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Cullen L, Greenslade JH, Stephensen L, Ranasinghe I, Gaikwad N, Khorramshahi Bayat M, Mahmoodi E, Than M, Apple F, Parsonage W. External validation of a rapid algorithm using high-sensitivity troponin assay results for evaluating patients with suspected acute myocardial infarction. Emerg Med J 2024; 41:313-319. [PMID: 38316538 DOI: 10.1136/emermed-2023-213539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/22/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE We sought to validate the clinical performance of a rapid assessment pathway incorporating the Siemens Atellica IM high sensitivity cardiac troponin I (hs-cTnI) assay in patients presenting to the emergency department (ED) with suspected acute myocardial infarction (AMI). METHODS This was a multicentre prospective observational study of adult ED patients presenting to five Australian hospitals between November 2020 and September 2021. Participants included those with symptoms of suspected AMI (without ST-segment elevation MI on presentation ECG). The Siemen's Atellica IM hs-cTnI laboratory-based assay was used to measure troponin concentrations at admission and after 2-3 hours and cardiologists adjudicated final diagnoses. The HighSTEACS diagnostic algorithm was evaluated, incorporating hs-cTnI concentrations at presentation and absolute changes within the first 2 to 3 hours. The primary outcome was index AMI, including type 1 or 2 non-ST segment elevation MI (NSTEMI) or ST-elevation MI (STEMI) following presentation. 30-day major adverse cardiac outcomes (including AMI, urgent revascularisation or cardiac death) were also reported. The trial was registered with the Australian and New Zealand Clinical Trials Registry. RESULTS 1994 patients were included. The average age was 56.2 years (SD=15.6), and 44.9% were women. 118 (5.9%) patients had confirmed index AMI. The 2-hour algorithm defined 61.3% of patients as low risk. Sensitivity was 99.1% (94.0%-99.9%) and negative predictive value was 99.9% (99.3%-100%). 24.4% of patients were deemed intermediate risk. When applying the parameters for high risk, 252 (14.3%) were identified, with a specificity of 91.5% (88.7%-93.6%) and a PPV of 42.0% (35.6-48.7%). CONCLUSIONS A 2-hour algorithm based on the HighSTEACS strategy using the Siemens Atellica IM hs-cTnI laboratory-based assay enables safe and efficient risk assessment of emergency patients with suspected AMI. TRIAL REGISTRATION NUMBER ACTRN12621000053820.
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Affiliation(s)
- Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Jaimi H Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women\'s Hospital, Herston, Queensland, Australia
- School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Laura Stephensen
- Department of Emergency Medicine, Royal Brisbane and Women\'s Hospital, Herston, Queensland, Australia
- School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Isuru Ranasinghe
- Cardiology, The University of Queensland, Saint Lucia, Queensland, Australia
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | | | | | - Ehsan Mahmoodi
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Fred Apple
- Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - William Parsonage
- Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
- Queensland University of Technology, Brisbane, Queensland, Australia
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Pickering JW, Hamill L, Aldous S, Joyce L, Stothart RA, Williams O, Florkowski CM, Than M. Determination of a whole-blood single-test low-risk threshold for a point-of-care high-sensitivity troponin assay. Emerg Med J 2024; 41:322-323. [PMID: 38429073 DOI: 10.1136/emermed-2023-213689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Affiliation(s)
- John W Pickering
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Laura Hamill
- Pegasus Health 24 Hour Surgery Ltd, Christchurch, New Zealand
| | - Sally Aldous
- Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Laura Joyce
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
- Department of Surgery and Critical Care, University of Otago Christchurch, Christchurch, New Zealand
| | - R Alex Stothart
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Otis Williams
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | | | - Martin Than
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
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3
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Stewart J, Freeman S, Eroglu E, Dumitrascu N, Lu J, Goudie A, Sprivulis P, Akhlaghi H, Tran V, Sanfilippo F, Celenza A, Than M, Fatovich D, Walker K, Dwivedi G. Attitudes towards artificial intelligence in emergency medicine. Emerg Med Australas 2024; 36:252-265. [PMID: 38044755 DOI: 10.1111/1742-6723.14345] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/24/2023] [Accepted: 10/30/2023] [Indexed: 12/05/2023]
Abstract
OBJECTIVE To assess Australian and New Zealand emergency clinicians' attitudes towards the use of artificial intelligence (AI) in emergency medicine. METHODS We undertook a qualitative interview-based study based on grounded theory. Participants were recruited through ED internal mailing lists, the Australasian College for Emergency Medicine Bulletin, and the research teams' personal networks. Interviews were transcribed, coded and themes presented. RESULTS Twenty-five interviews were conducted between July 2021 and May 2022. Thematic saturation was achieved after 22 interviews. Most participants were from either Western Australia (52%) or Victoria (16%) and were consultants (96%). More participants reported feeling optimistic (10/25) than neutral (6/25), pessimistic (2/25) or mixed (7/25) towards the use of AI in the ED. A minority expressed scepticism regarding the feasibility or value of implementing AI into the ED. Multiple potential risks and ethical issues were discussed by participants including skill loss from overreliance on AI, algorithmic bias, patient privacy and concerns over liability. Participants also discussed perceived inadequacies in existing information technology systems. Participants felt that AI technologies would be used as decision support tools and not replace the roles of emergency clinicians. Participants were not concerned about the impact of AI on their job security. Most (17/25) participants thought that AI would impact emergency medicine within the next 10 years. CONCLUSIONS Emergency clinicians interviewed were generally optimistic about the use of AI in emergency medicine, so long as it is used as a decision support tool and they maintain the ability to override its recommendations.
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Affiliation(s)
- Jonathon Stewart
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- Department of Advanced Clinical and Translational Cardiovascular Imaging, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - Samuel Freeman
- SensiLab, Monash University, Melbourne, Victoria, Australia
- Department of Emergency Medicine, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Ege Eroglu
- School of Medicine, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Nicole Dumitrascu
- School of Medicine, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Juan Lu
- Department of Advanced Clinical and Translational Cardiovascular Imaging, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
- Department of Computer Science and Software Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Adrian Goudie
- Department of Emergency Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Peter Sprivulis
- Strategy and Governance Division, Western Australia Department of Health, Perth, Western Australia, Australia
| | - Hamed Akhlaghi
- Department of Emergency Medicine, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Viet Tran
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Department of Emergency Medicine, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Frank Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Antonio Celenza
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- Department of Emergency Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Martin Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Daniel Fatovich
- Emergency Medicine, Royal Perth Hospital, The University of Western Australia, Perth, Western Australia, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - Katie Walker
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Girish Dwivedi
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- Department of Advanced Clinical and Translational Cardiovascular Imaging, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
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4
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Pickering JW, Joyce L, Than M. Twenty-six years of machine learning for ECG: and we are not there yet. CAN J EMERG MED 2023; 25:789-790. [PMID: 37801259 DOI: 10.1007/s43678-023-00598-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Affiliation(s)
- John W Pickering
- Department of Emergency Medicine, Christchurch Hospital, University of Otago Christchurch, Christchurch, New Zealand
| | - Laura Joyce
- Department of Emergency Medicine, Christchurch Hospital, University of Otago Christchurch, Christchurch, New Zealand
| | - Martin Than
- Department of Emergency Medicine, Christchurch Hospital, University of Otago Christchurch, Christchurch, New Zealand.
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5
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Addy K, Joyce LR, Al-Busaidi IS, Pickering JW, Troughton R, Than M. Implementation of an integrated emergency department acute atrial fibrillation pathway safely reduces cardioversions and hospitalisations: A comparative pre-post study. Emerg Med Australas 2023; 35:828-833. [PMID: 37169715 DOI: 10.1111/1742-6723.14240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/03/2023] [Accepted: 04/27/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Atrial fibrillation/flutter (AF/AFL) accounts for high rates of ED presentations and hospital admissions. There is increasing evidence to suggest that delaying cardioversion for acute uncomplicated AF is safe, and that many patients will spontaneously revert to sinus rhythm (SR). We conducted a before-and-after evaluation of AF/AFL management after a change in ED pathway using a conservative 'rate-and-wait' approach, incorporating next working day outpatient clinic follow-up and delayed cardioversion if required. METHODS We performed a before-and-after retrospective cohort study examining outcomes for patients who presented to the ED in Christchurch, New Zealand, with acute uncomplicated AF/AFL in the 1-year period before and after the implementation of a new conservative management pathway. RESULTS A total of 360 patients were included in the study (182 'Pre-pathway' vs 178 'Post-Pathway'). Compared to the pre-pathway cohort, those managed under the new pathway had an 81.2% reduction in ED cardioversions (n = 32 vs n = 6), and 50.7% reduction in all cardioversions (n = 65 vs n = 32). There was a 31.6% reduction in admissions from ED (n = 54 vs n = 79). ED length of stay (3.9 h vs 3.8 h, net difference -0.1 h, 95% confidence interval [CI] -0.6 to 0.3), 1-year ED AF representation (32.4% vs 26.4%, net difference -6.0% [95% CI -16.0% to 3.9%]), 1-year ED ischaemic stroke presentation (2.2% in both groups) and 7-day all-cause mortality rates (hazard ratio 1.05 [95% CI 0.6 to 1.9]) were all similar. CONCLUSIONS Using a conservative 'rate-and-wait' strategy with early follow-up for patients presenting to ED with AF/AFL can safely reduce unnecessary cardioversions and avoidable hospitalisations.
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Affiliation(s)
- Kaleb Addy
- Department of General Medicine, Auckland City Hospital, Auckland, New Zealand
- Department of Surgery and Critical Care, University of Otago, Christchurch, New Zealand
| | - Laura R Joyce
- Department of Surgery and Critical Care, University of Otago, Christchurch, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Ibrahim S Al-Busaidi
- Department of Primary Care and Clinical Simulation, University of Otago, Christchurch, New Zealand
- Department of Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - John W Pickering
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Richard Troughton
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Cardiology Department, Christchurch Hospital, Christchurch, New Zealand
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
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6
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Joyce LR, Addy KR, Al-Busaidi IS, Pickering JW, Troughton R, Than M. Response to Re: Implementation of an integrated emergency department acute atrial fibrillation pathway safely reduces cardioversions and hospitalisations: A comparative pre-post study. Emerg Med Australas 2023; 35:884. [PMID: 37435617 DOI: 10.1111/1742-6723.14286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 07/03/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Laura R Joyce
- Department of Surgery and Critical Care, University of Otago, Christchurch, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | | | - Ibrahim S Al-Busaidi
- Department of Primary Care and Clinical Simulation, University of Otago, Christchurch, New Zealand
- Department of Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - John W Pickering
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Richard Troughton
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
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Kavsak PA, Clark L, Arnoldo S, Lou A, Shea JL, Eintracht S, Lyon AW, Bhayana V, Thorlacius L, Raizman JE, Tsui AKY, Djiana R, Chen M, Huang Y, Booth RA, McCudden C, Lavoie J, Beriault DR, Blank DW, Fung AWS, Hoffman B, Taher J, St-Cyr J, Yip PM, Belley-Cote EP, Abramson BL, Borgundvaag B, Friedman SM, Mak S, McLaren J, Steinhart B, Udell JA, Wijeysundera HC, Atkinson P, Campbell SG, Chandra K, Cox JL, Mulvagh S, Quraishi AUR, Chen-Tournoux A, Clark G, Segal E, Suskin N, Johri AM, Sivilotti MLA, Garuba H, Thiruganasambandamoorthy V, Robinson S, Scheuermeyer F, Humphries KH, Than M, Pickering JW, Worster A, Mills NL, Devereaux PJ, Jaffe AS. Analytic Result Variation for High-Sensitivity Cardiac Troponin: Interpretation and Consequences. Can J Cardiol 2023; 39:947-951. [PMID: 37094710 DOI: 10.1016/j.cjca.2023.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/06/2023] [Accepted: 04/18/2023] [Indexed: 04/26/2023] Open
Affiliation(s)
| | - Lorna Clark
- McMaster University, Hamilton, Ontario, Canada
| | | | - Amy Lou
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jennifer L Shea
- Department of Laboratory Medicine, Saint John Regional Hospital, Saint John, New Brunswick, Canada
| | | | - Andrew W Lyon
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | | | - Joshua E Raizman
- Department of Laboratory Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Albert K Y Tsui
- Department of Laboratory Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | | | - Michael Chen
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Yun Huang
- Queen's University, Kingston, Ontario, Canada
| | | | | | - Joël Lavoie
- Institut de Cardiologie de Montréal, Montréal, Québec, Canada
| | | | | | - Angela W S Fung
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Paul M Yip
- University of Toronto, Toronto, Ontario, Canada
| | - Emilie P Belley-Cote
- McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
| | | | | | | | - Susanna Mak
- University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | | | | | | | | | - Eli Segal
- McGill University, Montréal, Québec, Canada
| | | | | | | | | | | | - Simon Robinson
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Martin Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - John W Pickering
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - P J Devereaux
- McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
| | - Allan S Jaffe
- Mayo Clinic and Medical Center, Rochester, Minnesota, United States
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Miller R, Nixon G, Stokes T, Smith M, Pickering JW, Liepins T, Than M. The cost savings of the rural accelerated chest pain pathway for low-risk chest pain in rural general practice: a cost minimisation analysis. J Prim Health Care 2023; 15:71-76. [PMID: 37000540 DOI: 10.1071/hc22117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/24/2022] [Indexed: 04/01/2023] Open
Abstract
Introduction The rural accelerated chest pain pathway (RACPP) has been shown to safely reduce the number of transfers to hospital for patients who present with chest pain to rural general practice. Aim This study aimed to estimate the costs associated with assessing patients with low-risk chest pain using the RACPP in rural general practice compared with transporting such patients to a distant emergency department (ED). Methods This was a retrospective cost minimisation analysis. All patients with low-risk chest pain that were assessed in New Zealand (NZ) rural general practice using the RACPP between 1 June 2018 and 31 December 2019 were asked to participate. The costs incurred by patients were determined by an online survey. Patients were also asked to estimate the costs if they would have been transferred to ED. System costs were obtained from the relevant healthcare organisations. The main outcome measure was the total cost for patients who present with low-risk chest pain. Results In total, 15 patients (22.7% response rate) responded to the survey. Using the RACPP in general practice resulted in a median cost saving of NZ$1184 (95% CI: $1111 to $1468) compared with transferring the same patient to ED. Discussion Although limited by low enrolment, this study suggests that there are significant savings if the RACPP is used to assess patients with low-risk chest pain in rural NZ general practice.
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Affiliation(s)
- Rory Miller
- Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
| | - Garry Nixon
- Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
| | - Tim Stokes
- Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
| | - Michelle Smith
- Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
| | - John W Pickering
- Emergency Department, Canterbury District Health Board, Christchurch, New Zealand; and Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Talis Liepins
- Southern District Health Board, Dunedin, New Zealand
| | - Martin Than
- Emergency Department, Canterbury District Health Board, Christchurch, New Zealand
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9
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Miller R, Nixon G, Stokes T, Smith-Vaughan M, Pickering JW, Liepins T, Than M. Corrigendum to: The cost savings of the rural accelerated chest pain pathway for low-risk chest pain in rural general practice: a cost minimisation analysis. J Prim Health Care 2023; 15:77. [PMID: 37000555 DOI: 10.1071/hc22117_co] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
Introduction The rural accelerated chest pain pathway (RACPP) has been shown to safely reduce the number of transfers to hospital for patients who present with chest pain to rural general practice. Aim This study aimed to estimate the costs associated with assessing patients with low-risk chest pain using the RACPP in rural general practice compared with transporting such patients to a distant emergency department (ED). Methods This was a retrospective cost minimisation analysis. All patients with low-risk chest pain that were assessed in New Zealand (NZ) rural general practice using the RACPP between 1 June 2018 and 31 December 2019 were asked to participate. The costs incurred by patients were determined by an online survey. Patients were also asked to estimate the costs if they would have been transferred to ED. System costs were obtained from the relevant healthcare organisations. The main outcome measure was the total cost for patients who present with low-risk chest pain. Results In total, 15 patients (22.7% response rate) responded to the survey. Using the RACPP in general practice resulted in a median cost saving of NZ$1184 (95% CI: $1111 to $1468) compared with transferring the same patient to ED. Discussion Although limited by low enrolment, this study suggests that there are significant savings if the RACPP is used to assess patients with low-risk chest pain in rural NZ general practice.
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Affiliation(s)
- Rory Miller
- Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
| | - Garry Nixon
- Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
| | - Tim Stokes
- Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
| | - Michelle Smith-Vaughan
- Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
| | - John W Pickering
- Emergency Department, Canterbury District Health Board, Christchurch, New Zealand; and Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Talis Liepins
- Southern District Health Board, Dunedin, New Zealand
| | - Martin Than
- Emergency Department, Canterbury District Health Board, Christchurch, New Zealand
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10
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Shaji EJ, Al-Busaidi IS, Joyce LR, Pickering JW, Troughton RW, Than M. Factors predictive of spontaneous reversion to sinus rhythm: Findings from an integrated acute atrial fibrillation pathway. Heart Rhythm 2023; 20:779-780. [PMID: 36708907 DOI: 10.1016/j.hrthm.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 12/19/2022] [Accepted: 01/17/2023] [Indexed: 01/26/2023]
Affiliation(s)
- Emmanuel J Shaji
- Department of Primary Care and Clinical Simulation, University of Otago, Christchurch, New Zealand; Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Ibrahim S Al-Busaidi
- Department of Primary Care and Clinical Simulation, University of Otago, Christchurch, New Zealand.
| | - Laura R Joyce
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand; Department of Surgery, University of Otago, Christchurch, New Zealand
| | - John W Pickering
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Richard W Troughton
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
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Chin PKL, Than M, Chambers S. One giant leap for cephalexin dosing, one small step for antimicrobial stewardship. CAN J EMERG MED 2023; 25:7-8. [PMID: 36617614 DOI: 10.1007/s43678-022-00442-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Paul Ken Leong Chin
- Department of Medicine, University of Otago, Private Bag 4345, Christchurch, New Zealand. .,Department of Clinical Pharmacology, Te Whatu Ora Health New Zealand, Waitaha Canterbury, Christchurch, New Zealand.
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Stephen Chambers
- Department of Pathology, University of Otago, Christchurch, New Zealand
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12
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Tan E, Beck S, Haskell L, MacLean A, Rogan A, Than M, Venning B, White C, Yates K, McKinlay CJD, Dalziel SR. Paediatric fever management practices and antipyretic use among doctors and nurses in New Zealand emergency departments. Emerg Med Australas 2022; 34:943-953. [PMID: 35644989 PMCID: PMC9796118 DOI: 10.1111/1742-6723.14022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To assess (i) paediatric fever management practices among New Zealand ED doctors and nurses, including adherence to best practice guidelines; and (ii) the acceptability of a randomised controlled trial (RCT) of antipyretics for relief of discomfort in young children. METHODS A cross-sectional survey of doctors and nurses across 11 New Zealand EDs. The primary outcome of adherence to paediatric fever management best practice guidelines was assessed with clinical vignettes and defined as single antipyretic use for the relief of fever-related discomfort. RESULTS Out of 602 participants (243 doctors, 353 nurses and six unknown; response rate 47.5%), only 64 (10.6%, 95% confidence interval [CI] 8.3-13.4%) demonstrated adherence to best practice guidelines. In a febrile settled child with normal fluid intake, the percentage of participants that would use antipyretics doubled with abnormal vital signs (33.7% vs 72.9%, difference -39.2%, 95% CI -44.4% to -34.0%). Most participants would use antipyretics for reduced fluid intake (n = 494, 82.1%, 95% CI 78.8-85.0%) in a febrile settled child. Over half (n = 339, 57.1%, 95% CI 53.0-61.1%) would advise giving antipyretics to prevent febrile convulsions. Most (n = 467, 80.0%, 95% CI 76.5-83.1%) participants agreed that a RCT of antipyretics in febrile children <2 years of age with relief of discomfort as a primary outcome is needed. CONCLUSIONS Just over 10% of New Zealand ED doctors and nurses demonstrated adherence to paediatric fever management best practice guidelines. A RCT of antipyretics in febrile children <2 years of age specifically addressing relief of discomfort as a primary outcome is strongly supported.
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Affiliation(s)
- Eunicia Tan
- Department of Surgery, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand,Emergency DepartmentMiddlemore HospitalAucklandNew Zealand
| | - Sierra Beck
- Emergency DepartmentDunedin HospitalDunedinNew Zealand,Department of MedicineUniversity of OtagoDunedinNew Zealand
| | - Libby Haskell
- Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand,Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
| | | | - Alice Rogan
- Emergency DepartmentWellington Regional HospitalWellingtonNew Zealand,Department of Surgery and AnaesthesiaUniversity of OtagoWellingtonNew Zealand
| | - Martin Than
- Emergency DepartmentChristchurch HospitalChristchurchNew Zealand
| | - Bridget Venning
- Emergency DepartmentMiddlemore HospitalAucklandNew Zealand,School of Nursing, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
| | | | - Kim Yates
- Emergency DepartmentNorth Shore HospitalAucklandNew Zealand,Emergency DepartmentWaitakere HospitalAucklandNew Zealand,Centre for Medical and Health Science Education, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
| | - Christopher JD McKinlay
- Liggins Institute, The University of AucklandAucklandNew Zealand,Kidz First Neonatal CareCounties Manukau HealthAucklandNew Zealand
| | - Stuart R Dalziel
- Department of Surgery, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand,Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand,Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
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13
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Lancini D, Greenslade J, Martin P, Prasad S, Atherton J, Parsonage W, Aldous S, Than M, Cullen L. Chest pain workup in the presence of atrial fibrillation: impacts on troponin testing, myocardial infarction diagnoses, and long-term prognosis. Eur Heart J Acute Cardiovasc Care 2022; 11:772-781. [PMID: 35925661 DOI: 10.1093/ehjacc/zuac090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/25/2022] [Accepted: 07/15/2022] [Indexed: 06/15/2023]
Abstract
AIMS Patients presenting to the emergency department (ED) with chest pain require evaluation for acute coronary syndrome (ACS). Atrial fibrillation (AF) can lead to troponin (cTn) elevation in the absence of ACS. There is limited evidence informing the impact of AF on the diagnostic performance of cTn testing for the diagnosis of Type 1 myocardial infarction (T1MI), or the association between AF and long-term outcomes in this context. METHODS AND RESULTS This study used the IMPACT and ADAPT study databases to compile a combined cohort of 3496 adults presenting to ED with chest pain between 2007 and 2014, with early cTn testing during ED workup. The mean age was 56.6 years, and 40.2% were female. Outcomes included adjudicated diagnoses for the index admission and mortality to 1-year after presentation. The specificity of initial cTn testing for T1MI diagnosis was lower for patients in AF compared with those not in AF (79.2% vs. 95.4%, P < 0.001), largely due to a relative increase in Type 2 myocardial infarction diagnoses. Sensitivity for T1MI did not differ between patients with or without AF (88.5% vs. 91.5%, P = 0.485). AF was associated with increased 1-year mortality (10.4% vs. 2.3%, P < 0.001), although this was not significant on multivariable analysis. CONCLUSION The specificity of serial cTn testing for the diagnosis of T1MI in patients presenting to ED with chest pain is reduced in the presence of AF. Further studies are needed to establish whether optimised cTn thresholds for patients with AF can improve workup and outcomes.
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Affiliation(s)
- Daniel Lancini
- Cardiology Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Jaimi Greenslade
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Australian Centre for Health Sciences Innovation, Centre for Healthcare Transformation, School of Public Health, Queensland University of Technology, Kelvin Grove, Australia
| | - Paul Martin
- Cardiology Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Sandhir Prasad
- Cardiology Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- School of Medicine, Griffith University, Gold Coast, Australia
| | - John Atherton
- Cardiology Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - William Parsonage
- Cardiology Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Australian Centre for Health Sciences Innovation, Centre for Healthcare Transformation, School of Public Health, Queensland University of Technology, Kelvin Grove, Australia
| | - Sally Aldous
- Cardiology Department, Christchurch Hospital, Christchurch, New Zealand
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Australian Centre for Health Sciences Innovation, Centre for Healthcare Transformation, School of Public Health, Queensland University of Technology, Kelvin Grove, Australia
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14
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Tan E, Haskell L, Beck S, MacLean A, Rogan A, Than M, Venning B, White C, Yates K, McKinlay CJD, Dalziel SR. Use of the Theoretical Domains Framework to explore factors influencing paediatric fever management practices and antipyretic use in New Zealand emergency departments. J Paediatr Child Health 2022; 58:1847-1854. [PMID: 35869746 PMCID: PMC9796887 DOI: 10.1111/jpc.16127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/09/2022] [Accepted: 07/06/2022] [Indexed: 01/07/2023]
Abstract
AIM To explore factors influencing fever management practices and antipyretic use among New Zealand Emergency Department (ED) doctors and nurses using the Theoretical Domains Framework (TDF). METHODS Cross-sectional survey of doctors and nurses across 11 New Zealand EDs. The questionnaire examined eight of 12 TDF domains, based on a generic questionnaire validated to assess TDF-based determinants of health-care professional behaviour. Relevant domains were identified by the frequency of beliefs; the presence of conflicting beliefs within a domain; and the likely strength of impact of a belief on paediatric fever management in the ED. RESULTS About 602 participants (243 doctors, 353 nurses and 6 unknown) completed the survey (response rate 47.5%). Over half (351/591, 59.6%, 95% confidence interval (CI) 55.5-63.5%) knew the content of clinical practice guidelines regarding antipyretic use in febrile children (TDF Domain Knowledge), or had been trained to ensure antipyretics are given to febrile children only if they appear distressed (347/592, 58.6%, 95% CI 54.5-62.6%) (Skills). Over 40% (246/590, 95% CI 37.7-45.8%) aim to reduce the fever before discharge (Goals). Most (444/591, 75.1%, 95% CI 71.4-78.6%) participants felt capable of explaining appropriate antipyretic use to parents/care givers (Beliefs about Capabilities). Only a minority (155/584, 26.5%, 95% CI 23.0-30.3%) thought that they can ensure antipyretics are given to febrile children only if they appear distressed when the ED is busy (Environmental Context and Resources). CONCLUSIONS Using the TDF, we identified factors influencing fever management practices and antipyretic use in the ED. These factors can guide the design of targeted, theory-informed knowledge translation strategies.
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Affiliation(s)
- Eunicia Tan
- Department of Surgery, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand,Emergency DepartmentMiddlemore HospitalAucklandNew Zealand
| | - Libby Haskell
- Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand,Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
| | - Sierra Beck
- Emergency DepartmentDunedin HospitalDunedinNew Zealand,Department of MedicineUniversity of OtagoDunedinNew Zealand
| | | | - Alice Rogan
- Emergency DepartmentWellington Regional HospitalWellingtonNew Zealand,Department of Surgery and AnaesthesiaUniversity of OtagoWellingtonNew Zealand
| | - Martin Than
- Emergency DepartmentChristchurch HospitalChristchurchNew Zealand
| | - Bridget Venning
- Emergency DepartmentMiddlemore HospitalAucklandNew Zealand,School of Nursing, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
| | | | - Kim Yates
- Emergency DepartmentsNorth Shore and Waitakere HospitalsAucklandNew Zealand,Centre for Medical and Health Science Education, Faculty of Medical & Health SciencesUniversity of AucklandAucklandNew Zealand
| | - Christopher JD McKinlay
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand,Kidz First Neonatal CareCounties Manukau HealthAucklandNew Zealand
| | - Stuart R Dalziel
- Department of Surgery, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand,Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand,Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
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15
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Peacock WF, Maisel AS, Mueller C, Anker SD, Apple FS, Christenson RH, Collinson P, Daniels LB, Diercks DB, Somma SD, Filippatos G, Headden G, Hiestand B, Hollander JE, Kaski JC, Kosowsky JM, Nagurney JT, Nowak RM, Schreiber D, Vilke GM, Wayne MA, Than M. Finding acute coronary syndrome with serial troponin testing for rapid assessment of cardiac ischemic symptoms (FAST-TRAC): a study protocol. Clin Exp Emerg Med 2022; 9:140-145. [PMID: 35843615 PMCID: PMC9288884 DOI: 10.15441/ceem.21.154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 01/05/2022] [Indexed: 11/23/2022] Open
Abstract
Objective To determine the utility of a highly sensitive troponin assay when utilized in the emergency department. Methods The FAST-TRAC study prospectively enrolled >1,500 emergency department patients with suspected acute coronary syndrome within 6 hours of symptom onset and 2 hours of emergency department presentation. It has several unique features that are not found in the majority of studies evaluating troponin. These include a very early presenting population in whom prospective data collection of risk score parameters and the physician’s clinical impression of the probability of acute coronary syndrome before any troponin data were available. Furthermore, two gold standard diagnostic definitions were determined by a pair of cardiologists reviewing two separate data sets; one that included all local troponin testing results and a second that excluded troponin testing so that diagnosis was based solely on clinical grounds. By this method, a statistically valid head-to-head comparison of contemporary and high sensitivity troponin testing is obtainable. Finally, because of a significant delay in sample processing, a unique ability to define the molecular stability of various troponin assays is possible. Trial registration ClinicalTrials.gov Identifier NCT00880802
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16
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Miller R, Nixon G, Pickering JW, Stokes T, Turner RM, Young J, Gutenstein M, Smith M, Norman T, Watson A, George P, Devlin G, Du Toit S, Than M. A prospective multi-centre study assessing the safety and effectiveness following the implementation of an accelerated chest pain pathway using point-of-care troponin for use in New Zealand rural hospital and primary care settings. European Heart Journal. Acute Cardiovascular Care 2022; 11:418-427. [PMID: 35373255 PMCID: PMC9197428 DOI: 10.1093/ehjacc/zuac037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/15/2022] [Indexed: 11/30/2022]
Abstract
Aims Most rural hospitals and general practices in New Zealand (NZ) are reliant on point-of-care troponin. A rural accelerated chest pain pathway (RACPP), combining an electrocardiogram (ECG), a structured risk score (Emergency Department Assessment of Chest Pain Score), and serial point-of-care troponin, was designed for use in rural hospital and primary care settings across NZ. The aim of this study was to evaluate the safety and effectiveness of the RACPP. Methods and results A prospective multi-centre evaluation following implementation of the RACPP was undertaken from 1 July 2018 to 31 December 2020 in rural hospitals, rural and urban general practices, and urgent care clinics. The primary outcome measure was the presence of 30-day major adverse cardiac events (MACEs) in low-risk patients. The secondary outcome was the percentage of patients classified as low-risk that avoided transfer or were eligible for early discharge. There were 1205 patients enrolled in the study. 132 patients were excluded. Of the 1073 patients included in the primary analysis, 474 (44.0%) patients were identified as low-risk. There were no [95% confidence interval (CI): 0–0.3%] MACE within 30 days of the presentation among low-risk patients. Most of these patients (91.8%) were discharged without admission to hospital. Almost all patients who presented to general practice (99%) and urgent care clinics (97.6%) were discharged to home directly. Conclusion The RACPP is safe and effective at excluding MACEs in NZ rural hospital and primary care settings, where it can identify a group of low-risk patients who can be safely discharged home without transfer to hospital.
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Affiliation(s)
- Rory Miller
- Department of General Practice and Rural Health, University of Otago, Dunedin School of Medicine , Dunedin , New Zealand
| | - Garry Nixon
- Department of General Practice and Rural Health, University of Otago, Dunedin School of Medicine , Dunedin , New Zealand
| | - John W Pickering
- Emergency Department, University of Otago – Christchurch , Christchurch , New Zealand
| | - Tim Stokes
- Department of General Practice and Rural Health, University of Otago, Dunedin School of Medicine , Dunedin , New Zealand
| | - Robin M Turner
- Centre for Biostatistics, Division of Health Sciences, University of Otago , Dunedin , New Zealand
| | - Joanna Young
- Canterbury DHB, Christchurch Hospital , Christchurch , New Zealand
| | - Marc Gutenstein
- Rural Health Academic Centre Ashburton, University of Otago – Christchurch , Christchurch , New Zealand
| | - Michelle Smith
- Department of General Practice and Rural Health, University of Otago, Dunedin School of Medicine , Dunedin , New Zealand
| | - Tim Norman
- Project Office, Midlands Regional Health Network Charitable Trust , Hamilton , New Zealand
| | - Antony Watson
- Canterbury DHB, Christchurch Hospital , Christchurch , New Zealand
| | - Peter George
- Chemical Pathology, PathoGene, Merivale , Christchurch , New Zealand
| | | | | | - Martin Than
- Emergency Department, Canterbury DHB, Christchurch Hospital , Christchurch , New Zealand
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17
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Zimmermann T, du Fay de Lavallaz J, Nestelberger T, Gualandro DM, Lopez-Ayala P, Badertscher P, Widmer V, Shrestha S, Strebel I, Glarner N, Diebold M, Miró Ò, Christ M, Cullen L, Than M, Martin-Sanchez FJ, Di Somma S, Peacock WF, Keller DI, Bilici M, Costabel JP, Kühne M, Breidthardt T, Thiruganasambandamoorthy V, Mueller C, Belkin M, Leu K, Lohrmann J, Boeddinghaus J, Twerenbold R, Koechlin L, Walter JE, Amrein M, Wussler D, Freese M, Puelacher C, Kawecki D, Morawiec B, Salgado E, Martinez-Nadal G, Inostroza CIF, Mandrión JB, Poepping I, Rentsch K, von Eckardstein A, Buser A, Greenslade J, Reichlin T, Bürgler F. International Validation of the Canadian Syncope Risk Score : A Cohort Study. Ann Intern Med 2022; 175:783-794. [PMID: 35467933 DOI: 10.7326/m21-2313] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The Canadian Syncope Risk Score (CSRS) was developed to predict 30-day serious outcomes not evident during emergency department (ED) evaluation. OBJECTIVE To externally validate the CSRS and compare it with another validated score, the Osservatorio Epidemiologico della Sincope nel Lazio (OESIL) score. DESIGN Prospective cohort study. SETTING Large, international, multicenter study recruiting patients in EDs in 8 countries on 3 continents. PARTICIPANTS Patients with syncope aged 40 years or older presenting to the ED within 12 hours of syncope. MEASUREMENTS Composite outcome of serious clinical plus procedural events (primary outcome) and the primary composite outcome excluding procedural interventions (secondary outcome). RESULTS Among 2283 patients with a mean age of 68 years, the primary composite outcome occurred in 7.2%, and the composite outcome excluding procedural interventions occurred in 3.1% at 30 days. Prognostic performance of the CSRS was good for both 30-day composite outcomes and better compared with the OESIL score (area under the receiver-operating characteristic curve [AUC], 0.85 [95% CI, 0.83 to 0.88] vs. 0.74 [CI, 0.71 to 0.78] and 0.80 [CI, 0.75 to 0.84] vs. 0.69 [CI, 0.64 to 0.75], respectively). Safety of triage, as measured by the frequency of the primary composite outcome in the low-risk group, was higher using the CSRS (19 of 1388 [0.6%]) versus the OESIL score (17 of 1104 [1.5%]). A simplified model including only the clinician classification of syncope (cardiac syncope, vasovagal syncope, or other) variable at ED discharge-a component of the CSRS-achieved similar discrimination as the CSRS (AUC, 0.83 [CI, 0.80 to 0.87] for the primary composite outcome). LIMITATION Unable to disentangle the influence of other CSRS components on clinician classification of syncope at ED discharge. CONCLUSION This international external validation of the CSRS showed good performance in identifying patients at low risk for serious outcomes outside of Canada and superior performance compared with the OESIL score. However, clinician classification of syncope at ED discharge seems to explain much of the performance of the CSRS in this study. The clinical utility of the CSRS remains uncertain. PRIMARY FUNDING SOURCE Swiss National Science Foundation & Swiss Heart Foundation.
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Affiliation(s)
- Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, and Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (T.Z.)
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, GREAT Network, Rome, Italy, and Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (T.N.)
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, GREAT Network, Rome, Italy, and Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil (D.M.G.)
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Velina Widmer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland (V.W., N.G.)
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland (V.W., N.G.)
| | - Matthias Diebold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Òscar Miró
- GREAT Network, Rome, Italy, and Hospital Clinic, Barcelona, Catalonia, Spain (Ò.M.)
| | - Michael Christ
- GREAT Network, Rome, Italy, and Kantonsspital Luzern, Luzern, Switzerland (M.C.)
| | - Louise Cullen
- GREAT Network, Rome, Italy, and Royal Brisbane & Women's Hospital, Herston, Australia (L.C.)
| | - Martin Than
- GREAT Network, Rome, Italy, and Christchurch Hospital, Christchurch, New Zealand (M.T.)
| | - F Javier Martin-Sanchez
- GREAT Network, Rome, Italy, and Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain (F.J.M.)
| | - Salvatore Di Somma
- GREAT Network, Rome, Italy, and Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Italy (S.D.S.)
| | - W Frank Peacock
- GREAT Network, Rome, Italy, and Baylor College of Medicine, Department of Emergency Medicine, Houston, Texas (W.F.P.)
| | - Dagmar I Keller
- Emergency Department, University Hospital Zürich, Zürich, Switzerland (D.I.K.)
| | - Murat Bilici
- Department of Orthopedics and Traumatology, University Hospital Basel, University of Basel, Basel, Switzerland (M.B.)
| | | | - Michael Kühne
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Tobias Breidthardt
- Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, and Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (T.B.)
| | | | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
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18
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du Fay de Lavallaz J, Zimmermann T, Badertscher P, Lopez-Ayala P, Nestelberger T, Miró Ò, Salgado E, Zaytseva X, Gafner MS, Christ M, Cullen L, Than M, Martin-Sanchez FJ, Di Somma S, Peacock WF, Keller DI, Costabel JP, Sigal A, Puelacher C, Wussler D, Koechlin L, Strebel I, Schuler S, Manka R, Bilici M, Lohrmann J, Kühne M, Breidthardt T, Clark CL, Probst M, Gibson TA, Weiss RE, Sun BC, Mueller C. Performance of the American Heart Association/American College of Cardiology/Heart Rhythm Society versus European Society of Cardiology guideline criteria for hospital admission of patients with syncope. Heart Rhythm 2022; 19:1712-1722. [PMID: 35644354 DOI: 10.1016/j.hrthm.2022.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/28/2022] [Accepted: 05/23/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Current American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) and European Society of Cardiology (ESC) guidelines recommend different strategies to avoid low-yield admissions in patients with syncope. OBJECTIVE The purpose of this study was to directly compare the safety and efficacy of applying admission criteria of both guidelines to patients presenting with syncope to the emergency department in 2 multicenter studies. METHODS The international BASEL IX (BAsel Syncope EvaLuation) study (median age 71 years) and the U.S. SRS (Improving Syncope Risk Stratification in Older Adults) study (median age 72 years) were investigated. Primary endpoints were sensitivity/specificity for the adjudicated diagnosis of cardiac syncope (BASEL IX only) and 30-day major adverse cardiovascular events (30d-MACE). RESULTS Among 2560 patients in the BASEL IX and 2085 in SRS studies, ACC/AHA/HRS and ESC criteria recommended admission for a comparable number of patients in BASEL IX (27% vs 28%), but ACC/AHA/HRS criteria less often in SRS (19% vs 32%; P <.01). Recommendations were discordant in ∼25% of patients. In BASEL IX, sensitivity for cardiac syncope and 30d-MACE among patients without admission criteria was comparable for ACC/AHA/HRS and ESC criteria (64% vs 65%, P = .86; and 67% vs 71%, P = .15, respectively). In SRS, sensitivity for 30d-MACE was lower with ACC/AHA/HRS (54%) vs ESC criteria (88%; P <.001). Similarly, specificity for cardiac syncope and 30d-MACE in BASEL IX was comparable for both guidelines, but in SRS the ACC/AHA/HRS guidelines showed a higher specificity for 30d-MACE than the ESC guidelines. CONCLUSION ACC/AHA/HRS and ESC guidelines showed disagreement regarding admission for 1 in 4 patients and had only modest sensitivity, all indicating possible opportunities for improvements.
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Affiliation(s)
- Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network.
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Òscar Miró
- GREAT Network; Hospital Clinic, Barcelona, Catalonia, Spain
| | - Emilio Salgado
- GREAT Network; Hospital Clinic, Barcelona, Catalonia, Spain
| | - Xenia Zaytseva
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; University Hospital Zürich, Zürich, Switzerland
| | - Michele Sara Gafner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Michael Christ
- Department of Emergency Medicine, Kantonsspital Luzern, Lucerne, Switzerland
| | - Louise Cullen
- GREAT Network; Royal Brisbane & Women's Hospital, Herston, Australia
| | - Martin Than
- GREAT Network; Christchurch Hospital, Christchurch, New Zealand
| | | | - Salvatore Di Somma
- GREAT Network; Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Rome, Italy
| | - W Frank Peacock
- GREAT Network; Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | | | | | - Alan Sigal
- Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network; Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Sereina Schuler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; University Hospital Zürich, Zürich, Switzerland
| | | | - Murat Bilici
- Department of Orthopedics and Traumatology, Basel University Hospital, Basel, Switzerland
| | - Jens Lohrmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michael Kühne
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tobias Breidthardt
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
| | - Carol L Clark
- Beaumont Health System-Royal Oak, Royal Oak, Michigan
| | - Marc Probst
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York
| | - Thomas A Gibson
- Department of Biostatistics, University of California Fielding School of Public Health, Los Angeles, California
| | - Robert E Weiss
- Department of Biostatistics, University of California Fielding School of Public Health, Los Angeles, California
| | - Benjamin C Sun
- Department of Emergency Medicine, Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network
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19
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Norman T, Young J, Scott Jones J, Egan G, Pickering J, Du Toit S, Hamilton F, Miller R, Frampton C, Devlin G, George P, Than M. Implementation and evaluation of a rural general practice assessment pathway for possible cardiac chest pain using point-of-care troponin testing: a pilot study. BMJ Open 2022; 12:e044801. [PMID: 35428610 PMCID: PMC9013998 DOI: 10.1136/bmjopen-2020-044801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES To assess the feasibility and acceptability, and additionally to preliminarily evaluate, the effectiveness and safety of an accelerated diagnostic chest pain pathway in rural general practice using point-of-care troponin to identify patients at low risk of acute myocardial infarction, avoiding unnecessary patient transfer to hospital and enabling early discharge home. DESIGN A prospective observational pilot evaluation. SETTING Twelve rural general (family) practices in the Midlands region of New Zealand. PARTICIPANTS Patients aged ≥18 years who presented acutely to rural general practice with suspected ischaemic chest pain for whom the doctor intended transfer to hospital for serial troponin measurement. OUTCOME MEASURES The proportion of patients managed using the low-risk pathway without transfer to hospital and without 30-day major adverse cardiac event (MACE); pathway adherence; rate of 30-day MACE; patient satisfaction with care; and agreement between point-of-care and laboratory measured troponin concentrations. RESULTS A total of 180 patients were assessed by the pathway. The pathway classified 111 patients (61.7%) as low-risk and all were managed in rural general practice with no 30-day MACE (0%, 95% CI 0.0% to 3.3%). Adherence to the low-risk pathway was 95.5% (106 out of 111). Of the 56 patients classified as non-low-risk and referred to hospital, 9 (16.1%) had a 30-day MACE. A further 13 non-low-risk patients were not transferred to hospital, with no events. The sensitivity of the pathway for 30-day MACE was 100.0% (95% CI 70.1% to 100%). Of low-risk patients, 94% reported good to excellent satisfaction with care. Good concordance was observed between point-of-care and duplicate laboratory measured troponin concentrations. CONCLUSIONS The use of an accelerated diagnostic chest pain pathway incorporating point-of-care troponin in a rural general practice setting was feasible and acceptable, with preliminary results suggesting that it may safely and effectively reduce the urgent transfer of low-risk patients to hospital.
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Affiliation(s)
- Tim Norman
- Project Office, Pinnacle Midlands Health Network, Hamilton, New Zealand
- Department of Population Health, University of Waikato, Hamilton, New Zealand
| | - Joanna Young
- Department of Cardiology, Canterbury District Health Board, Christchurch, New Zealand
| | - Jo Scott Jones
- Project Office, Pinnacle Midlands Health Network, Hamilton, New Zealand
| | - Gishani Egan
- Project Office, Pinnacle Midlands Health Network, Hamilton, New Zealand
| | - John Pickering
- Emergency Department, Canterbury District Health Board, Christchurch, New Zealand
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Stephen Du Toit
- Department of Clinical Chemistry, Waikato District Health Board, Hamilton, New Zealand
| | - Fraser Hamilton
- Project Office, Pinnacle Midlands Health Network, Hamilton, New Zealand
- Heart Foundation of New Zealand, Auckland, New Zealand
| | - Rory Miller
- Project Office, Pinnacle Midlands Health Network, Hamilton, New Zealand
- Department of Medicine, University of Otago - Dunedin Campus, Dunedin, New Zealand
| | - Chris Frampton
- Christchurch School of Medicine and Health Sciences, University of Otago Christchurch, Christchurch, New Zealand
| | - Gerard Devlin
- Heart Foundation of New Zealand, Auckland, New Zealand
- Department of Cardiology, Waikato District Health Board, Hamilton, New Zealand
| | - Peter George
- MedLab Pathology, Sydney, New South Wales, Australia
| | - Martin Than
- Emergency Department, Canterbury District Health Board, Christchurch, New Zealand
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20
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Roberts T, Horner D, Chu K, Than M, Kelly AM, Investigators HEADS. 745 Thunderclap headache syndrome presenting to the emergency department: an international multicentre observational cohort study. Emerg Med J 2022. [DOI: 10.1136/emermed-2022-rcem.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundAcute headache is a common reason for presentation to emergency departments. Some have significant structural pathology requiring further intervention. Emergency clinicians often rely on presenting headache features (such as thunderclap onset) to guide the need for neuroimaging and further investigation. It is unclear whether these features discriminate accurately or how the investigations of patients presenting with thunderclap headache differs internationally.ObjectivesTo determine the proportion of patients presenting with thunderclap onset of headache from a general headache cohort and compare demographics, investigation strategy and final diagnosis, across an international sample of patients.MethodsAn international, multicentre, observational prospective cohort study. This planned sub-study focussed on patients presenting with thunderclap onset headache, with characteristics compared to the general headache cohort. The prospective observational design was chosen to capture real-world data on current international practice.ResultsThe study recruited 4536 patients across 67 hospitals and 10 countries during 2019. Of this, 644 patients presented with thunderclap headache onset (14.2%). Median age was 44. The majority of patients self-referred to hospital. CT brain imaging was performed in 62.7% cases and lumbar puncture in 10.6%, with wide international variation. New Zealand reported the highest rate of neuroimaging, 78.4% of patients presenting with thunderclap headache, compared to 25.0% in Romania. All cases of subarachnoid haemorrhage (SAH) were diagnosed on CT imaging results.When compared with the parent cohort of all headache patients presenting to the ED, those with thunderclap headache had a significantly higher rate of serious cranial pathology (13.7% vs 8.5%, p<0.001) and final diagnosis of SAH (3.6% vs 0.8% p<0.001).ConclusionsThunderclap headache presenting to the ED appears to correlate with a higher risk for serious intracranial pathology and/or SAH. Investigation strategies varied within this international cohort. Neuroimaging rates did not align with international guidelines, suggesting potential for further work on standardisation.
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21
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Roberts T, Horner DE, Chu K, Than M, Kelly AM, Klim S, Kinnear F, Keijzers G, Karamercan MA, Wijeratne T, Kamona S, Kuan WS, Graham CA, Body R, Laribi S. Thunderclap headache syndrome presenting to the emergency department: an international multicentre observational cohort study. Emerg Med J 2022; 39:803-809. [PMID: 35144978 DOI: 10.1136/emermed-2021-211370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 01/26/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Most headache presentations to emergency departments (ED) have benign causes; however, approximately 10% will have serious pathology. International guidelines recommend that patients describing the onset of headache as 'thunderclap' undergo neuroimaging and further investigation. The association of this feature with serious headache cause is unclear. The objective of this study was to determine if patients presenting with thunderclap headache are significantly more likely to have serious underlying pathology than patients with more gradual onset and to determine compliance with guidelines for investigation. METHODS This was a planned secondary analysis of an international, multicentre, observational study of adult ED patients presenting with a main complaint of headache. Data regarding demographics, investigation strategies and final ED diagnoses were collected. Thunderclap headache was defined as severe headache of immediate or almost immediate onset and peak intensity. Proportion of patients with serious pathology in thunderclap and non-thunderclap groups were compared by χ² test. RESULTS 644 of 4536 patients presented with thunderclap headache (14.2%). CT brain imaging and lumbar puncture were performed in 62.7% and 10.6% of cases, respectively. Among patients with thunderclap headache, serious pathology was identified in 10.9% (95%CI 8.7% to 13.5%) of cases-significantly higher than the proportion found in patients with a different headache onset (6.6% (95% CI 5.9% to 7.4%), p<0.001.). The incidence of subarachnoid haemorrhage (SAH) was 3.6% (95% CI 2.4% to 5.3%) in those with thunderclap headache vs 0.3% (95% CI 0.2% to 0.5%) in those without (p<0.001). All cases of SAH were diagnosed on CT imaging. Non-serious intracranial pathology was diagnosed in 87.7% of patients with thunderclap headache. CONCLUSIONS Thunderclap headache presenting to the ED appears be associated with higher risk for serious intracranial pathology, including SAH, although most patients with this type of headache had a benign cause. Neuroimaging rates did not align with international guidelines, suggesting potential need for further work on standardisation.
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Affiliation(s)
- Tom Roberts
- Trainee Emergency Research Network (TERN), The Royal College of Emergency Medicine, London, UK .,Emergency Department, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
| | - Daniel E Horner
- Emergency/Critical Care Department, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Infection Immunity and Respiratory Medicine, The University of Manchester, Manchester, England, UK
| | - Kevin Chu
- Department of Emergency, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine and Biomedical Sciences, The University of Queensland, Herston, Queensland, Australia
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, Canterbury, New Zealand
| | - Anne-Maree Kelly
- JECEMR, Western Health, St Albans, Victoria, Australia.,Department of Emergency Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sharon Klim
- Department of Emergency Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Joseph Epstein Centre for Emergency Medicine Research at Western Health, St Albans, Victoria, Australia
| | - Frances Kinnear
- Emergency, Prince Charles Hospital, Chermside, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia.,Department of Emergency Medicine, Bond University, Gold Coast, Queensland, Australia
| | | | - Tissa Wijeratne
- Department of Neurology, La Trobe University, Melbourne, Victoria, Australia
| | - Sinan Kamona
- School of Medicine, University of Auckland, Auckland, New Zealand.,Auckland District Health Board, Auckland, New Zealand
| | - Win Sen Kuan
- Emergency Medicine, National University Health System, Singapore.,Department of Surgery, National University Singapore Yong Loo Lin School of Medicine, Singapore
| | - Colin A Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Richard Body
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
| | - Said Laribi
- Emergency Medicine, University Hospital of Tours, Tours, France.,EUSEM Research Network, Aarselaar, Belgium
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22
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Vincent A, Pearson S, Pickering JW, Weaver J, Toney L, Hamill L, Hurrell M, Than M. Sensitivity of modern multislice CT for subarachnoid haemorrhage at incremental timepoints after headache onset: a 10-year analysis. Emerg Med J 2021; 39:810-817. [PMID: 34819306 DOI: 10.1136/emermed-2020-211068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 11/02/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND CT performed within 6 hours of headache onset is highly sensitive for the detection of subarachnoid haemorrhage (SAH). Beyond this time frame, if the CT is negative for blood, a lumbar puncture is often performed. Technology improvements in image noise reduction, resolution and motion artefact have enhanced the performance of multislice CT (MSCT) and may have further improved sensitivity. We aimed to describe how the sensitivity to SAH of modern MSCT changes with time from headache onset. METHODS This was a retrospective analysis of electronic data collected as part of routine care among all patients presenting to Christchurch Hospital diagnosed with a SAH between 1 January 2008 and 31 December 2017. Patients were imaged with MSCT. The primary outcome was the proportion of patients with spontaneous aneurysmal SAH (identified via coding and confirmed by clinical and radiological records) that had a positive MSCT. The secondary outcome was the proportion of patients with any type of spontaneous SAH that had a positive MSCT. RESULTS There were 347 patients with an SAH of whom 260 were aneurysmal SAH. MSCT identified 253 (97.3%) of all aneurysmal SAH and 332 (95.7%) of all SAH. The sensitivity of MSCT was 99.6% (95% CI 97.6 to 100) for aneurysmal SAH and 99.0% (95% CI 97.1 to 99.8) for all SAH at 48 hours after headache onset. At 24 hours after headache onset, the sensitivity for aneurysmal SAH was 100% (95% CI 98.3 to 100). CONCLUSION These data suggest that it may be possible to extend the timeframe from headache onset within which modern MSCT can be used to rule out aneurysmal SAH.
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Affiliation(s)
- Annabel Vincent
- Christchurch Hospital Emergency Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand
| | - Scott Pearson
- Christchurch Hospital Emergency Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand
| | - John W Pickering
- Christchurch Hospital Emergency Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand.,Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - James Weaver
- Christchurch Hospital Emergency Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand
| | - Leanne Toney
- Christchurch Hospital Emergency Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand
| | - Laura Hamill
- Christchurch Hospital Emergency Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand
| | - Michael Hurrell
- Christchurch Hospital Radiology Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand
| | - Martin Than
- Christchurch Hospital Emergency Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand
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23
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Kavsak PA, Than M. Single troponin to rule-out MI in early presenters, perhaps, but not major adverse cardiac events. Int J Cardiol 2021; 342:29-30. [PMID: 34437935 DOI: 10.1016/j.ijcard.2021.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 08/17/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada.
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
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24
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Peacock W, Daniels L, Headdon G, Diercks D, Hiestand B, Hollander J, Kosowsky J, Nowak R, Vilke G, Than M. 98 HEART, EDACS, and TIMI: Little Value After High-Sensitivity Troponin Testing. Ann Emerg Med 2021. [DOI: 10.1016/j.annemergmed.2021.09.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
OBJECTIVES To determine the proportion of children with postconcussive symptoms (PCSs) and to explore the influence of noninjury and injury factors on parents' PCS report at 3 months postinjury. DESIGN A cross-sectional analysis of the 3-month postinjury data from a larger, prospective, longitudinal study. METHODS Parents and their child aged 2 to 12 years who presented at the emergency department with either a mild traumatic brain injury (mTBI) or a superficial injury to the head (SIH) were recruited. Parents reported their child's symptoms at the time of injury and at 3 months postinjury. Child, family/parent, and injury characteristics were considered as potential predictors. Logistic regression was conducted to determine which factors increase the likelihood of parents' PCS report. RESULTS At 3 months postinjury, 30% and 13% of children in the mTBI and SIH groups exhibited 1 or more symptoms, respectively. On the other hand, 18% (mTBI) and 8% (SIH) continued to have ongoing problems when 2 or more symptoms were considered at follow-up. The final model, which included child's sex, injury group, number of symptoms at the time of injury, and parental stress, had a significant predictive utility in determining parents' report of 1 or more symptoms at follow-up. Only parental stress continued to be a significant predictor when considering 2 or more symptoms at 3 months postinjury. CONCLUSIONS Children with mTBI have worse outcomes than children with SIH at follow-up, with parents more likely to report 1 or more ongoing symptoms if their children had an mTBI. Postinjury assessment of parental stress and ongoing symptom monitoring in young children with mTBI will allow for timely provision of support for the family.
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Affiliation(s)
- Joy Noelle Yumul
- Melbourne School of Psychological Sciences, University of Melbourne, Australia (Ms Yumul and Drs McKinlay, Anderson, and Catroppa); Murdoch Children's Research Institute, Melbourne, Australia (Ms Yumul and Drs McKinlay, Anderson, and Catroppa); Royal Children's Hospital, Melbourne, Australia (Ms Yumul and Drs Anderson and Catroppa); Department of Psychology, University of Canterbury, Christchurch, New Zealand (Dr McKinlay); and Department of Emergency Medicine, Canterbury District Health Board, Christchurch, New Zealand (Dr Than)
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26
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du Fay de Lavallaz J, Badertscher P, Zimmermann T, Nestelberger T, Walter J, Strebel I, Coelho C, Miró Ò, Salgado E, Christ M, Geigy N, Cullen L, Than M, Javier Martin-Sanchez F, Di Somma S, Frank Peacock W, Morawiec B, Wussler D, Keller DI, Gualandro D, Michou E, Kühne M, Lohrmann J, Reichlin T, Mueller C. Early standardized clinical judgement for syncope diagnosis in the emergency department. J Intern Med 2021; 290:728-739. [PMID: 33755279 DOI: 10.1111/joim.13269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/16/2020] [Accepted: 01/08/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND The diagnosis of cardiac syncope remains a challenge in the emergency department (ED). OBJECTIVE Assessing the diagnostic accuracy of the early standardized clinical judgement (ESCJ) including a standardized syncope-specific case report form (CRF) in comparison with a recommended multivariable diagnostic score. METHODS In a prospective international observational multicentre study, diagnostic accuracy for cardiac syncope of ESCJ by the ED physician amongst patients ≥ 40 years presenting with syncope to the ED was directly compared with that of the Evaluation of Guidelines in Syncope Study (EGSYS) diagnostic score. Cardiac syncope was centrally adjudicated independently of the ESCJ or conducted workup by two ED specialists based on all information available up to 1-year follow-up. Secondary aims included direct comparison with high-sensitivity cardiac troponin I (hs-cTnI) and B-type natriuretic peptide (BNP) concentrations and a Lasso regression to identify variables contributing most to ESCJ. RESULTS Cardiac syncope was adjudicated in 252/1494 patients (15.2%). The diagnostic accuracy of ESCJ for cardiac syncope as quantified by the area under the curve (AUC) was 0.87 (95% CI: 0.84-0.89), and higher compared with the EGSYS diagnostic score (0.73 (95% CI: 0.70-0.76)), hs-cTnI (0.77 (95% CI: 0.73-0.80)) and BNP (0.77 (95% CI: 0.74-0.80)), all P < 0.001. Both biomarkers (alone or in combination) on top of the ESCJ significantly improved diagnostic accuracy. CONCLUSION ESCJ including a standardized syncope-specific CRF has very high diagnostic accuracy and outperforms the EGSYS score, hs-cTnI and BNP.
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Affiliation(s)
- J du Fay de Lavallaz
- From the, Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT - Global Research on Acute Conditions Team, Roma, Italy
| | - P Badertscher
- From the, Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT - Global Research on Acute Conditions Team, Roma, Italy.,Department of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - T Zimmermann
- From the, Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT - Global Research on Acute Conditions Team, Roma, Italy
| | - T Nestelberger
- From the, Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT - Global Research on Acute Conditions Team, Roma, Italy
| | - J Walter
- From the, Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT - Global Research on Acute Conditions Team, Roma, Italy
| | - I Strebel
- From the, Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT - Global Research on Acute Conditions Team, Roma, Italy
| | - C Coelho
- From the, Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT - Global Research on Acute Conditions Team, Roma, Italy
| | - Ò Miró
- GREAT - Global Research on Acute Conditions Team, Roma, Italy.,Hospital Clinic, Barcelona, Catalonia, Spain
| | - E Salgado
- GREAT - Global Research on Acute Conditions Team, Roma, Italy.,Hospital Clinic, Barcelona, Catalonia, Spain
| | - M Christ
- Department of Emergency Medicine, Kantonsspital, Luzern, Switzerland
| | - N Geigy
- Department of Emergency Medicine, Hospital of Liestal, Liestal, Switzerland
| | - L Cullen
- GREAT - Global Research on Acute Conditions Team, Roma, Italy.,Royal Brisbane & Women's Hospital, Herston, Australia
| | - M Than
- GREAT - Global Research on Acute Conditions Team, Roma, Italy.,Christchurch Hospital, Christchurch, New Zealand
| | - F Javier Martin-Sanchez
- GREAT - Global Research on Acute Conditions Team, Roma, Italy.,Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain
| | - S Di Somma
- GREAT - Global Research on Acute Conditions Team, Roma, Italy.,Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Rome, Italy
| | - W Frank Peacock
- GREAT - Global Research on Acute Conditions Team, Roma, Italy.,Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - B Morawiec
- GREAT - Global Research on Acute Conditions Team, Roma, Italy.,2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - D Wussler
- From the, Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT - Global Research on Acute Conditions Team, Roma, Italy
| | - D I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - D Gualandro
- From the, Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT - Global Research on Acute Conditions Team, Roma, Italy
| | - E Michou
- From the, Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT - Global Research on Acute Conditions Team, Roma, Italy
| | - M Kühne
- From the, Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT - Global Research on Acute Conditions Team, Roma, Italy
| | - J Lohrmann
- From the, Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT - Global Research on Acute Conditions Team, Roma, Italy
| | - T Reichlin
- From the, Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,Department of Cardiology, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - C Mueller
- From the, Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.,GREAT - Global Research on Acute Conditions Team, Roma, Italy
| | -
- From the, Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
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27
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Than M, Richardson S, Pickering J. Emergency department frequent attenders: big data insights for a big and complex problem. Emerg Med J 2021; 39:2. [PMID: 34404679 DOI: 10.1136/emermed-2021-211560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/08/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Sandra Richardson
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - John Pickering
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand.,Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
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28
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Schwab K, Nguyen D, Ungab G, Feld G, Maisel AS, Than M, Joyce L, Peacock WF. Artificial intelligence MacHIne learning for the detection and treatment of atrial fibrillation guidelines in the emergency department setting (AIM HIGHER): Assessing a machine learning clinical decision support tool to detect and treat non-valvular atrial fibrillation in the emergency department. J Am Coll Emerg Physicians Open 2021; 2:e12534. [PMID: 34401870 PMCID: PMC8353018 DOI: 10.1002/emp2.12534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 01/04/2021] [Accepted: 07/20/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Advanced machine learning technology provides an opportunity to improve clinical electrocardiogram (ECG) interpretation, allowing non-cardiology clinicians to initiate care for atrial fibrillation (AF). The Lucia Atrial Fibrillation Application (Lucia App) photographs the ECG to determine rhythm detection, calculates CHA2DS2-VASc and HAS-BLED scores, and then provides guideline-recommended anticoagulation. Our purpose was to determine the rate of accurate AF identification and appropriate anticoagulation recommendations in emergency department (ED) patients ultimately diagnosed with AF. METHODS We performed a single-center, observational retrospective chart review in an urban California ED, with an annual census of 70,000 patients. A convenience sample of hospitalized patients with AF as a primary or secondary discharge diagnosis were evaluated for accurate ED AF diagnosis and ED anticoagulation rates. This was done by comparing the Lucia App against a gold standard board-certified cardiologist diagnosis and using the American College of Emergency Physicians AF anticoagulation guidelines. RESULTS Two hundred and ninety seven patients were enrolled from January 2016 until December 2019. The median age was 79 years and 44.1% were female. Compared to the gold standard diagnosis, the Lucia App detected AF in 98.3% of the cases. Physicians recommended guideline-consistent anticoagulation therapy in 78.5% versus 98.3% for the Lucia App. Of the patients with indications for anticoagulation and discharged from the ED, only 25.0% were started at discharge. CONCLUSION Use of a cloud-based ECG identification tool can allow non-cardiologists to achieve similar rates of AF identification as board-certified cardiologists and achieve higher rates of guideline-recommended anticoagulation therapy in the ED.
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Affiliation(s)
- Kim Schwab
- Sharp Chula Vista Medical CenterChula VistaCaliforniaUSA
- Keck Graduate InstituteClaremontCaliforniaUSA
| | - Dacloc Nguyen
- Sharp Chula Vista Medical CenterChula VistaCaliforniaUSA
| | | | - Gregory Feld
- Department of MedicineUC San Diego HealthSan DiegoCaliforniaUSA
| | - Alan S. Maisel
- Coronary Care Unit and Heart Failure ProgramVeterans Affairs San Diego Healthcare SystemSan DiegoCaliforniaUSA
| | - Martin Than
- Department of Emergency MedicineChristchurch HospitalChristchurchNew Zealand
| | - Laura Joyce
- Department of Emergency MedicineChristchurch HospitalChristchurchNew Zealand
| | - W. Frank Peacock
- Henry JN Taub Department of Emergency MedicineBaylor College of MedicineHoustonTexasUSA
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Al-Busaidi IS, Clare GC, Joyce LR, Pearson S, Lainchbury J, Than M, Troughton RW. Presentation, Treatment and Long-Term Outcomes of a Multidisciplinary Acute Atrial Fibrillation Pathway: A 12-Month Follow-Up Study. Heart Lung Circ 2021; 31:216-223. [PMID: 34210615 DOI: 10.1016/j.hlc.2021.05.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/01/2021] [Accepted: 05/16/2021] [Indexed: 11/17/2022]
Abstract
AIM Atrial fibrillation/flutter (AF/AFL) is associated with high rates of emergency department (ED) visits and acute hospitalisation. A recently established multidisciplinary acute AF treatment pathway seeks to avoid hospital admissions by early discharge of haemodynamically stable, low risk patients from the ED with next-working-day return to a ward-based AF clinic for further assessment. We conducted a preliminary analysis of the clinical outcomes of this pathway. METHODS We retrospectively reviewed clinical records of all patients assessed at the AF clinic at Christchurch Hospital over a 12-month period. Data related to presentation, patient characteristics, treatment, and 12-month outcomes were analysed. RESULTS A total of 143 patients (median age 65, interquartile range: 57-74 years, 59% male, 87% European) were assessed. Of these, 87 (60.8%) presented with their first episode of AF/AFL. Spontaneous cardioversion occurred in 41% at ED discharge, and this increased to 73% at AF clinic review. Electrical cardioversion was subsequently performed in 16 patients (11.2%), and 16 (11.2%) ultimately required hospital admission (eight to facilitate electrical cardioversion). At a median of 1 day, 83.9% were discharged from the AF clinic in sinus rhythm. During 12-month follow-up, there were 25 AF-related hospitalisations (20 patients, 14%) and one patient underwent electrical cardioversion; additionally, one patient had had a stroke and eight had bleeding complications giving a combined outcome rate of 6.3%. CONCLUSION Utilising a rate-control strategy with ED discharge and early return to a dedicated AF clinic can safely prevent the majority of hospitalisations, avert unnecessary procedures, and facilitate longitudinal care.
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Affiliation(s)
- Ibrahim S Al-Busaidi
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand.
| | - Geoffrey C Clare
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Laura R Joyce
- Department of Surgery, University of Otago, Christchurch, New Zealand; Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Scott Pearson
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - John Lainchbury
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Martin Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Richard W Troughton
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
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30
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Miller R, Young J, Nixon G, Pickering JW, Stokes T, Turner R, Devlin G, Watson A, Gutenstein M, Norman T, George PM, Du Toit S, Than M. Study protocol for an observational study to evaluate an accelerated chest pain pathway using point-of-care troponin in New Zealand rural and primary care populations. J Prim Health Care 2021; 12:129-138. [PMID: 32594980 DOI: 10.1071/hc19059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 03/15/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Accelerated diagnostic chest pain pathways are used widely in urban New Zealand hospitals. These pathways use laboratory-based troponin assays with good analytical precision. Widespread implementation has not occurred in many of New Zealand's rural hospitals and general practices as they are reliant on point-of-care troponin assays, which are less sensitive and precise. An accelerated chest pain pathway using point-of-care troponin has been adapted for use in rural settings. A pilot study in a low-risk rural population showed no major adverse cardiac events at 30 days. A larger study is required to be confident that the pathway is safe. AIMS To assess the safety and effectiveness of an accelerated chest pain pathway adapted for rural settings and general practice using point-of-care troponin to identify low-risk patients and allow early discharge. METHODS This is a prospective observational study of an accelerated chest pain pathway using point-of-care troponin in rural hospitals and general practices in New Zealand. A total of 1000 patients, of whom we estimate 400 will be low risk, will be enrolled in the study. OUTCOME MEASURES The primary outcome is the proportion of patients identified by the pathway as low risk for a 30-day major adverse cardiac event. Secondary outcomes include the proportion of low-risk patients who were discharged directly from general practice or rural hospitals, the proportion of patients reclassified as having acute myocardial infarction by the pathway and the proportion of patients with low and intermediate risk safely managed in the rural hospital.
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Affiliation(s)
- Rory Miller
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; and Corresponding author.
| | - Joanna Young
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Garry Nixon
- Cardiology, Canterbury DHB, Christchurch Hospital, Christchurch and Department of Medicine, University of Otago - Christchurch, Christchurch, New Zealand
| | - John W Pickering
- Medicine, University of Otago - Christchurch and Emergency Department, Christchurch Hospital and Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Tim Stokes
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Robin Turner
- Centre for Biostatistics, Division of Health Sciences, University of Otago, Dunedin, New Zealand
| | | | - Antony Watson
- Emergency Care Foundation, St Albans, Christchurch, New Zealand
| | - Marc Gutenstein
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; and Rural Health Academic Centre Ashburton, University of Otago and Christchurch and Emergency Department, Nelson Hospital, Nelson, New Zealand
| | - Tim Norman
- Project Office, Midlands Regional Health Network Charitable Trust, Hamilton, New Zealand
| | | | - Stephen Du Toit
- Biochemistry, Waikato DHB. Biochemistry Department, Waikato Hospital, Hamilton, New Zealand
| | - Martin Than
- Emergency Department, Canterbury DHB, Christchurch Hospital, Christchurch, New Zealand
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31
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Peacock WF, Baumann BM, Rivers EJ, Davis TE, Handy B, Jones CW, Hollander JE, Limkakeng AT, Mehrotra A, Than M, Cullen L, Ziegler A, Dinkel‐Keuthage C. Using Sex-specific Cutoffs for High-sensitivity Cardiac Troponin T to Diagnose Acute Myocardial Infarction. Acad Emerg Med 2021; 28:463-466. [PMID: 32726505 PMCID: PMC8247402 DOI: 10.1111/acem.14098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 11/29/2022]
Affiliation(s)
- W. Frank Peacock
- From the Department of Emergency Medicine Baylor College of Medicine Houston TXUSA
| | - Brigitte M. Baumann
- the Department of Emergency Medicine Cooper Medical School of Rowan University Camden NJUSA
| | - E. Joy Rivers
- Agent representing Roche Diagnostics Indianapolis INUSA
| | - Thomas E. Davis
- the Indiana University School of Medicine Indianapolis INUSA
| | - Beverly Handy
- the Department of Laboratory Medicine University of Texas MD Anderson Cancer Center Houston TXUSA
| | - Christopher W. Jones
- the Department of Emergency Medicine Cooper Medical School of Rowan University Camden NJUSA
| | - Judd E. Hollander
- the Department of Emergency Medicine Thomas Jefferson University Philadelphia PAUSA
| | | | - Abhi Mehrotra
- the Department of Emergency Medicine University of North Carolina School of Medicine Chapel Hill NCUSA
| | - Martin Than
- the Emergency Department Christchurch Hospital Christchurch New Zealand
| | - Louise Cullen
- the Department of Emergency Medicine Royal Brisbane and Women's Hospital Brisbane QLD Australia
| | - André Ziegler
- Roche Diagnostics International Ltd Rotkreuz Switzerland
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32
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Chuang A(MY, Nguyen MT, Khan E, Jones D, Horsfall M, Lehman S, Smilowitz NR, Lambrakis K, Than M, Vaile J, Sinhal A, French JK, Chew DP. Troponin elevation pattern and subsequent cardiac and non-cardiac outcomes: Implementing the Fourth Universal Definition of Myocardial Infarction and high-sensitivity troponin at a population level. PLoS One 2021; 16:e0248289. [PMID: 33711079 PMCID: PMC7954292 DOI: 10.1371/journal.pone.0248289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/23/2021] [Indexed: 01/19/2023] Open
Abstract
Background The Fourth Universal Definition of Myocardial Infarction (MI) differentiates MI from myocardial injury. We characterised the temporal course of cardiac and non-cardiac outcomes associated with MI, acute and chronic myocardial injury. Methods We included all patients presenting to public emergency departments in South Australia between June 2011–Sept 2019. Episodes of care (EOCs) were classified into 5 groups based on high-sensitivity troponin-T (hs-cTnT) and diagnostic codes: 1) Acute MI [rise/fall in hs-cTnT and primary diagnosis of acute coronary syndrome], 2) Acute myocardial injury with coronary artery disease (CAD) [rise/fall in hs-cTnT and diagnosis of CAD], 3) Acute myocardial injury without CAD [rise/fall in hs-cTnT without diagnosis of CAD], 4) Chronic myocardial injury [elevated hs-cTnT without rise/fall], and 5) No myocardial injury. Multivariable flexible parametric models were used to characterize the temporal hazard of death, MI, heart failure (HF), and ventricular arrhythmia. Results 372,310 EOCs (218,878 individuals) were included: acute MI (19,052 [5.12%]), acute myocardial injury with CAD (6,928 [1.86%]), acute myocardial injury without CAD (32,231 [8.66%]), chronic myocardial injury (55,056 [14.79%]), and no myocardial injury (259,043 [69.58%]). We observed an early hazard of MI and HF after acute MI and acute myocardial injury with CAD. In contrast, subsequent MI risk was lower and more constant in patients with acute injury without CAD or chronic injury. All patterns of myocardial injury were associated with significantly higher risk of all-cause mortality and ventricular arrhythmia. Conclusions Different patterns of myocardial injury were associated with divergent profiles of subsequent cardiac and non-cardiac risk. The therapeutic approach and modifiability of such excess risks require further research.
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Affiliation(s)
- Anthony (Ming-yu) Chuang
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
- * E-mail:
| | - Mau T. Nguyen
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Ehsan Khan
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Dylan Jones
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Matthew Horsfall
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Sam Lehman
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Nathaniel R. Smilowitz
- Division of Cardiology, Department of Medicine, New York University School of Medicine, New York City, New York, United States of America
| | - Kristina Lambrakis
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Martin Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Julian Vaile
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Ajay Sinhal
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - John K. French
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
- Western Sydney University, Sydney, Australia
| | - Derek P. Chew
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
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33
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Stewart RAH, Jones P, Dicker B, Jiang Y, Smith T, Swain A, Kerr A, Scott T, Smyth D, Ranchord A, Edmond J, Than M, Webster M, White HD, Devlin G. High flow oxygen and risk of mortality in patients with a suspected acute coronary syndrome: pragmatic, cluster randomised, crossover trial. BMJ 2021; 372:n355. [PMID: 33653685 PMCID: PMC7923953 DOI: 10.1136/bmj.n355] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To determine the association between high flow supplementary oxygen and 30 day mortality in patients presenting with a suspected acute coronary syndrome (ACS). DESIGN Pragmatic, cluster randomised, crossover trial. SETTING Four geographical regions in New Zealand. PARTICIPANTS 40 872 patients with suspected or confirmed ACS included in the All New Zealand Acute Coronary Syndrome Quality Improvement registry or ambulance ACS pathway during the study periods. 20 304 patients were managed using the high oxygen protocol and 20 568 were managed using the low oxygen protocol. Final diagnosis of ST elevation myocardial infarction (STEMI) and non-STEMI were determined from the registry and ICD-10 discharge codes. INTERVENTIONS The four geographical regions were randomly allocated to each of two oxygen protocols in six month blocks over two years. The high oxygen protocol recommended oxygen at 6-8 L/min by face mask for ischaemic symptoms or electrocardiographic changes, irrespective of the transcapillary oxygen saturation (SpO2). The low oxygen protocol recommended oxygen only if SpO2 was less than 90%, with a target SpO2 of less than 95%. MAIN OUTCOME MEASURE 30 day all cause mortality determined from linkage to administrative data. RESULTS Personal and clinical characteristics of patients managed under both oxygen protocols were well matched. For patients with suspected ACS, 30 day mortality for the high and low oxygen groups was 613 (3.0%) and 642 (3.1%), respectively (odds ratio 0.97, 95% confidence interval 0.86 to 1.08). For 4159 (10%) patients with STEMI, 30 day mortality for the high and low oxygen groups was 8.8% (n=178) and 10.6% (n=225), respectively (0.81, 0.66 to 1.00) and for 10 218 (25%) patients with non-STEMI was 3.6% (n=187) and 3.5% (n=176), respectively (1.05, 0.85 to 1.29). CONCLUSION In a large patient cohort presenting with suspected ACS, high flow oxygen was not associated with an increase or decrease in 30 day mortality. TRIAL REGISTRATION ANZ Clinical Trials ACTRN12616000461493.
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Affiliation(s)
- Ralph A H Stewart
- Green Lane Cardiovascular Service, Auckland City Hospital, Private Bag 92024, Auckland 1030, New Zealand
- Department of Medicine, University of Auckland, New Zealand
| | - Peter Jones
- Emergency Medicine Research, Auckland City Hospital, New Zealand
- Department of Surgery, University of Auckland, New Zealand
| | - Bridget Dicker
- St John Auckland and Paramedicine Department, Auckland University of Technology, New Zealand
| | - Yannan Jiang
- National Institute for Health Innovation, University of Auckland, New Zealand
| | - Tony Smith
- St John Ambulance, Auckland, New Zealand
| | - Andrew Swain
- Wellington Free Ambulance, Wellington, New Zealand
| | - Andrew Kerr
- Department of Cardiology, Middlemore Hospital, Otahuhu, Aukland, New Zealand
- Section of Epidemiology and Biostatistics, University of Auckland, New Zealand
| | - Tony Scott
- Cardiology Department, Northshore Hospital, Takapuna, Auckland, New Zealand
| | - David Smyth
- Canterbury District Health Board, Christchurch, New Zealand
| | - Anil Ranchord
- Cardiology Department, Capital and Coast District Health Board, Wellington Hospital, New Zealand
| | - John Edmond
- Southern District Health Board, Dunedin and Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Martin Than
- Department of Emergency Medicine, Christchurch Hospital, New Zealand
| | - Mark Webster
- Green Lane Cardiovascular Service, Auckland City Hospital, Private Bag 92024, Auckland 1030, New Zealand
- Department of Medicine, University of Auckland, New Zealand
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Private Bag 92024, Auckland 1030, New Zealand
- Department of Medicine, University of Auckland, New Zealand
| | - Gerard Devlin
- Hauroa Tairāwhiti, Gisborne and Heart Foundation of New Zealand, Gisborn, New Zealand
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34
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Zimmermann T, du Fay de Lavallaz J, Walter JE, Strebel I, Nestelberger T, Joray L, Badertscher P, Flores D, Widmer V, Geigy N, Miro O, Salgado E, Christ M, Cullen L, Than M, Martín-Sánchez FJ, Di Somma S, Peacock WF, Keller D, Costabel JP, Wussler DN, Kawecki D, Lohrmann J, Gualandro DM, Kuehne M, Reichlin T, Sun B, Mueller C. Development of an electrocardiogram-based risk calculator for a cardiac cause of syncope. Heart 2021; 107:1796-1804. [PMID: 33504514 DOI: 10.1136/heartjnl-2020-318430] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/31/2020] [Accepted: 01/03/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To develop an ECG-based tool for rapid risk assessment of a cardiac cause of syncope in patients ≥40 years. METHODS In a prospective international multicentre study, 2007 patients ≥40 years presenting with syncope were recruited in the emergency department (ED) of participating centres ranging from large university hospitals to smaller rural hospitals in eight countries from May 2010 to July 2017. 12-Lead ECG recordings were obtained at ED presentation following the syncopal event. The primary diagnostic outcome, a cardiac cause of syncope, was centrally adjudicated by two independent cardiologists using all available clinical information including 12-month follow-up. ECG predictors for a cardiac cause of syncope were identified using penalised backward selection and a continuous-scale likelihood was calculated based on regression analysis coefficients. Findings were validated in an independent US multicentre cohort including 2269 patients. RESULTS In the derivation cohort, a cardiac cause of syncope was adjudicated in 267 patients (16%). Seven ECG criteria were identified as predictors for this outcome: heart rate and QTc-interval (continuous predictors), rhythm, atrioventricular block, ST-segment depression, bundle branch block and ventricular extrasystole/non-sustained ventricular tachycardia (categorical predictors). Diagnostic accuracy of these combined predictors for a cardiac cause of syncope was high (area under the curve 0.80, 95% CI 0.77 to 0.83). Overall, 138 patients (8%) were rapidly triaged towards rule-out and 181 patients (11%) towards rule-in of a cardiac cause of syncope. External validation showed similar performance. CONCLUSION In patients ≥40 years with a syncopal event, a combination of seven ECG criteria enabled rapid assessment of the likelihood that syncope was due to a cardiac cause. TRIAL REGISTRATION NUMBER NCT01548352 (BASEL IX), NCT01802398 (SRS study).
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Affiliation(s)
- Tobias Zimmermann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Jeanne du Fay de Lavallaz
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Joan Elias Walter
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy.,Department of Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Ivo Strebel
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Thomas Nestelberger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Lydia Joray
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Patrick Badertscher
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Dayana Flores
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Velina Widmer
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Baselland, Liestal, Switzerland
| | - Oscar Miro
- GREAT network, Rome, Italy.,Emergency Department, Hospital Clinic, Barcelona, Spain
| | | | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Luzern, Switzerland
| | - Louise Cullen
- GREAT network, Rome, Italy.,Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Martin Than
- GREAT network, Rome, Italy.,Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | | | - Salvatore Di Somma
- GREAT network, Rome, Italy.,Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Rome, Italy
| | - W Frank Peacock
- GREAT network, Rome, Italy.,Emergency Department, Baylor College of Medicine, Houston, Texas, USA
| | - Dagmar Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | | | - Desiree Nadine Wussler
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy.,Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Damian Kawecki
- Department of Cardiology, Medical University of Silesia, Zabrze, Poland
| | - Jens Lohrmann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Danielle Menosi Gualandro
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Michael Kuehne
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Tobias Reichlin
- GREAT network, Rome, Italy.,Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Benjamin Sun
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland .,GREAT network, Rome, Italy
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35
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Sandoval Y, Chapman AR, Mills NL, Than M, Pickering JW, Worster A, Kavsak P, Apple FS. Sex-Specific Kinetics of High-Sensitivity Cardiac Troponin I and T following Symptom Onset and Early Presentation in Non-ST-Segment Elevation Myocardial Infarction. Clin Chem 2021; 67:321-324. [PMID: 33279956 DOI: 10.1093/clinchem/hvaa263] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 11/14/2022]
Affiliation(s)
- Yader Sandoval
- Department of Cardiology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Andrew R Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Department of Emergency Medicine, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Martin Than
- Christchurch Hospital, Christchurch, New Zealand
| | - John W Pickering
- Christchurch Hospital, Christchurch, New Zealand
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Andrew Worster
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Peter Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology and Hennepin Healthcare Research Institute, Hennepin Healthcare System/Hennepin County Medical Center, Minneapolis, MN
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36
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Lim JC, Borland ML, Middleton PM, Moore K, Shetty A, Babl FE, Lee RS, Acworth J, Wilson C, Than M, Craig S. Where are children seen in Australian emergency departments? Implications for research efforts. Emerg Med Australas 2021; 33:631-639. [PMID: 33393221 DOI: 10.1111/1742-6723.13698] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/10/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE With most paediatric emergency research in Australia conducted at tertiary EDs, it is important to understand how presentations differ between those at tertiary paediatric EDs and all other EDs. METHODS Retrospective epidemiological study assessing paediatric case-mix and time-based performance metrics (aged 0-14 years) obtained from a national health service minimum dataset for the 2017-2018 financial year, comparing tertiary paediatric EDs and all other EDs. We defined a 'major tertiary paediatric hospital' as one which was accredited for training in both paediatric emergency medicine and paediatric intensive care. RESULTS Of the 1 695 854 paediatric ED presentations, 23.8% were seen in nine major metropolitan tertiary paediatric hospitals. Reasons for presentations were more distinctive between cohorts among children aged 10-14 years, where psychiatric illness (5.2% vs 2.5%) and neurological illness (4.5% vs 2.5%) were more commonly seen in major tertiary paediatric EDs. Australian Indigenous children were significantly less likely to present to tertiary paediatric EDs (3.0%), compared with other EDs (9.7%) (odds ratio 0.27, 95% confidence interval 0.26-0.27). While median waiting times were longer in major tertiary paediatric EDs (28 min [interquartile range 11-65]) than in other EDs (20 min [interquartile range 8-48], P < 0.001), patients were also less likely to leave without being seen (5.5% in tertiary paediatric EDs vs 6.9% in other EDs; odds ratio 0.80, 95% confidence interval 0.78-0.81). CONCLUSIONS The present study identified key areas of difference in paediatric presentations between tertiary paediatric EDs and other EDs. It is vital to broaden paediatric ED research beyond tertiary paediatric centres, to ensure relevance and generalisability.
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Affiliation(s)
- Jolene Cj Lim
- Policy and Research Division, Department of Policy and Strategic Partnerships, Australasian College for Emergency Medicine, Melbourne, Victoria, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Divisions of Emergency Medicine and Paediatrics, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Paul M Middleton
- South Western Emergency Research Institute, Ingham Institute, Liverpool Hospital, Sydney, New South Wales, Australia.,Emergency Department Epidemiology Network, Australasian College for Emergency Medicine, Melbourne, Victoria, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,MARCS Institute, Western Sydney University, Sydney, New South Wales, Australia.,Emergency Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Katie Moore
- Policy and Research Division, Department of Policy and Strategic Partnerships, Australasian College for Emergency Medicine, Melbourne, Victoria, Australia
| | - Amith Shetty
- Emergency Department Epidemiology Network, Australasian College for Emergency Medicine, Melbourne, Victoria, Australia.,Emergency Department, NSW Ministry of Health, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Franz E Babl
- Department of Paediatrics and Centre of Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Robert S Lee
- Policy and Research Division, Department of Policy and Strategic Partnerships, Australasian College for Emergency Medicine, Melbourne, Victoria, Australia
| | - Jason Acworth
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Emergency Department, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Catherine Wilson
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Martin Than
- Emergency Department Epidemiology Network, Australasian College for Emergency Medicine, Melbourne, Victoria, Australia.,Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Simon Craig
- Emergency Department Epidemiology Network, Australasian College for Emergency Medicine, Melbourne, Victoria, Australia.,Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Monash Medical Centre, Emergency Program, Monash Health, Melbourne, Victoria, Australia.,Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
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Zimmermann T, du Fay de Lavallaz J, Nestelberger T, Gualandro DM, Strebel I, Badertscher P, Lopez-Ayala P, Widmer V, Freese M, Miró Ò, Christ M, Cullen L, Than M, Martin-Sanchez FJ, Di Somma S, Peacock WF, Keller DI, Boeddinghaus J, Twerenbold R, Wussler D, Koechlin L, Walter JE, Bürgler F, Geigy N, Kühne M, Reichlin T, Lohrmann J, Mueller C. Incidence, characteristics, determinants, and prognostic impact of recurrent syncope. Europace 2020; 22:1885-1895. [PMID: 33038231 DOI: 10.1093/europace/euaa227] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/17/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS The aim of this study is to characterize recurrent syncope, including sex-specific aspects, and its impact on death and major adverse cardiovascular events (MACE). METHODS AND RESULTS We characterized recurrent syncope in a large international multicentre study, enrolling patients ≥40 years presenting to the emergency department (ED) with a syncopal event within the last 12 h. Syncope aetiology was centrally adjudicated by two independent cardiologists using all information becoming available during syncope work-up and long-term follow-up. Overall, 1790 patients were eligible for this analysis. Incidence of recurrent syncope was 20% [95% confidence interval (CI) 18-22%] within the first 24 months. Patients with an adjudicated final diagnosis of cardiac syncope (hazard ratio (HR) 1.50, 95% CI 1.11-2.01) or syncope with an unknown aetiology even after central adjudication (HR 2.11, 95% CI 1.54-2.89) had an increased risk for syncope recurrence. Least Absolute Shrinkage and Selection Operator regression fit on all patient information available early in the ED identified >3 previous episodes of syncope as the only independent predictor for recurrent syncope (HR 2.13, 95% CI 1.64-2.75). Recurrent syncope carried an increased risk for death (HR 1.87, 95% CI 1.26-2.77) and MACE (HR 2.69, 95% CI 2.02-3.59) over 24 months of follow-up, however, with a time-dependent effect. These findings were confirmed in a sensitivity analysis excluding patients with syncope recurrence or MACE before or during ED evaluation. CONCLUSION Recurrence rates of syncope are substantial and vary depending on syncope aetiology. Importantly, recurrent syncope carries a time-dependent increased risk for death and MACE. TRIAL REGISTRATION BAsel Syncope EvaLuation (BASEL IX, ClinicalTrials.gov registry number NCT01548352).
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Affiliation(s)
- Tobias Zimmermann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Jeanne du Fay de Lavallaz
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Thomas Nestelberger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Danielle M Gualandro
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ivo Strebel
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Patrick Badertscher
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Department of Cardiology, University of Illinois at Chicago, Chicago, IL, USA
| | - Pedro Lopez-Ayala
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Velina Widmer
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Michael Freese
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Òscar Miró
- GREAT Network, Rome, Italy.,Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Michael Christ
- GREAT Network, Rome, Italy.,Emergency Department, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Louise Cullen
- GREAT Network, Rome, Italy.,Emergency & Trauma Centre, Royal Brisbane & Women's Hospital, Herston, Australia
| | - Martin Than
- GREAT Network, Rome, Italy.,Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - F Javier Martin-Sanchez
- GREAT Network, Rome, Italy.,Department of Emergency Medicine, Hospital Clínico San Carlos, Madrid, Spain
| | - Salvatore Di Somma
- GREAT Network, Rome, Italy.,Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Roma, Italy
| | - W Frank Peacock
- GREAT Network, Rome, Italy.,Department of Emergency Medicine, Houston, Baylor College of Medicine, TX, USA
| | - Dagmar I Keller
- Emergency Department, University Hospital Zürich, Zürich, Switzerland
| | - Jasper Boeddinghaus
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Raphael Twerenbold
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Desiree Wussler
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luca Koechlin
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Joan E Walter
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Franz Bürgler
- Emergency Department, Kantonsspital Liestal, Liestal, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Liestal, Liestal, Switzerland
| | - Michael Kühne
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Tobias Reichlin
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jens Lohrmann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
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Lopez Ayala P, Flores D, Zimmermann T, Du Fay De Lavallaz J, Nestelberger T, Strebel I, Gualandro D, Badertscher P, Miro O, Martin-Sanchez F, Geigy N, Christ M, Keller D, Than M, Mueller C. Incidence, characteristics and prognosis of different cardiac etiologies underlying cardiac syncope. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Cardiac syncope has been shown to carry the highest hazard for all-cause death compared to other causes of syncope including vasovagal and orthostatic syncope. However, little is known about the incidence, characteristics and prognosis of different cardiac etiologies underlying cardiac syncope.
Purpose
To evaluate the incidence, characteristics and prognosis of different cardiac etiologies underlying cardiac syncope.
Methods
We enrolled patients presenting to the emergency department (ED) with syncope in a large prospective international multicentre study. The cause of syncope (cardiac vs non-cardiac) including the detailed cardiac aetiology (if cardiac) was centrally adjudicated by two independent cardiologists based on detailed in-hospital as well as outpatient cardiac work-up during 360 days following presentation. Cardiac syncope was classified into four groups: bradyarrhythmia, tachyarrhythmia, structural disease and other (cardiopulmonary and great vessels), as recommended in the ESC Syncope Guidelines. All-cause death during 2-years follow-up was the primary outcome.
Results
Among 2025 patients presenting with syncope to the ED, cardiac syncope was the final adjudicated diagnoses in 318 (15.7%) patients. The incidence rate of all-cause death among cardiac syncope patients was 103 cases per 1000 person-years. Bradyarrhythmia was the most frequent primary cause of cardiac syncope (n=146, 45.9%) followed by tachyarrhythmia (n=75, 23.6%), structural disease (n=64, 20.1%) and other cardiac (n=26, 8.2%). Patients were 37% female with a median age of 77 years (IQR 67–83) showing no statistically significant difference between subgroups. Clinical characteristics differed significantly among the four subgroups. E.g. syncope occurred during exercise in 12 patients (8.2%) with bradyarrhythmia, 10 patients (13.3%) with tachyarrhythmia, 16 patients (25%) with structural disease, and 5 patients (19%) with other cardiac (p<0.01). Likely of most importance, long-term mortality differed significantly among the four different cardiac subgroups. The multivariable-adjusted hazard ratios (HR) among patients with bradyarrhythmia, tachyarrhythmia, structural disease and other cardiac as compared to patients with vasovagal syncope, the HR were 1.3 (95% CI 0.7–2.5), 4.6 (95% CI 2.3–9.1), 3.1 (95% CI 1.5–6.4) and 5.9 (95% CI 2.3–15.2), respectively (Figure 1).
Conclusions
Bradyarrhythmia, tachyarrhythmia, and structural cardiac disease are the dominant causes of cardiac syncope. Interestingly, with the appropriate therapy initiated long-term mortality of bradyarrhythmia is comparable to that of vasovagal syncope, while long-term mortality of tachyarrhythmia and structural cardiac disease were substantially increased 3 to 5 fold.
Figure 1. Kaplan-Meier curve
Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Swiss National Science Foundation, the Swiss Heart Foundation, the Stiftung für kardiovaskuläre Forschung Basel, the University of Basel and the University Hospital Basel.
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Affiliation(s)
- P Lopez Ayala
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - D Flores
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - T Zimmermann
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - J Du Fay De Lavallaz
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - T Nestelberger
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - I Strebel
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - D.M Gualandro
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - P Badertscher
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - O Miro
- Barcelona Hospital Clinic, Emergency Department, Barcelona, Spain
| | | | - N Geigy
- University Hospital Liestal, Emergency Department, Liestal, Switzerland
| | - M Christ
- Kantonsspital Lucerne, Lucerne, Switzerland
| | - D Keller
- University Hospital Zurich, Emergency Department, Zurich, Switzerland
| | - M Than
- Christchurch Hospital, Christchurch, New Zealand
| | - C Mueller
- University Hospital Basel, Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
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Doudesis D, Yang J, Tsanas A, Stables C, Shah A, Anand A, Lee K, Strachan F, Pickering J, Than M, Mills N. Validation of a machine learned model to predict the diagnosis of myocardial infarction. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
The myocardial-ischemic-injury-index (MI3) is a promising machine learned algorithm that predicts the likelihood of myocardial infarction in patients with suspected acute coronary syndrome. Whether this algorithm performs well in unselected patients or predicts recurrent events is unknown.
Methods
In an observational analysis from a multi-centre randomised trial, we included all patients with suspected acute coronary syndrome and serial high-sensitivity cardiac troponin I measurements without ST-segment elevation myocardial infarction. Using gradient boosting, MI3 incorporates age, sex, and two troponin measurements to compute a value (0–100) reflecting an individual's likelihood of myocardial infarction, and estimates the negative predictive value (NPV) and positive predictive value (PPV). Model performance for an index diagnosis of myocardial infarction, and for subsequent myocardial infarction or cardiovascular death at one year was determined using previously defined low- and high-probability thresholds (1.6 and 49.7, respectively).
Results
In total 20,761 of 48,282 (43%) patients (64±16 years, 46% women) were eligible of whom 3,278 (15.8%) had myocardial infarction. MI3 was well discriminated with an area under the receiver-operating-characteristic curve of 0.949 (95% confidence interval 0.946–0.952) identifying 12,983 (62.5%) patients as low-probability (sensitivity 99.3% [99.0–99.6%], NPV 99.8% [99.8–99.9%]), and 2,961 (14.3%) as high-probability (specificity 95.0% [94.7–95.3%], PPV 70.4% [69–71.9%]). At one year, subsequent myocardial infarction or cardiovascular death occurred more often in high-probability compared to low-probability patients (17.6% [520/2,961] versus 1.5% [197/12,983], P<0.001).
Conclusions
In unselected consecutive patients with suspected acute coronary syndrome, the MI3 algorithm accurately estimates the likelihood of myocardial infarction and predicts probability of subsequent adverse cardiovascular events.
Performance of MI3 at example thresholds
Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): Medical Research Council
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Affiliation(s)
- D Doudesis
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
| | - J Yang
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
| | - A Tsanas
- University of Edinburgh, Usher Institute, Edinburgh, United Kingdom
| | - C Stables
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
| | - A Shah
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
| | - A Anand
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
| | - K Lee
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
| | - F Strachan
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
| | - J Pickering
- Christchurch Hospital, Emergency Department, Christchurch, New Zealand
| | - M Than
- Christchurch Hospital, Emergency Department, Christchurch, New Zealand
| | - N Mills
- University of Edinburgh, Centre for Cardiovascular Sciences, Edinburgh, United Kingdom
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40
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Ratmann P, Nestelberger T, Cullen L, Lindahl B, Boeddinghaus J, Rubini M, Lopez Ayala P, Than M, Greenslade J, Mueller C. Utility of echocardiography in patients with suspected acute myocardial infarction in the presence of left bundle-branch block. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Rapid identification of acute myocardial infarction (AMI) as life-threatening disorder by clinical assessment, cardiac troponin and the electrocardiogram (ECG) is important for the early initiation of highly effective, evidence-based therapy. Patients presenting with suspected AMI and left bundle branch block (LBBB) to the emergency department (ED) represent a unique diagnostic and therapeutic challenge, as altered ventricular depolarization masks changes in ventricular repolarization associated with myocardial ischemia. Current guidelines suggest, based on expert opinion, early echocardiography as a helpful tool in patients with suspected AMI and LBBB to identify new wall motion abnormalities, which guides further diagnostics strategies in these patients.
Purpose
To evaluate the diagnostic accuracy of echocardiography among patients with suspected AMI and LBBB in the recorded ECG at ED presentation.
Methods
We prospectively evaluated the diagnostic accuracy of echocardiography in patients with LBBB presenting with chest discomfort to 26 ED's in three international, prospective, diagnostic studies. Two independent cardiologists centrally adjudicated the final diagnosis in each study according to the universal definition of myocardial infarction. All patients underwent a clinical assessment that included standardized and detailed medical history including assessment of chest pain characteristics, vital signs, physical examination, 12-lead ECG, continuous ECG rhythm monitoring, pulse oximetry, standard blood test, and chest radiography and echocardiography if indicated. We compared echocardiographic findings in patients with LBBB who were diagnosed with an AMI to those without an AMI.
Results
Among 283 patients presenting with chest pain and LBBB to the ED, AMI was the final diagnosis in 36% (102 of 283 patients) of patients. An echocardiography had been performed in 100/283 patients (35%) in the emergency department. AMI was the final diagnosis in 41/100 (41%) of patients. A wall motion abnormality in any region was seen in 77 (77%) of patients with no difference between patients diagnosed with AMI (33 patients, 81%) versus without AMI (44 patients, 75%, p=0.49). Additionally, we found no differences for each wall region (Table 1). Most patients with LBBB had moderately reduced left ventricular ejection fraction (LVEF, median 40%), a dilated left atrium (67%) or left ventricular hypertrophy (55%) without any differences between the two groups (Table 1).
Conclusions
Early echocardiography in patients with suspected AMI and LBBB provided only limited utility to identify patients, which may benefit from immediate coronary angiography. Our findings scrutinize current guidelines and downgrades the utility of echocardiography in this setting.
Funding Acknowledgement
Type of funding source: Other. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation, the European Union, the Cardiovascular Research Foundation Basel, the University Hospital Basel, Queensland Emergency Medicine Research Foundation, Christchurch Heart Institute and Health Research Council and Heart Foundation of New Zealand, Christchurch Emergency Care Foundation
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Affiliation(s)
- P.D Ratmann
- University Hospital Basel, Basel, Switzerland
| | | | - L Cullen
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - B Lindahl
- Uppsala University Hospital, Uppsala, Sweden
| | | | - M Rubini
- University Hospital Basel, Basel, Switzerland
| | | | - M Than
- Christchurch Hospital, Christchurch, New Zealand
| | - J Greenslade
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - C Mueller
- University Hospital Basel, Basel, Switzerland
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41
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Parsonage WA, Cullen L, Brieger D, Hillis GS, Nasis A, Dwyer N, Wahi S, Lo S, Than M, Kerr A, Devlin G, Chew DK. CSANZ Position Statement on the Evaluation of Patients Presenting With Suspected Acute Coronary Syndromes During the COVID-19 Pandemic. Heart Lung Circ 2020; 29:e105-e110. [PMID: 32601022 PMCID: PMC7241352 DOI: 10.1016/j.hlc.2020.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
A pandemic of Coronavirus-19 disease was declared by the World Health Organization on March 11, 2020. The pandemic is expected to place unprecedented demand on health service delivery. This position statement has been developed by the Cardiac Society of Australia and New Zealand to assist clinicians to continue to deliver rapid and safe evaluation of patients presenting with suspected acute cardiac syndrome at this time. The position statement complements, and should be read in conjunction with, the National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016: Section 2 'Assessment of Possible Cardiac Chest Pain'.
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Affiliation(s)
| | - Louise Cullen
- Royal Brisbane & Women's Hospital, Brisbane, Qld, Australia
| | | | | | | | | | - Sudhir Wahi
- Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Sidney Lo
- Liverpool Hospital, Greater Western Sydney, NSW, Australia
| | - Martin Than
- Christchurch Hospital, Christchurch, New Zealand
| | | | | | - Derek K Chew
- Flinders Medical Centre, Adelaide, SA, Australia
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42
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Tan WCJ, Inoue K, AbdelWareth L, Giannitsis E, Kasim S, Shiozaki M, Aw TC, Cheng F, Dung HT, Li YH, Lim SH, Lukito AA, Than M, Chu FY, Devasia T, Lee CC, Phrommintikul A, Youn JC, Chew DP. The Asia-Pacific Society of Cardiology (APSC) Expert Committee Consensus Recommendations for Assessment of Suspected Acute Coronary Syndrome Using High-Sensitivity Cardiac Troponin T in the Emergency Department. Circ J 2019; 84:136-143. [PMID: 31852863 DOI: 10.1253/circj.cj-19-0874] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The Asia-Pacific Society of Cardiology (APSC) high-sensitivity troponin T (hs-TnT) consensus recommendations and rapid algorithm were developed to provide guidance for healthcare professionals in the Asia-Pacific region on assessing patients with suspected acute coronary syndrome (ACS) using a hs-TnT assay. Experts from Asia-Pacific convened in 2 meetings to develop evidence-based consensus recommendations and an algorithm for appropriate use of the hs-TnT assay. The Expert Committee defined a cardiac troponin assay as a high-sensitivity assay if the total imprecision is ≤10% at the 99th percentile of the upper reference limit and measurable concentrations below the 99th percentile are attainable with an assay at a concentration value above the assay's limit of detection for at least 50% of healthy individuals. Recommendations for single-measurement rule-out/rule-in cutoff values, as well as for serial measurements, were also developed. The Expert Committee also adopted similar hs-TnT cutoff values for men and women, recommended serial hs-TnT measurements for special populations, and provided guidance on the use of point-of-care troponin T devices in individuals suspected of ACS. These recommendations should be used in conjunction with all available clinical evidence when making the diagnosis of ACS.
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Affiliation(s)
- Wei Chieh Jack Tan
- Department of Cardiology, National Heart Centre Singapore.,Department of Cardiology, Sengkang General Hospital
| | - Kenji Inoue
- Department of Cardiology, Juntendo University Nerima Hospital
| | | | - Evangelos Giannitsis
- Departments of Cardiology, Angiology and Pulmonology, University Hospital Heidelberg
| | | | | | - Tar Choon Aw
- Department of Laboratory Medicine, Changi General Hospital
| | | | - Ho Thuong Dung
- Cardiovascular Center and Interventional Cardiology, Thong Nhat Hospital
| | - Yi-Heng Li
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital
| | | | - Martin Than
- Department of Emergency Medicine, Christchurch Public Hospital
| | - Fang-Yeh Chu
- Department of Clinical Pathology, Far Eastern Memorial Hospital.,Graduate School of Biotechnology and Bioengineering, Yuan Ze University.,Department of Medical Laboratory Science and Biotechnology, Yuanpei University of Medical Technology
| | - Tom Devasia
- Department of Cardiology, Kasturba Medical College, Manipal Academy of Higher Education
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital
| | | | - Jong-Chan Youn
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea
| | - Derek P Chew
- Department of Cardiovascular Medicine, Flinders University
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43
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Greenslade JH, Sieben N, Parsonage WA, Knowlman T, Ruane L, Than M, Pickering JW, Hawkins T, Cullen L. Factors influencing physician risk estimates for acute cardiac events in emergency patients with suspected acute coronary syndrome. Emerg Med J 2019; 37:2-7. [PMID: 31719104 DOI: 10.1136/emermed-2019-208916] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/09/2019] [Accepted: 10/21/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Emergency physicians frequently assess risk of acute cardiac events (ACEs) in patients with undifferentiated chest pain. Such estimates have been shown to have moderate to high sensitivity for ACE but are conservative. Little is known about the factors implicitly used by physicians to determine the pretest probability of risk. This study sought to identify the accuracy of physician risk estimates for ACE in patients presenting to the ED with chest pain and to identify the demographic and clinical information emergency physicians use in their determination of patient risk. METHODS This study used data from two prospective studies of consenting adult patients presenting to the ED with symptoms of possible acute coronary syndrome. ED physicians estimated the pretest probability of ACE. Multiple linear regression analysis was used to identify predictors of physician risk estimates. Logistic regression was used to determine whether there was a correlation between physicians' estimated risk and ACE. RESULTS Increasing age, male sex, abnormal ECG features, heavy/crushing chest pain and risk factors were correlated with physician risk estimates. Physician risk estimates were consistently found to be higher than the expected proportion of ACE from the sampled population. CONCLUSION Physicians systematically overestimate ACE risk. A range of factors are associated with physician risk estimates. These include factors strongly predictive of ACE, such as age and ECG characteristics. They also include other factors that have been shown to be unreliable predictors of ACE in an ED setting, such as typicality of pain and risk factors.
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Affiliation(s)
- Jaimi H Greenslade
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia .,Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Nicolas Sieben
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - William A Parsonage
- Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Cardiology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Thomas Knowlman
- Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Lorcan Ruane
- Department of Cardiology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Martin Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - John W Pickering
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand.,Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Tracey Hawkins
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Nestelberger T, Boeddinghaus J, Greenslade J, Parsonage WA, Than M, Wussler D, Lopez-Ayala P, Zimmermann T, Meier M, Troester V, Badertscher P, Koechlin L, Wildi K, Anwar M, Freese M, Keller DI, Reichlin T, Twerenbold R, Cullen L, Mueller C, Puelacher C, du Fay de Lavallaz J, Rubini Giménez M, Strebel I, Walter J, Huber J, Christ M, Kozhuharov N, Gualandro DM, Potlukova E, Baumgartner B, Hafner B, Rentsch K, Miró Ò, Fuenzalida C, Gil B, Martin-Sanchez FJ, Kawecki D, Geigy N, Meissner K, Kulangara C, López B, Rodriguez Adrada E, Ganovská E, Lohrmann J, Kloos W, Steude J, Buser A, von Eckardstein A, Nowalany-Kozielska E, Muzyk P. Two-Hour Algorithm for Rapid Triage of Suspected Acute Myocardial Infarction Using a High-Sensitivity Cardiac Troponin I Assay. Clin Chem 2019; 65:1437-1447. [DOI: 10.1373/clinchem.2019.305193] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 08/07/2019] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
We aimed to derive and externally validate a 0/2-h algorithm using the high-sensitivity cardiac troponin I (hs-cTnI)-Access assay.
METHODS
We enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI) in 2 prospective diagnostic studies using central adjudication. Two independent cardiologists adjudicated the final diagnosis, including all available medical information including cardiac imaging. hs-cTnI-Access concentrations were measured at presentation and after 2 h in a blinded fashion.
RESULTS
AMI was the adjudicated final diagnosis in 164 of 1131 (14.5%) patients in the derivation cohort. Rule-out by the hs-cTnI-Access 0/2-h algorithm was defined as 0-h hs-cTnI-Access concentration <4 ng/L in patients with an onset of chest pain >3 h (direct rule-out) or a 0-h hs-cTnI-Access concentration <5 ng/L and an absolute change within 2 h <5 ng/L in all other patients. Derived thresholds for rule-in were a 0-h hs-cTnI-Access concentration ≥50 ng/L (direct rule-in) or an absolute change within 2 h ≥20 ng/L. In the derivation cohort, these cutoffs ruled out 55% of patients with a negative predictive value (NPV) of 99.8% (95% CI, 99.3–100) and sensitivity of 99.4% (95% CI, 96.5–99.9), and ruled in 30% of patients with a positive predictive value (PPV) of 73% (95% CI, 66.1–79). In the validation cohort, AMI was the adjudicated final diagnosis in 88 of 1280 (6.9%) patients. These cutoffs ruled out 77.9% of patients with an NPV of 99.8% (95% CI, 99.3–100) and sensitivity of 97.7% (95% CI, 92.0–99.7), and ruled in 5.8% of patients with a PPV of 77% (95% CI, 65.8–86) in the validation cohort.
CONCLUSIONS
Safety and efficacy of the l hs-cTnI-Access 0/2-h algorithm for triage toward rule-out or rule-in of AMI are very high.
TRIAL REGISTRATION
APACE, NCT00470587; ADAPT, ACTRN1261100106994; IMPACT, ACTRN12611000206921.
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Affiliation(s)
- Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jaimi Greenslade
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- Queensland University of Technology, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - William A Parsonage
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- Queensland University of Technology, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Mario Meier
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Valentina Troester
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Division of Cardiology, University of Illinois at Chicago, Chicago, IL
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- Critical Care Research Institute, The Prince Charles Hospital, Brisbane and University of Queensland, Brisbane, Australia
| | - Mahnoor Anwar
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Michael Freese
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Louise Cullen
- GREAT network
- Royal Brisbane and Women's Hospital, Brisbane, Australia
- Queensland University of Technology, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
- Heart Centre Leipzig, University Hospital of Cardiology, Leipzig, Germany
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Joan Walter
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Jeffrey Huber
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Michael Christ
- Department of Emergency Medicine Lucerne Hospital, Lucerne, Switzerland
| | - Nikola Kozhuharov
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Eliska Potlukova
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Benjamin Baumgartner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Benjamin Hafner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Katharina Rentsch
- Department of Laboratory Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Òscar Miró
- GREAT network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Carolina Fuenzalida
- GREAT network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Beatriz Gil
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Damian Kawecki
- GREAT network
- Department of Cardiology, University Hospital Brno, Brno, Czech Republic and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Nicolas Geigy
- Department of Emergency Medicine, Hospital Baselland, Liestal, Switzerland
| | - Kathrin Meissner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Caroline Kulangara
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT network
| | - Beatriz López
- GREAT network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Eva Ganovská
- GREAT network
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Jens Lohrmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wanda Kloos
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jana Steude
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland and Department of Hematology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Arnold von Eckardstein
- Emergency Department of Laboratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Ewa Nowalany-Kozielska
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Piotr Muzyk
- GREAT network
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
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Nestelberger T, Cullen L, Lindahl B, Reichlin T, Greenslade J, Giannitsis E, Morawiec B, Koechlin L, Twerenbold R, Boeddinghaus J, Rubini M, Osswald S, Pickering J, Than M, Mueller C. P2723Diagnosis of acute myocardial infarction in the presence of left bundle-branch block. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.1040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Objective
Patients with suspected acute myocardial infarction (AMI) in the setting of left bundle branch block (LBBB) present an important diagnostic and therapeutic challenge to the clinician.
Methods
We prospectively evaluated incidence of AMI, and diagnostic performance of specific electrocardiographic (ECG) and high-sensitivity cardiac troponin (hs-cTn) criteria in patients presenting with chest discomfort to 26 emergency departments in three international, prospective, diagnostic studies. Presence of LBBB, ECG criteria, and final diagnoses were centrally adjudicated by two independent cardiologists using the fourth universal definition of myocardial infarction.
Results
Among 8830 patients, LBBB was present in 247 patients (2.8%). AMI was the final diagnosis in 30% of patients with LBBB, with similar incidence in those with known LBBB versus those with presumably new LBBB (29% vs 35%, p=0.42). ECG criteria had low sensitivity (1–12%), but high specificity (95–100%). The diagnostic accuracy as quantified by the receiver-operating-characteristics curve of hs-cTnT and hs-cTnI concentrations at presentation (AUC 0.91; 95% CI 0.85–0.96 and 0.89; 95% CI 0.83–0.95) as well as that of their 0/1h and 0/2h changes was very high. A diagnostic algorithm (Figure 1) combining ECG criteria with hs-cTnT/I concentrations and their absolute changes at 1h or 2h derived in cohort 1 (45 of 45 (100%) of patients with AMI correctly identified), showed high efficacy and accuracy when externally validated in cohort 2 & 3 (28 of 29 patients, 97%).
Figure 1
Conclusion
Most patients presenting with suspected AMI and LBBB will be found to have diagnoses other than AMI. Combining ECG criteria with Hs-cTn testing at 0/1h or 0/2h allows early and accurate diagnosis of AMI in LBBB.
Acknowledgement/Funding
European Union, Swiss National Foundation, University Hospital Basel, University Basel
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Affiliation(s)
- T Nestelberger
- University Hospital Basel, Cardiovascular Research Institute Basel, Basel, Switzerland
| | - L Cullen
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - B Lindahl
- Uppsala University Hospital, Uppsala, Sweden
| | - T Reichlin
- Preventive Cardiology & Sports Medicine, Inselspital Bern, Bern, Switzerland
| | - J Greenslade
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - E Giannitsis
- University Hospital of Heidelberg, Heidelberg, Germany
| | - B Morawiec
- Silesian Center for Heart Diseases (SCHD), Zabrze, Poland
| | - L Koechlin
- University Hospital Basel, Cardiovascular Research Institute Basel, Basel, Switzerland
| | - R Twerenbold
- University Hospital Basel, Cardiovascular Research Institute Basel, Basel, Switzerland
| | - J Boeddinghaus
- University Hospital Basel, Cardiovascular Research Institute Basel, Basel, Switzerland
| | - M Rubini
- University Hospital Basel, Cardiovascular Research Institute Basel, Basel, Switzerland
| | - S Osswald
- University Hospital Basel, Cardiovascular Research Institute Basel, Basel, Switzerland
| | - J Pickering
- Christchurch Hospital, Christchurch, New Zealand
| | - M Than
- Christchurch Hospital, Christchurch, New Zealand
| | - C Mueller
- University Hospital Basel, Cardiovascular Research Institute Basel, Basel, Switzerland
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Pemberton CJ, Lee JA, Aldous S, Skelton L, Frampton CM, Than M, Troughton RW, Adamson P, Richards AM. P1756The protein APRIL predicts adverse outcomes in DAPT patients better than NT-proBNP and troponin. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aim
Dual antiplatelet therapy (DAPT) is a mainstay of post-ACS treatment. However, prediction of adverse events in these patients needs improving. We show here that the TNFα-related protein APRIL (which is produced in platelets and atherosclerotic plaque) is a superior predictor of MACE and new MI in DAPT recipients post-ACS.
Methods
We prospectively recruited 518 patients presenting with the primary complaint of acute chest pain to our hospital ED. Patients were adjudicated to have ACS by 2 independent cardiologists in accordance with ESC guidelines with hsTnI as biomarker. Plasma EDTA samples taken at presentation and 2 hours after were interrogated for APRIL measurements using a two site ELISA. Clinical data/variables, standard biochemistry analytes, hsTnT and NT-proBNP were also measured. Statistical assessments were made using SPSS v23 (IBM). Data for all biomarkers were treated as continuous variables and are presented as median (interquartile range, (IQR)). Statistical assessment of the comparative diagnostic abilities of APRIL, hsTnT, NT-proBNP and hsTnI were assessed using receiver operator curve (ROC) area under the curve (AUC) analysis. The comparative power of each biomarker (log values) to predict new MACE, MI, bleeding and mortality in 1) the whole group and in 2) DAPT recipients alone, within 2 yrs of index presentation was undertaken using a logistic regression base model (95% CI) that included all clinical variables and hsTnI and hsTnT, with APRIL and NT-proBNP each included in additional multivariate analyses.
Results
Of the 518 recruited patients (median age 63 (IQR: 54–73, 35% female), 152 were adjudicated to have ACS (29%, 115 MI, 37 UAP). Presentation APRIL levels were higher in those with a cardiac versus non-cardiac cause for presentation (3.0, (2.0–4.7) vs. 2.4, (1.6–3.8) ng/mL, P=0.001) and positively correlated with hsTnT and NT-proBNP (all P<0.001), but it did not add to the hsTnI (ROC = 0.96) or hsTnT (ROC =0.92) assisted diagnosis of ACS. In all 518 patients, in the multivariate regression model, APRIL was a significant independent predictor of mortality (n=54, P=0.032), new MI (n=43, P=0.006), new ADHF (n=24, P=0.016) and MACE (n=71, P=0.005) that was additive to NT-proBNP and troponin. In DAPT recipients alone (n=156), APRIL was the only biomarker to independently predict new MI (n=27, 95% CI: 1.125–3.982, P=0.020) and MACE (n=37, 95% CI: 1.058–3.389, P=0.031). None of the markers, only age, predicted bleeding episodes.
Conclusion
APRIL is an platelet/plaque derived marker that provides independent risk assessment in ACS patients. In DAPT recipients, the ability of APRIL to predict new MI and MACE is superior to that of cardiac troponins and NT-proBNP and could be used to identify high risk individuals.
Acknowledgement/Funding
Health Research Council of New Zealand; Heart Foundation of New Zealand
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Affiliation(s)
- C J Pemberton
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - J A Lee
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - S Aldous
- Christchurch Hospital, Christchurch, New Zealand
| | - L Skelton
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - C M Frampton
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - M Than
- Christchurch Hospital, Christchurch, New Zealand
| | - R W Troughton
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - P Adamson
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - A M Richards
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
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Aldous S, Pickering J, Young J, George P, Watson A, Troughton R, Pemberton C, Richards M, Cullen L, Than M. P2674Rapid rule-out of myocardial infarction with a novel high precision point-of-care troponin assay appears safe and effective. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
High sensitivity troponin assays were developed to improve analytical sensitivity and precision at the decision cut-points for the diagnosis and rule out of acute myocardial infarction (AMI). Central laboratory assays have achieved this but point of care assays, which have the ability to accelerate decision making due to much shorter turnaround times, have remained lacking.
Purpose
To ascertain the threshold for decision making and subsequent clinical utility for ruling out AMI on presentation in patients attending the emergency department acutely with chest pain, using a high precision point of care troponin assay (TnI Nx), (i-STAT, Abbott).
Methods
We measured arrival TnI-Nx concentrations in stored plasma samples in adults presenting acutely to the emergency department with chest pain. The primary outcome was an AMI or cardiac death on index admission or within 30 days. We used 2000 bootstrapped data sets to derive and validate a suitable threshold for TnI-Nx before calculating diagnostic test performance. We pre-specified this threshold must have a <1% false negative rate for the primary outcome. We compared this with a core laboratory high sensitivity troponin I (hs-TnI) (Abbott Architect) using the early rule-out cut-point (European Society of Cardiology) at the limit of detection (2 ng/L).
Results
We recruited 1320 patients of whom 192 (14.1%) had the primary outcome. The TnI-Nx threshold was determined to be 8 ng/L with subsequent sensitivity of 99.0% (95% confidence interval: 97.3% to 100%), negative predictive value of 99.7% (99.2% to 100%) and specificity of 59.0% (56.0% to 62.0%). The hs-TnI had a sensitivity of 99.5% (98.2% to 100%), negative predictive value of 99.7% (99.0% to 100%), and specificity of 28.4% (25.8% to 31.2%) at 2ng/L.
Conclusion
A high precision point of care assay, TnI-Nx, with a decision threshold of 8ng/L, has comparable rule out performance compared with a core laboratory high sensitivity assay and therefore could potentially be used for early decision making in the assessment of acute chest pain.
Acknowledgement/Funding
Research grant from Abbott Point of Care. Senior Research Fellowship from ECF, CMRF and CDHB. Clinical Research Fellowship from NZ HRC
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Affiliation(s)
- S Aldous
- Christchurch Hospital, Christchurch, New Zealand
| | - J Pickering
- University of Otago Christchurch, Christchurch Heart Institute, Christchurch, New Zealand
| | - J Young
- University of Otago Christchurch, Christchurch Heart Institute, Christchurch, New Zealand
| | - P George
- Christchurch Hospital, Christchurch, New Zealand
| | - A Watson
- Christchurch Hospital, Christchurch, New Zealand
| | - R Troughton
- Christchurch Hospital, Christchurch, New Zealand
| | - C Pemberton
- University of Otago Christchurch, Christchurch Heart Institute, Christchurch, New Zealand
| | - M Richards
- University of Otago Christchurch, Christchurch Heart Institute, Christchurch, New Zealand
| | - L Cullen
- Royal Brisbane and Women's Hospital, Emergency Department, Brisbane, Australia
| | - M Than
- Christchurch Hospital, Christchurch, New Zealand
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48
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Pemberton CJ, Lee JA, Aldous S, Appleby S, Chew-Harris J, Than M, Troughton RW, Richards AM. P3408The signal peptide of CNP is a novel predictor of MI, MACE and bleeding risk in chest pain patients. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aim
CNP is an important vascular and cardiac derived member of the natriuretic peptide family. We have previously provided the first reports that the signal peptide of CNP (CNPsp) is present in the human circulation and is elevated in those with chest pain suspicious of ACS. Here, show that CNPsp levels are highly predictive of new MI, MACE and post-index bleeding in patients presenting with potential ACS.
Methods
We prospectively recruited 493 patients presenting with the primary complaint of acute chest pain to our hospital ED. Patients were adjudicated as ACS by 2 independent cardiologists in accordance with ESC guidelines with hsTnI as biomarker. Plasma EDTA samples taken at presentation and 2 hours after were interrogated for CNPsp measurements using our validated, specific assay. Clinical data/variables, standard biochemistry analytes, hsTnT and NT-proBNP (both Roche Cobas e411) were also measured. Statistical assessments were made using SPSS v23. Data for all biomarkers were treated as continuous variables and are presented as median (interquartile range, (IQR)). Statistical assessment of the comparative abilities of CNPsp, hsTnT, NT-proBNP and hsTnI (log values) to predict new MACE, MI, bleeding and mortality within 2 yrs of index presentation was undertaken using a logistic regression base model (95% CI) that included all clinical variables and hsTnI and hsTnT and NT-proBNP, with CNPsp added to into the multivariate analyses.
Results
Of the 493 recruited patients (median age 63 (IQR: 54–73, 35% female), 148 were adjudicated to have ACS (30%, 109 MI, 39 UAP). Presentation CNPsp levels were not higher in those with adjudicated ACS versus non-ACS (51, (45–65) vs. 50, (42–63) pmol/L, P=0.412), did not correlate with hsTnI, hsTnT or NT-proBNP, but were significantly lower in those with a history of MI (49, (42–59) vs. 51, (43–64) pmol/L, P=0.044). In contrast, they were significantly higher in those with ECG ST-depression (56, (47–85) vs. 50 (42–62) pmol/L, P=0.038). In the multivariate regression model of all 493 patients, lower values of CNPsp were a significant multivariate predictor of new MI (n=37, 95% CI: 0.06–0.89, P=0.038), MACE (n=64, 95% CI: 0.08–0.81, P=0.020) and new bleeding (n=40, 95% CI: 0.05–0.63, P=0.005) within 2 years of presentation. This predictive ability was additive and independent from NT-proBNP and troponin.
Conclusion
This is the first report that CNPsp measurement provides meaningful and independent risk assessment of important outcomes in ACS patients. In particular, the fact that lower levels of CNPsp are predictive of negative MI, MACE and bleeding outcomes suggests that CNPsp may have an unappreciated protective role in the cardiovascular system.
Acknowledgement/Funding
Health Research Council of New Zealand; Heart Foundation of New Zealand
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Affiliation(s)
- C J Pemberton
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - J A Lee
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - S Aldous
- Christchurch Hospital, Christchurch, New Zealand
| | - S Appleby
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - J Chew-Harris
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - M Than
- Christchurch Hospital, Christchurch, New Zealand
| | - R W Troughton
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - A M Richards
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
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49
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Kavsak PA, Neumann JT, Cullen L, Than M, Shortt C, Greenslade JH, Pickering JW, Ojeda F, Ma J, Clayton N, Sherbino J, Hill SA, McQueen M, Westermann D, Sörensen NA, Parsonage WA, Griffith L, Mehta SR, Devereaux PJ, Richards M, Troughton R, Pemberton C, Aldous S, Blankenberg S, Worster A. Clinical chemistry score versus high-sensitivity cardiac troponin I and T tests alone to identify patients at low or high risk for myocardial infarction or death at presentation to the emergency department. CMAJ 2019; 190:E974-E984. [PMID: 30127037 DOI: 10.1503/cmaj.180144] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Testing for high-sensitivity cardiac troponin (hs-cTn) may assist triage and clinical decision-making in patients presenting to the emergency department with symptoms of acute coronary syndrome; however, this could result in the misclassification of risk because of analytical variation or laboratory error. We sought to evaluate a new laboratory-based risk-stratification tool that incorporates tests for hs-cTn, glucose level and estimated glomerular filtration rate to identify patients at risk of myocardial infarction or death when presenting to the emergency department. METHODS We constructed the clinical chemistry score (CCS) (range 0-5 points) and validated it as a predictor of 30-day myocardial infarction (MI) or death using data from 4 cohort studies involving patients who presented to the emergency department with symptoms suggestive of acute coronary syndrome. We calculated diagnostic parameters for the CCS score separately using high-sensitivity cardiac troponin I (hs-cTnI) and high-sensitivity cardiac troponin T (hs-cTnT). RESULTS For the combined cohorts (n = 4245), 17.1% of participants had an MI or died within 30 days. A CCS score of 0 points best identified low-risk participants: the hs-cTnI CCS had a sensitivity of 100% (95% confidence interval [CI] 99.5%-100%), with 8.9% (95% CI 8.1%-9.8%) of the population classified as being at low risk of MI or death within 30 days; the hs-cTnT CCS had a sensitivity of 99.9% (95% CI 99.2%-100%), with 10.5% (95% CI 9.6%-11.4%) of the population classified as being at low risk. The CCS had better sensitivity than hs-cTn alone (hs-cTnI < 5 ng/L: 96.6%, 95% CI 95.0%-97.8%; hs-cTnT < 6 ng/L: 98.2%, 95% CI 97.0%-99.0%). A CCS score of 5 points best identified patients at high risk (hs-cTnI CCS: specificity 96.6%, 95% CI 96.0%-97.2%; 11.2% [95% CI 10.3%-12.2%] of the population classified as being at high risk; hs-cTnT CCS: specificity 94.0%, 95% CI 93.1%-94.7%; 13.1% [95% CI 12.1%-14.1%] of the population classified as being at high risk) compared with using the overall 99th percentiles for the hs-cTn assays (specificity of hs-cTnI 93.2%, 95% CI 92.3-94.0; specificity of hs-cTnT 73.8%, 95% CI 72.3-75.2). INTERPRETATION The CCS score at the chosen cut-offs was more sensitive and specific than hs-cTn alone for risk stratification of patients presenting to the emergency department with suspected acute coronary syndrome. Study registration: ClinicalTrials.gov, nos. NCT01994577; NCT02355457.
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Affiliation(s)
- Peter A Kavsak
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Johannes T Neumann
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Louise Cullen
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Martin Than
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Colleen Shortt
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Jaimi H Greenslade
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - John W Pickering
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Francisco Ojeda
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Jinhui Ma
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Natasha Clayton
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Jonathan Sherbino
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Stephen A Hill
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Matthew McQueen
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Dirk Westermann
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Nils A Sörensen
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - William A Parsonage
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Lauren Griffith
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Shamir R Mehta
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - P J Devereaux
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Mark Richards
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Richard Troughton
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Chris Pemberton
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Sally Aldous
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Stefan Blankenberg
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
| | - Andrew Worster
- Departments of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), Health Research Methods, Evidence and Impact (Ma, Griffith); and Medicine (Clayton); Division of Emergency Medicine (Shortt, Sherbino, Worster); Division of Cardiology (Mehta, Devereaux); Population Health Research Institute (Devereaux), McMaster University, Hamilton, Ont.; Department of General and Interventional Cardiology (Neumann, Ojeda, Westermann, Sörensen, Blankenberg), University Heart Center Hamburg Eppendorf, Hamburg, Germany; Royal Brisbane and Women's Hospital (Cullen, Greenslade, Parsonage), Brisbane, Australia; Christchurch Hospital (Than, Pickering, Troughton, Aldous), Christchurch, New Zealand; Department of Medicine and Christchurch Heart Institute, University of Otago (Richards, Pickering, Troughton, Pemberton), Christchurch, New Zealand; Cardiovascular Research Institute (Richards), National University of Singapore
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van der Linden N, Wildi K, Twerenbold R, Pickering JW, Than M, Cullen L, Greenslade J, Parsonage W, Nestelberger T, Boeddinghaus J, Badertscher P, Rubini Giménez M, Klinkenberg LJJ, Bekers O, Schöni A, Keller DI, Sabti Z, Puelacher C, Cupa J, Schumacher L, Kozhuharov N, Grimm K, Shrestha S, Flores D, Freese M, Stelzig C, Strebel I, Miró Ò, Rentsch K, Morawiec B, Kawecki D, Kloos W, Lohrmann J, Richards AM, Troughton R, Pemberton C, Osswald S, van Dieijen-Visser MP, Mingels AM, Reichlin T, Meex SJR, Mueller C. Combining High-Sensitivity Cardiac Troponin I and Cardiac Troponin T in the Early Diagnosis of Acute Myocardial Infarction. Circulation 2019; 138:989-999. [PMID: 29691270 DOI: 10.1161/circulationaha.117.032003] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Combining 2 signals of cardiomyocyte injury, cardiac troponin I (cTnI) and T (cTnT), might overcome some individual pathophysiological and analytical limitations and thereby increase diagnostic accuracy for acute myocardial infarction with a single blood draw. We aimed to evaluate the diagnostic performance of combinations of high-sensitivity (hs) cTnI and hs-cTnT for the early diagnosis of acute myocardial infarction. METHODS The diagnostic performance of combining hs-cTnI (Architect, Abbott) and hs-cTnT (Elecsys, Roche) concentrations (sum, product, ratio, and a combination algorithm) obtained at the time of presentation was evaluated in a large multicenter diagnostic study of patients with suspected acute myocardial infarction. The optimal rule-out and rule-in thresholds were externally validated in a second large multicenter diagnostic study. The proportion of patients eligible for early rule-out was compared with the European Society of Cardiology 0/1 and 0/3 hour algorithms. RESULTS Combining hs-cTnI and hs-cTnT concentrations did not consistently increase overall diagnostic accuracy as compared with the individual isoforms. However, the combination improved the proportion of patients meeting criteria for very early rule-out. With the European Society of Cardiology 2015 guideline recommended algorithms and cut-offs, the proportion meeting rule-out criteria after the baseline blood sampling was limited (6% to 24%) and assay dependent. Application of optimized cut-off values using the sum (9 ng/L) and product (18 ng2/L2) of hs-cTnI and hs-cTnT concentrations led to an increase in the proportion ruled-out after a single blood draw to 34% to 41% in the original (sum: negative predictive value [NPV] 100% [95% confidence interval (CI), 99.5% to 100%]; product: NPV 100% [95% CI, 99.5% to 100%]) and in the validation cohort (sum: NPV 99.6% [95% CI, 99.0-99.9%]; product: NPV 99.4% [95% CI, 98.8-99.8%]). The use of a combination algorithm (hs-cTnI <4 ng/L and hs-cTnT <9 ng/L) showed comparable results for rule-out (40% to 43% ruled out; NPV original cohort 99.9% [95% CI, 99.2-100%]; NPV validation cohort 99.5% [95% CI, 98.9-99.8%]) and rule-in (positive predictive value [PPV] original cohort 74.4% [95% Cl, 69.6-78.8%]; PPV validation cohort 84.0% [95% Cl, 79.7-87.6%]). CONCLUSIONS New strategies combining hs-cTnI and hs-cTnT concentrations may significantly increase the number of patients eligible for very early and safe rule-out, but do not seem helpful for the rule-in of acute myocardial infarction. CLINICAL TRIAL REGISTRATION URL (APACE): https://www.clinicaltrial.gov . Unique identifier: NCT00470587. URL (ADAPT): www.anzctr.org.au . Unique identifier: ACTRN12611001069943.
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Affiliation(s)
- Noreen van der Linden
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), The Netherlands (N.v.d.L., L.J.J.K., O.B., M.P.v.D.-V., A.M.M., S.J.R.M.)
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - John W Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P., M.T., A.M.R., R.T., C.P.)
| | - Martin Than
- Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P., M.T., A.M.R., R.T., C.P.)
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia (L.C., W.P.).,School of Public Health, Queensland University of Technology, Brisbane, Australia (L.C., J.G., W.P.).,School of Medicine, The University of Queensland, Brisbane, Australia (L.C., J.G., W.P.)
| | - Jaimi Greenslade
- School of Public Health, Queensland University of Technology, Brisbane, Australia (L.C., J.G., W.P.).,School of Medicine, The University of Queensland, Brisbane, Australia (L.C., J.G., W.P.)
| | - William Parsonage
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia (L.C., W.P.).,School of Public Health, Queensland University of Technology, Brisbane, Australia (L.C., J.G., W.P.).,School of Medicine, The University of Queensland, Brisbane, Australia (L.C., J.G., W.P.)
| | - Thomas Nestelberger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Jasper Boeddinghaus
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Patrick Badertscher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Maria Rubini Giménez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.).,Emergency Department, CIBERES ISC III, Hospital del Mar - IMIM, Barcelona, Spain (M.R.)
| | - Lieke J J Klinkenberg
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), The Netherlands (N.v.d.L., L.J.J.K., O.B., M.P.v.D.-V., A.M.M., S.J.R.M.)
| | - Otto Bekers
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), The Netherlands (N.v.d.L., L.J.J.K., O.B., M.P.v.D.-V., A.M.M., S.J.R.M.)
| | - Aline Schöni
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.).,Emergency Department, University Hospital Zürich, Switzerland (A.S., D.I.K.)
| | - Dagmar I Keller
- Emergency Department, University Hospital Zürich, Switzerland (A.S., D.I.K.)
| | - Zaid Sabti
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Janosch Cupa
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Lukas Schumacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Nikola Kozhuharov
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Karin Grimm
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Samyut Shrestha
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Dayana Flores
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Michael Freese
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Claudia Stelzig
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Ivo Strebel
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Òscar Miró
- Emergency Department, Hospital Clinic, Barcelona, Spain (O.M.)
| | | | - Beata Morawiec
- 2nd Department of Cardiology and School of Medicine with the Division of Dentistry, Zabrze, Medical University of Katowice, Katowice, Poland (B.M., D.K.)
| | - Damian Kawecki
- 2nd Department of Cardiology and School of Medicine with the Division of Dentistry, Zabrze, Medical University of Katowice, Katowice, Poland (B.M., D.K.)
| | - Wanda Kloos
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.).,Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia (K.W.)
| | - Jens Lohrmann
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - A Mark Richards
- Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P., M.T., A.M.R., R.T., C.P.)
| | - Richard Troughton
- Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P., M.T., A.M.R., R.T., C.P.)
| | - Christopher Pemberton
- Department of Medicine, University of Otago, Christchurch, New Zealand (J.W.P., M.T., A.M.R., R.T., C.P.)
| | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Marja P van Dieijen-Visser
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), The Netherlands (N.v.d.L., L.J.J.K., O.B., M.P.v.D.-V., A.M.M., S.J.R.M.)
| | - Alma M Mingels
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), The Netherlands (N.v.d.L., L.J.J.K., O.B., M.P.v.D.-V., A.M.M., S.J.R.M.)
| | - Tobias Reichlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
| | - Steven J R Meex
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), The Netherlands (N.v.d.L., L.J.J.K., O.B., M.P.v.D.-V., A.M.M., S.J.R.M.)
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland (K.W., R.T., T.N., J.B., P.B., M.R.G., A.S., Z.S., C.P., J.C., L.S., N.K., K.G., S.S., D.F., M.F., C.S., I.S., W.K., J.L., S.O., T.R., C.M.)
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