018] [Accepted: 09/21/2018] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVE Rapid growth in emergency department (ED) triage literature has been accompanied by diversity in study design, methodology, and outcome assessment. We aim to synthesize existing ED triage literature by using a framework that enables performance comparisons and benchmarking across triage systems, with respect to clinical outcomes and reliability. METHODS PubMed, EMBASE, Scopus, and Web of Science were systematically searched for studies of adult ED triage systems through 2016. Studies evaluating triage systems with evidence of widespread adoption (Australian Triage Scale, Canadian Triage and Acuity Scale, Emergency Severity Index, Manchester Triage Scale, and South African Triage Scale) were cataloged and compared for performance in identifying patients at risk for mortality, critical illness and hospitalization, and interrater reliability. This study was performed and reported in adherence to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RESULTS A total of 6,160 publications were identified, with 182 meeting eligibility criteria and 50 with sufficient data for inclusion in comparative analysis. The Canadian Triage and Acuity Scale (32 studies), Emergency Severity Index (43), and Manchester Triage Scale (38) were the most frequently studied triage scales, and all demonstrated similar performance. Most studies (6 of 8) reported high sensitivity (>90%) of triage scales for identifying patients with ED mortality as high acuity at triage. However, sensitivity was low (<80%) for identification of patients who had critical illness outcomes and those who died within days of the ED visit or during the index hospitalization. Sensitivity varied by critical illness and was lower for severe sepsis (36% to 74%), pulmonary embolism (54%), and non-ST-segment elevation myocardial infarction (44% to 85%) compared with ST-segment elevation myocardial infarction (56% to 92%) and general outcomes of ICU admission (58% to 100%) and lifesaving intervention (77% to 98%). Some proportion of hospitalized patients (3% to 45%) were triaged to low acuity (level 4 to 5) in all studies. Reliability measures (κ) were variable across evaluations, with only a minority (11 of 42) reporting κ above 0.8. CONCLUSION We found that a substantial proportion of ED patients who die postencounter or are critically ill are not designated as high acuity at triage. Opportunity to improve interrater reliability and triage performance in identifying patients at risk of adverse outcome exists.
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Affiliation(s)
- Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Diego A Martinez
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephanie Cabral
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Kevin George
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD
| | - Madeleine Whalen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Whiting School of Engineering, Johns Hopkins University, Baltimore, MD
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Siniorakis E, Arvanitakis S, Tsitsimpikou C, Tsarouhas K, Tzevelekos P, Panta S, Aivalioti F, Zampelis C, Triposkiadis F, Limberi S. Acute Heart Failure in the Emergency Department: Respiratory Rate as a Risk Predictor. In Vivo 2018; 32:921-925. [PMID: 29936481 DOI: 10.21873/invivo.11330] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 04/21/2018] [Accepted: 04/26/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND/AIM Several risk scores can stratify patients with acute heart failure (AHF) at the Emergency Department (ED). Registration of vital signs, such as blood pressure (BP), heart rate (HR) and respiratory rate (RR) upon admission is mandatory. Nevertheless, measurement of RR remains neglected worldwide. PATIENTS AND METHODS The predictive value of RR in classifying patients with AHF was investigated by processing several vital signs recorded in the ED. RESULTS HR and RR individually did not discriminate patients according to hospitalization length, Intensive Care Unit (ICU) admittance, mechanical respiratory support or death. The derivative indices, HR:RR and Respiratory Efficacy Index (REFI) (=RR×100/SatO2), differentiated study patients regarding hospitalization length. Receiver operating characteristic curves predicting mortality and ICU admission for REFI and HR:RR revealed high accuracy, sensitivity and specificity for cut-off values of REFI >27 and HR:RR ≥4. CONCLUSION The RR and its derivative indices are easily accessible vital signs monitored at the ED which merit 'revitalization'.
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Affiliation(s)
| | | | | | | | | | - Stamatia Panta
- Cardiology Department, Sotiria Chest Diseases General Hospital, Athens, Greece
| | - Fotini Aivalioti
- Cardiology Department, Sotiria Chest Diseases General Hospital, Athens, Greece
| | | | | | - Sotiria Limberi
- Cardiology Department, Sotiria Chest Diseases General Hospital, Athens, Greece
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11
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SINIORAKIS EFTYCHIOS, ARVANITAKIS SPYRIDON, TSITSIMPIKOU CHRISTINA, TSAROUHAS KONSTANTINOS, TZEVELEKOS PANAGIOTIS, PANTA STAMATIA, AIVALIOTI FOTINI, ZAMPELIS CONSTANTINOS, TRIPOSKIADIS FILIPPOS, LIMBERI SOTIRIA. Acute Heart Failure in the Emergency Department: Respiratory Rate as a Risk Predictor. In Vivo 2018; 32. [PMID: 29936481 PMCID: PMC6117786 DOI: 10.21873/invivo.112330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND/AIM Several risk scores can stratify patients with acute heart failure (AHF) at the Emergency Department (ED). Registration of vital signs, such as blood pressure (BP), heart rate (HR) and respiratory rate (RR) upon admission is mandatory. Nevertheless, measurement of RR remains neglected worldwide. PATIENTS AND METHODS The predictive value of RR in classifying patients with AHF was investigated by processing several vital signs recorded in the ED. RESULTS HR and RR individually did not discriminate patients according to hospitalization length, Intensive Care Unit (ICU) admittance, mechanical respiratory support or death. The derivative indices, HR:RR and Respiratory Efficacy Index (REFI) (=RR×100/SatO2), differentiated study patients regarding hospitalization length. Receiver operating characteristic curves predicting mortality and ICU admission for REFI and HR:RR revealed high accuracy, sensitivity and specificity for cut-off values of REFI >27 and HR:RR ≥4. CONCLUSION The RR and its derivative indices are easily accessible vital signs monitored at the ED which merit 'revitalization'.
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Affiliation(s)
| | | | | | | | | | - STAMATIA PANTA
- Cardiology Department, Sotiria Chest Diseases General Hospital, Athens, Greece
| | - FOTINI AIVALIOTI
- Cardiology Department, Sotiria Chest Diseases General Hospital, Athens, Greece
| | | | | | - SOTIRIA LIMBERI
- Cardiology Department, Sotiria Chest Diseases General Hospital, Athens, Greece
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12
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Slemon A. Embracing the wild profusion: A Foucauldian analysis of the impact of healthcare standardization on nursing knowledge and practice. Nurs Philos 2018; 19:e12215. [PMID: 29952072 DOI: 10.1111/nup.12215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/20/2018] [Accepted: 05/28/2018] [Indexed: 01/22/2023]
Abstract
Standardization has emerged as the dominant principle guiding the organization and provision of healthcare, with standards resultantly shaping how nurses conceptualize and deliver patient care. Standardization has been critiqued as homogenizing diverse patient experiences and diminishing nurses' skills and critical thinking; however, there has been limited examination of the philosophical implications of standardization for nursing knowledge and practice. In this manuscript, I draw on Foucault's philosophy of order and categorization to inform an analysis of the consequences of healthcare standardization for the profession of nursing. I utilize three exemplars to illustrate the impact of the primacy of standardized thinking and practices on nurses, patients and families: pain assessments using the 0-10 pain scale; patient triage emergency departments through the Canadian Triage and Acuity Scale; and determination of cause of death within the context of the current opioid crisis. Through each exemplar, I demonstrate that standardization reductively constrains nursing knowledge and the health and healthcare experiences of patients and populations. I argue that the centrality of standardization must be re-envisioned to embrace the complexity of health and more effectively and meaningfully frame nursing knowledge and practice within healthcare systems.
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Affiliation(s)
- Allie Slemon
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
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13
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Short-term predictive capacity of two different triage systems in patients with acute heart failure: TRICA-EAHFE study. Eur J Emerg Med 2016. [PMID: 26225614 DOI: 10.1097/mej.0000000000000290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To evaluate whether prioritization of patients with acute heart failure (AHF) in the Andorran Triage Model/Spanish Triage System (MAT/SET) and the Manchester Triage System (MTS) also allows the identification of different profiles of outcome and prognosis and determine whether either system has a better predictive capacity of outcomes. PATIENTS AND METHODS Patients with AHF included in the Spanish EAHFE registry from hospitals using the MAT/SET or MTS were selected and divided according to the triage system used. Outcome variables included hospital admission, length of stay, death during admission, 3, 7, and 30-day all-cause mortality, and emergency department (ED) reconsultation at 30 days. The results were compared according to the level of priority and the triage system used. RESULTS We included 3837 patients (MAT/SET=2474; MTS=1363) classified as follows: 4.0% level 1; 34.7% level 2; 55.1% level 3; and 6.3% levels 4-5. Both systems associated greater priority with higher rates of admission and mortality; the MTS associated greater priority with greater ED reconsultation and the MAT/SET found greater priority to be associated with less ED reconsultation. The discriminative capacity of the two scales for adverse outcomes was statistically significant, albeit poor, for almost all the outcome events and it was of scarce clinical relevance (Area under the curve of the receiver operating characteristic between 0.458 and 0.661). CONCLUSION The prediction of the outcome of patients with AHF determined with the MAT/SET or MTS showed scarce differences between the two systems, and their discriminative capacity does not seem to be clinically relevant.
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14
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Siniorakis EE, Arapi SM, Panta SG, Pyrgakis VN, Ntanos IT, Limberi SJ. Emergency department triage of acute heart failure triggered by pneumonia; when an intensive care unit is needed? Int J Cardiol 2016; 220:479-82. [PMID: 27390973 DOI: 10.1016/j.ijcard.2016.06.228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/25/2016] [Indexed: 11/30/2022]
Abstract
Community acquired pneumonia (CAP) is a frequent triggering factor for decompensation of a chronic cardiac dysfunction, leading to acute heart failure (AHF). Patients with AHF exacerbated by CAP, are often admitted through the emergency department for ICU hospitalization, even though more than half the cases do not warrant any intensive care treatment. Emergency department physicians are forced to make disposition decisions based on subjective criteria, due to lack of evidence-based risk scores for AHF combined with CAP. Currently, the available risk models refer distinctly to either AHF or CAP patients. Extrapolation of data by arbitrarily combining these models, is not validated and can be treacherous. Examples of attempts to apply acuity scales provenient from different disciplines and the resulting discrepancies, are given in this review. There is a need for severity classification tools especially elaborated for use in the emergency department, applicable to patients with mixed AHF and CAP, in order to rationalize the ICU dispositions. This is bound to facilitate the efforts to save both lives and resources.
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Affiliation(s)
| | - Sophia M Arapi
- Department of Cardiology, G. Gennimatas General Hospital, Athens, Greece.
| | - Stamatia G Panta
- Department of Cardiology, Sotiria Chest Diseases Hospital, Athens, Greece
| | | | - Ioannis Th Ntanos
- 9th Department of Pneumonology, Sotiria Chest Diseases Hospital, Athens, Greece
| | - Sotiria J Limberi
- Department of Cardiology, Sotiria Chest Diseases Hospital, Athens, Greece
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15
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Goldraich L, Austin PC, Zhou L, Tu JV, Schull MJ, Mak S, Ross HJ, Morrow DA, Lee DS. Care Setting Intensity and Outcomes After Emergency Department Presentation Among Patients With Acute Heart Failure. J Am Heart Assoc 2016; 5:JAHA.116.003232. [PMID: 27451461 PMCID: PMC5015368 DOI: 10.1161/jaha.116.003232] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Patients with heart failure (HF) presenting to the emergency department (ED) can be admitted to care settings of different intensity, where the intensive care unit (ICU) is the highest intensity, ward admission is intermediate intensity, and those discharged home are of lowest intensity. Despite the costs associated with higher‐intensity care, little is known about disposition decisions and outcomes of HF patients treated in different care settings. Methods and Results We identified predictors of ICU or ward admission and determined whether survival differs in patients admitted to higher‐intensity versus lower‐intensity care settings (ie, ICU vs ward, or ward vs ED‐discharged). Among 9054 patients (median, 78 years; 51% men) presenting to an ED in Ontario, Canada, 1163 were ICU‐admitted, 5240 ward‐admitted, and 2651 were ED‐discharged. Predictors of ICU (vs ward) admission included: use of noninvasive positive pressure ventilation (adjusted odds ratio [OR], 2.01; 95% CI, 1.36–2.98), higher respiratory rate (OR, 1.10 per 5 breaths/min; 95% CI, 1.05–1.15), and lower oxygen saturation (OR, 0.90 per 5%; 95% CI, 0.86–0.94; all P<0.001). Predictors of ward‐admitted versus ED‐discharged were similar. Propensity‐matched analysis comparing lower‐risk ICU to ward‐admitted patients demonstrated a nonsignificant trend at 100 days (relative risk [RR], 0.69; 95% CI, 0.43–1.10; P=0.148). At 1 year, however, survival was higher among those initially admitted to ICU (RR, 0.68; 95% CI, 0.49–0.94; P=0.022). There was no survival difference among low‐risk ward‐admitted versus ED‐discharged patients. Conclusions Respiratory factors were associated with admission to higher‐intensity settings. There was no difference in early survival between some lower‐risk patients admitted to higher‐intensity units compared to those treated in lower‐intensity settings.
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Affiliation(s)
- Livia Goldraich
- Division of Cardiology, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada The Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada The University of Toronto, Ontario, Canada
| | - Limei Zhou
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Jack V Tu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Sunnybrook Health Sciences Center, Toronto, Ontario, Canada The Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada The University of Toronto, Ontario, Canada
| | - Michael J Schull
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Sunnybrook Health Sciences Center, Toronto, Ontario, Canada The Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada The University of Toronto, Ontario, Canada
| | - Susanna Mak
- Mt. Sinai Hospital, Toronto, Ontario, Canada The University of Toronto, Ontario, Canada
| | - Heather J Ross
- Division of Cardiology, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada The University of Toronto, Ontario, Canada
| | - David A Morrow
- The Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Douglas S Lee
- Division of Cardiology, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada The Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada The Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada The University of Toronto, Ontario, Canada
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Vold ML, Aasebø U, Wilsgaard T, Melbye H. Low oxygen saturation and mortality in an adult cohort: the Tromsø study. BMC Pulm Med 2015; 15:9. [PMID: 25885261 PMCID: PMC4342789 DOI: 10.1186/s12890-015-0003-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 01/20/2015] [Indexed: 11/18/2022] Open
Abstract
Background Oxygen saturation has been shown in risk score models to predict mortality in emergency medicine. The aim of this study was to determine whether low oxygen saturation measured by a single-point measurement by pulse oximetry (SpO2) is associated with increased mortality in the general adult population. Methods Pulse oximetry was performed in 5,152 participants in a cross-sectional survey in Tromsø, Norway, in 2001–2002 (“Tromsø 5”). Ten-year follow-up data for all-cause mortality and cause of death were obtained from the National Population and the Cause of Death Registries, respectively. Cause of death was grouped into four categories: cardiovascular disease, cancer except lung cancer, pulmonary disease, and others. SpO2 categories were assessed as predictors for all-cause mortality and death using Cox proportional-hazards regression models after correcting for age, sex, smoking history, body mass index (BMI), C-reactive protein level, self-reported diseases, respiratory symptoms, and spirometry results. Results The mean age was 65.8 years, and 56% were women. During the follow-up, 1,046 (20.3%) participants died. The age- and sex-adjusted hazard ratios (HRs) (95% confidence intervals) for all-cause mortality were 1.99 (1.33–2.96) for SpO2 ≤ 92% and 1.36 (1.15–1.60) for SpO2 93–95%, compared with SpO2 ≥ 96%. In the multivariable Cox proportional-hazards regression models that included self-reported diseases, respiratory symptoms, smoking history, BMI, and CRP levels as the explanatory variables, SpO2 remained a significant predictor of all-cause mortality. However, after including forced expiratory volume in 1 s percent predicted (FEV1% predicted), this association was no longer significant. Mortality caused by pulmonary diseases was significantly associated with SpO2 even when FEV1% predicted was included in the model. Conclusions Low oxygen saturation was independently associated with increased all-cause mortality and mortality caused by pulmonary diseases. When FEV1% predicted was included in the analysis, the strength of the association weakened but was still statistically significant for mortality caused by pulmonary diseases.
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Affiliation(s)
- Monica Linea Vold
- Department of Respiratory Medicine, University Hospital of North Norway, 9038, Tromsø, Norway. .,Department of Community Medicine, University of Tromsø, Tromsø, Norway.
| | - Ulf Aasebø
- Department of Respiratory Medicine, University Hospital of North Norway, 9038, Tromsø, Norway. .,Department of Clinical Medicine, University of Tromsø, Tromsø, Norway.
| | - Tom Wilsgaard
- Department of Community Medicine, University of Tromsø, Tromsø, Norway.
| | - Hasse Melbye
- Department of Community Medicine, University of Tromsø, Tromsø, Norway.
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Atzema CL, Austin PC, Miller E, Chong AS, Yun L, Dorian P. A Population-Based Description of Atrial Fibrillation in the Emergency Department, 2002 to 2010. Ann Emerg Med 2013; 62:570-577.e7. [DOI: 10.1016/j.annemergmed.2013.06.005] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 05/16/2013] [Accepted: 05/29/2013] [Indexed: 11/26/2022]
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Stiell IG, Clement CM, Brison RJ, Rowe BH, Borgundvaag B, Aaron SD, Lang E, Calder LA, Perry JJ, Forster AJ, Wells GA. A risk scoring system to identify emergency department patients with heart failure at high risk for serious adverse events. Acad Emerg Med 2013; 20:17-26. [PMID: 23570474 DOI: 10.1111/acem.12056] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 07/06/2012] [Accepted: 07/14/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES There are no validated guidelines to guide physicians with difficult disposition decisions for emergency department (ED) patients with heart failure (HF). The authors sought to develop a risk scoring system to identify HF patients at high risk for serious adverse events (SAEs). METHODS This was a prospective cohort study at six large Canadian EDS that enrolled adult patients who presented with acute decompensated HF. Each patient was assessed for standardized clinical and laboratory variables as well as for SAEs defined as death, intubation, admission to a monitored unit, or relapse requiring admission. Adjusted odds ratios for predictors of SAEs were calculated by stepwise logistic regression. RESULTS In 559 visits, 38.1% resulted in patient admission. Of 65 (11.6%) SAE cases, 31 (47.7%) occurred in patients not initially admitted. The multivariate model and resultant Ottawa Heart Failure Risk Scale consists of 10 elements, and the risk of SAEs varied from 2.8% to 89.0%, with good calibration between observed and expected probabilities. Internal validation showed the risk scores to be very accurate across 1,000 replications using the bootstrap method. A threshold of 1, 2, or 3 total scores for admission would be associated with sensitivities of 95.2, 80.6, or 64.5%, respectively, all better than current practice. CONCLUSIONS Many HF patients are discharged home from the ED and then suffer SAEs or death. The authors have developed an accurate risk scoring system that could ultimately be used to stratify the risk of poor outcomes and to enable rational and safe disposition decisions.
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Affiliation(s)
- Ian G. Stiell
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Catherine M. Clement
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; University of Ottawa; Ottawa Ontario Canada
| | - Robert J. Brison
- Department of Emergency Medicine; Queen's University; Kingston Ontario Canada
| | - Brian H. Rowe
- Department of Emergency Medicine; University of Alberta; Edmonton Alberta Canada
| | - Bjug Borgundvaag
- Division of Emergency Medicine; University of Toronto; Toronto Ontario Canada
| | - Shawn D. Aaron
- Department of Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Eddy Lang
- Division of Emergency Medicine; University of Calgary; Calgary Alberta Canada
| | - Lisa A. Calder
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Jeffrey J. Perry
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Alan J. Forster
- Department of Medicine; University of Ottawa; Ottawa Ontario Canada
| | - George A. Wells
- University of Ottawa Heart Institute; University of Ottawa; Ottawa Ontario Canada
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Collins SP, Lindsell CJ, Jenkins CA, Harrell FE, Fermann GJ, Miller KF, Roll SN, Sperling MI, Maron DJ, Naftilan AJ, McPherson JA, Weintraub NL, Sawyer DB, Storrow AB. Risk stratification in acute heart failure: rationale and design of the STRATIFY and DECIDE studies. Am Heart J 2012. [PMID: 23194482 DOI: 10.1016/j.ahj.2012.07.033] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND A critical challenge for physicians facing patients presenting with signs and symptoms of acute heart failure (AHF) is how and where to best manage them. Currently, most patients evaluated for AHF are admitted to the hospital, yet not all warrant inpatient care. Up to 50% of admissions could be potentially avoided and many admitted patients could be discharged after a short period of observation and treatment. Methods for identifying patients that can be sent home early are lacking. Improving the physician's ability to identify and safely manage low-risk patients is essential to avoiding unnecessary use of hospital beds. METHODS Two studies (STRATIFY and DECIDE) have been funded by the National Heart Lung and Blood Institute with the goal of developing prediction rules to facilitate early decision making in AHF. Using prospectively gathered evaluation and treatment data from the acute setting (STRATIFY) and early inpatient stay (DECIDE), rules will be generated to predict risk for death and serious complications. Subsequent studies will be designed to test the external validity, utility, generalizability and cost-effectiveness of these prediction rules in different acute care environments representing racially and socioeconomically diverse patient populations. RESULTS A major innovation is prediction of 5-day as well as 30-day outcomes, overcoming the limitation that 30-day outcomes are highly dependent on unpredictable, post-visit patient and provider behavior. A novel aspect of the proposed project is the use of a comprehensive cardiology review to correctly assign post-treatment outcomes to the acute presentation. CONCLUSIONS Finally, a rigorous analysis plan has been developed to construct the prediction rules that will maximally extract both the statistical and clinical properties of every data element. Upon completion of this study we will subsequently externally test the prediction rules in a heterogeneous patient cohort.
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Abstract
Acute decompensated heart failure is a common reason for presentation to the emergency department and is associated with high rates of admission to hospital. Distinguishing between higher-risk patients needing hospitalization and lower-risk patients suitable for discharge home is important to optimize both cost-effectiveness and clinical outcomes. However, this can be challenging and few validated risk stratification tools currently exist to help clinicians. Some prognostic variables predict risks broadly in those who are admitted or discharged from the emergency department. Risk stratification methods such as the Emergency Heart Failure Mortality Risk Grade and Acute Heart Failure Index clinical decision support tools, which utilize many of these predictors, have been found to be accurate in identifying low-risk patients. The use of observation units may also be a cost-effective adjunctive strategy that can assist in determining disposition from the emergency department.
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Affiliation(s)
- Edwin C. Ho
- Institute for Clinical Evaluative Sciences, Division of Cardiology, University Health Network, Room G-106, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
| | - Michael J. Schull
- Institute for Clinical Evaluative Sciences, Division of Cardiology, University Health Network, Room G-106, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
- Sunnybrook and Institute for Clinical Evaluative Sciences, and the Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Douglas S. Lee
- Institute for Clinical Evaluative Sciences, Division of Cardiology, University Health Network, Room G-106, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
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21
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Summers RL, Sterling S. Early emergency management of acute decompensated heart failure. Curr Opin Crit Care 2012; 18:301-7. [PMID: 22732433 DOI: 10.1097/mcc.0b013e328354f05a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Acute decompensated heart failure (ADHF) is characterized by a complex spectrum of pathophysiology that emerges as a common clinical disease state, which manifests as a failure of the circulation to provide for the needs of the body systems. Whereas ADHF is often characterized by the findings of pulmonary congestion and dyspnea, a variety of clinical presentations are possible, with each requiring differing management strategies. This review examines the approach of the four-quadrant clinical profile for differentiation of the ADHF patient during the emergent resuscitative phase of the decompensation. RECENT FINDINGS Clinical and diagnostic information can be used to determine the relative degree of pulmonary congestion and peripheral tissue perfusion in patients suspected of ADHF. This information can be used in a four-quadrant approach to differentiate patients into pathophysiologic categories. These profiles can then be translated into management strategies from a physiology based perspective in which the specific mechanisms of the failure are targeted. SUMMARY ADHF can present in a variety of clinical forms in the emergent setting. Categorization of the ADHF patient according to their individual hemodynamic profile can assist in management decisions during the emergent resuscitative phase of the decompensation based upon an approach that targets causative pathophysiologic mechanisms.
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Affiliation(s)
- Richard L Summers
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA.
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