J Lee Garvey

Carolinas Medical Center University, Charlotte, North Carolina, United States

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Publications (30)169.65 Total impact

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    ABSTRACT: A 10-fold regional variation in survival after out-of-hospital cardiac arrest (OHCA) has been reported in the United States, which partly relates to variability in bystander cardiopulmonary resuscitation (CPR) rates. In order for resources to be focused on areas of greatest need, we conducted a geospatial analysis of variation of CPR rates.
    Resuscitation 08/2014; · 4.10 Impact Factor
  • JACC. Cardiovascular Interventions 03/2014; 7(3):340. · 1.07 Impact Factor
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    ABSTRACT: A network approach to transfer ST-segment elevation myocardial infarction (STEMI) patients can achieve durable first door-to-balloon times (1st D2B) for percutaneous coronary intervention (PCI) within 90 min. Nationally, a minority of STEMI patients from referral centers obtain 1st D2B in <2 h and even fewer in <90 min. Included were transfer STEMI patients from 9 network hospitals treated in 2007 compared with 2008 to 2011 after installing the following initiatives: 1) established hospital referral system; 2) goal-oriented performance protocols; 3) expedited transport by ground or air; 4) first hospital activation of the PCI hospital catheterization laboratory; and 5) outreach coordinator and patient-level web-based feedback to the referring hospital. A total of 101 STEMI patients transported in 2007 were compared with 442 STEMI patients transferred after starting these initiatives for STEMI from 2008 to 2011, with the median door-in to door-out time decreased from 44 to 35 min (p < 0.0001), the median 1st D2B decreasing from 109.5 to 88.0 min (p < 0.0001), and the percentage under 90 min increased from 22.8% to 55.9% (p < 0.0001). Overall, throughout the study period (2007 to 2011), the transport times remained consistent (median 36.5 vs. 36.0 min, p = 0.98), whereas the PCI hospital D2B decreased from 20.0 to 16.0 min (p < 0.0001). Length of stay and in-hospital mortality remained low at 3.0 days and under 4%, respectively. A system-wide network program can achieve sustained (over 4 years) 1st D2B times of <90 min.
    JACC. Cardiovascular Interventions 09/2013; · 1.07 Impact Factor
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    ABSTRACT: BACKGROUND: AMONG PATIENTS IDENTIFIED PREHOSPITAL WITH ST-SEGMENTELEVATION MYOCARDIAL INFARCTION, EMERGENCY MEDICAL SERVICE TRANSPORT FROM THE FIELD DIRECTLY TO THE CATHETERIZATION LABORATORY, THEREBY BYPASSING THE EMERGENCY DEPARTMENT (ED), MAY SHORTEN TIME TO REPERFUSION.METHODS AND RESULTS: WE STUDIED 1687 PATIENTS IDENTIFIED PREHOSPITAL WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION FROM THE REPERFUSION IN ACUTE MYOCARDIAL INFARCTION IN CAROLINA EMERGENCY DEPARTMENTS (RACE) PROJECT, TRANSPORTED VIA EMERGENCY MEDICAL SERVICE DIRECTLY TO 21 NORTH CAROLINA HOSPITALS FOR PRIMARY PERCUTANEOUS CORONARY INTERVENTION BETWEEN JULY 2008 AND DECEMBER 2009. TREATMENT TIME INTERVALS WERE COMPARED BETWEEN PATIENTS EVALUATED IN THE ED (ED EVALUATION) AND THOSE TRANSPORTED DIRECTLY TO THE CATHETERIZATION LABORATORY (ED BYPASS). EMERGENCY MEDICAL SERVICE TRANSPORTED 1401 (83.0%) PATIENTS TO THE ED, WHEREAS THE ED WAS BYPASSED FOR 286 (17.0%) PATIENTS. OVERALL, FIRST MEDICAL CONTACT TO DEVICE ACTIVATION WITHIN 90 MINUTES WAS ACHIEVED IN 913 (54.1%) PATIENTS. AMONG PATIENTS EVALUATED IN THE ED, MEDIAN TIME (25TH75TH PERCENTILES) FROM ED ARRIVAL TO CATHETERIZATION LABORATORY ARRIVAL WAS 30 (2041) MINUTES. FIRST MEDICAL CONTACT TO DEVICE ACTIVATION OCCURRED FASTER (75 [5993] VERSUS 90 [76109] MINUTES; P0.001) AND WAS MORE FREQUENTLY ACHIEVED WITHIN 90 MINUTES (74.1% VERSUS 50.1%; P0.001) AMONG ED BYPASS PATIENTS.CONCLUSIONS: Among patients identified prehospital with ST-segment-elevation myocardial infarction and transported directly to a percutaneous coronary intervention hospital, only 1 in 2 achieve device activation within 90 minutes. A median of 30 minutes is spent in the ED, contributing significantly to the failure to achieve timely reperfusion. The strategy to bypass the ED is used infrequently and represents a potential opportunity to improve reperfusion times.
    Circulation Cardiovascular Interventions 07/2013; · 6.54 Impact Factor
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    ABSTRACT: Emergency medical services (EMS) are critical in the treatment of ST-segment elevation myocardial infarction (STEMI). Prehospital system delays are an important target for improving timely STEMI care, yet few limited data are available. Using a deterministic approach, we merged EMS data from the North Carolina Pre-hospital Medical Information System (PreMIS) with data from the Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments-Emergency Response (RACE-ER) Project. Our sample included all patients with STEMI from June 2008 to October 2010 who arrived by EMS and who had primary percutaneous coronary intervention (PCI). Prehospital system delays were compared using both RACE-ER and PreMIS to examine agreement between the 2 data sources. Overall, 8,680 patients with STEMI in RACE-ER arrived at a PCI hospital by EMS; 21 RACE-ER hospitals and 178 corresponding EMS agencies across the state were represented. Of these, 6,010 (69%) patients were successfully linked with PreMIS. Linked and notlinked patients were similar. Overall, 2,696 patients were treated with PCI only and were taken directly to a PCI-capable hospital by EMS; 1,750 were transferred from a non-PCI facility. For those being transported directly to a PCI center, 53% reached the 90-minute target guideline goal. For those transferred from a non-PCI facility, 24% reached the 120-minute target goal for primary PCI. We successfully linked prehospital EMS data with inhospital clinical data. With this linked STEMI cohort, less than half of patients reach goals set by guidelines. Such a data source could be used for future research and quality improvement interventions.
    American heart journal 03/2013; 165(3):363-70. · 4.65 Impact Factor
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    ABSTRACT: Prehospital 12-lead electrocardiography (ECG) is critical to timely STEMI care although its use remains inconsistent. Previous studies to identify reasons for failure to obtain a prehospital ECG have generally only focused on individual emergency medical service (EMS) systems in urban areas. Our study objective was to identify patient, geographic, and EMS agency-related factors associated with failure to perform a prehospital ECG across a statewide geography. We analyzed data from the Prehospital Medical Information System (PreMIS) in North Carolina from January 2008 to November 2010 for patients >30 years of age who used EMS and had a prehospital chief complaint of chest pain. Among 3.1 million EMS encounters, 134 350 patients met study criteria. From 2008-2010, 82 311 (61%) persons with chest pain received a prehospital ECG; utilization increased from 55% in 2008 to 65% in 2010 (trend P<0.001). Utilization by health referral region ranged from 22.9% to 74.2% and was lowest in rural areas. Men were more likely than women to have an ECG performed (63.0% vs 61.3%, adjusted RR 1.02, 95% CI 1.01 to 1.04). The certification-level of the EMS provider (paramedic vsbasic/intermediate) and system-level ECG equipment availability were the strongest predictors of ECG utilization. Persons in an ambulance with a certified paramedic were significantly more likely to receive a prehospital ECG than nonparamedics (RR 2.15, 95% CI 1.55, 2.99). Across a large geographic area prehospital ECG use increased significantly, although important quality improvement opportunities remain. Increasing ECG availability and improving EMS certification and training levels are needed to improve overall care and reduce rural-urban treatment differences.
    Journal of the American Heart Association. 01/2013; 2(4):e000289.
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    ABSTRACT: BACKGROUND: The ultimate treatment goal for ST-segment elevation myocardial infarction (STEMI) is rapid reperfusion via primary percutaneous intervention (PCI). North Carolina has adopted a statewide STEMI referral strategy that advises paramedics to "bypass" local hospitals and transport STEMI patients directly to a PCI-capable hospital, even if a non-PCI-capable hospital is closer. METHODS AND RESULTS: We assessed emergency medical services (EMS) adherence to this STEMI protocol, as well as subsequent associations with patient treatment times and outcomes by linking data from the ACTION Registry-GWTG and a statewide EMS data system from 06/2008-09/2010 for all STEMI patients. Patients were divided into those: (1) transported directly to a PCI hospital, thereby bypassing a closer non-PCI hospital; and (2) first taken to a closer non-PCI center and later transferred to a PCI hospital. Among 6010 STEMI patients, 1288 were eligible and included in our study cohort. Of these, 826 (64%) were transported directly to a PCI facility, whereas 462 (36%) were first taken to a non-PCI hospital and later transferred. In a multivariable model, increase in differential driving time and cardiac arrest were associated with a lesser likelihood of being taken directly to a PCI center, whereas a history of PCI was associated with a higher likelihood of being taken directly to a PCI center. Patients sent directly to a PCI center were more likely to have first medical contact-to-PCI times within guideline recommendations CONCLUSIONS: We found that patients who were sent directly to a PCI center had significantly shorter time to reperfusion.
    Circulation 12/2012; · 15.20 Impact Factor
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    ABSTRACT: Despite national guidelines calling for timely coronary artery reperfusion, treatment is often delayed, particularly for patients requiring interhospital transfer. One hundred nineteen North Carolina hospitals developed coordinated plans to rapidly treat patients with ST-segment-elevation myocardial infarction according to presentation: walk-in, ambulance, or hospital transfer. A total of 6841 patients with ST-segment-elevation myocardial infarction (3907 directly presenting to 21 percutaneous coronary intervention hospitals, 2933 transferred from 98 non-percutaneous coronary intervention hospitals) were treated between July 2008 and December 2009 (age, 59 years; 30% women; 19% uninsured; chest pain duration, 91 minutes; shock, 9.2%). The rate of patients not receiving reperfusion fell from 5.4% to 4.0% (P=0.04). Treatment times for hospital transfer patients substantially improved. First-hospital-door-to-device time for hospitals that adopted a "transfer for percutaneous coronary intervention" reperfusion strategy fell from 117 to 103 minutes (P=0.0008), whereas times at hospitals with a mixed strategy of transfer or fibrinolysis fell from 195 to 138 minutes (P=0.002). Median door-to-device times for patients presenting directly to PCI hospitals fell from 64 to 59 minutes (P<0.001). Emergency medical services-transported patients were most likely to reach door-to-device goals, with 91% treated within 90 minutes and 52% being treated with 60 minutes. Patients treated within guideline goals had a mortality of 2.2% compared with 5.7% for those exceeding guideline recommendations (P<0.001). Through extension of regional coordination to an entire state, rapid diagnosis and treatment of ST-segment-elevation myocardial infarction has become an established standard of care independently of healthcare setting or geographic location.
    Circulation 06/2012; 126(2):189-95. · 15.20 Impact Factor
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    ABSTRACT: For patients with an acute ST-segment elevation myocardial infarction, cardiac catheterization laboratory (CCL) activation by emergency medical technicians or emergency physicians has been shown to substantially reduce treatment times. One drawback to this approach involves overtriage, whereby CCL staffs are activated for patients who ultimately do not require emergent coronary angiography or for patients who undergo angiography but are not found to have coronary artery occlusion. We examined CCL activation at 14 primary angioplasty hospitals to determine the course of management, including the rate of inappropriate activation. Among 3973 activations (29% by emergency medical technicians, 71% by emergency physicians) between December 2008 and December 2009, appropriate CCL activations occurred for 3377 patients (85%), with 2598 patients (76.9% of appropriate activations) receiving primary percutaneous coronary intervention. Reasons for inappropriate activations (596 patients; 15%) included ECG reinterpretations (427 patients; 72%) or the fact that the patient was not a CCL candidate (169 patients; 28%). The rate of cancellation because of reinterpretation of emergency medical technicians' ECG (6% of all activations) was more common than for cancellation because of reinterpretation of emergency physicians' ECG (4.6%). This represents the first report of the rates of CCL cancellation for ST-segment elevation myocardial infarction system activation by emergency medical technicians and emergency physicians in a large group of hospitals organized within a statewide program. The high rate of coronary intervention and relatively low rate of inappropriate activation suggest that systematic CCL activation by emergency personnel on a broad scale is feasible and accurate, and these rates set a benchmark for ST-segment elevation myocardial infarction systems.
    Circulation 12/2011; 125(2):308-13. · 15.20 Impact Factor
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    ABSTRACT: The ability to rapidly identify patients with ST-segment elevation-myocardial infarction (STEMI) at hospitals without percutaneous coronary intervention (PCI) and transfer them to hospitals with PCI capability is critical to STEMI regionalization efforts. Our objective was to assess the association of prehospital, emergency department (ED), and hospital processes of care implemented as part of a statewide STEMI regionalization program with door-in-door-out times at non-PCI hospitals. Door-in-door-out times for 436 STEMI patients at 55 non-PCI hospitals were determined before (July 2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of standardized protocols as part of a statewide regionalization program (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments, RACE). The association of 8 system care processes (encompassing emergency medical services [EMS], ED, and hospital settings) with door-in-door-out times was determined using multivariable linear regression. Median door-in-door-out times improved significantly with the intervention (before: 97.0 minutes, interquartile range, 56.0 to 160.0 minutes; after: 58.0 minutes, interquartile range, 35.0 to 90.0 minutes; P<0.0001). Hospital, ED, and EMS care processes were each independently associated with shorter door-in-door-out times (-17.7 [95% confidence interval, -27.5 to -7.9]; -10.1 [95% confidence interval, -19.0 to -1.1], and -7.3 [95% confidence interval, -13.0 to -1.5] minutes for each additional hospital, ED, and EMS process, respectively). Combined, adoption of EMS processes was associated with the shortest median treatment times (44 versus 138 minutes for hospitals that adopted all EMS processes versus none). Prehospital, ED, and hospital processes of care were independently associated with shorter door-in-door-out times for STEMI patients requiring transfer. Adoption of several EMS processes was associated with the largest reduction in treatment times. These findings highlight the need for an integrated, system-based approach to improving STEMI care.
    Circulation Cardiovascular Quality and Outcomes 06/2011; 4(4):382-8. · 5.66 Impact Factor
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    ABSTRACT: The management of low-risk patients presenting to emergency departments is a common and challenging clinical problem entailing 8 million emergency department visits annually. Although a majority of these patients do not have a life-threatening condition, the clinician must distinguish between those who require urgent treatment of a serious problem and those with more benign entities who do not require admission. Inadvertent discharge of patients with acute coronary syndrome from the emergency department is associated with increased mortality and liability, whereas inappropriate admission of patients without serious disease is neither indicated nor cost-effective. Clinical judgment and basic clinical tools (history, physical examination, and electrocardiogram) remain primary in meeting this challenge and affording early identification of low-risk patients with chest pain. Additionally, established and newer diagnostic methods have extended clinicians' diagnostic capacity in this setting. Low-risk patients presenting with chest pain are increasingly managed in chest pain units in which accelerated diagnostic protocols are performed, comprising serial electrocardiograms and cardiac injury markers to exclude acute coronary syndrome. Patients with negative findings usually complete the accelerated diagnostic protocol with a confirmatory test to exclude ischemia. This is typically an exercise treadmill test or a cardiac imaging study if the exercise treadmill test is not applicable. Rest myocardial perfusion imaging has assumed an important role in this setting. Computed tomography coronary angiography has also shown promise in this setting. A negative accelerated diagnostic protocol evaluation allows discharge, whereas patients with positive findings are admitted. This approach has been found to be safe, accurate, and cost-effective in low-risk patients presenting with chest pain.
    Circulation 10/2010; 122(17):1756-76. · 15.20 Impact Factor
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    ABSTRACT: Prior studies have demonstrated differences in time to reperfusion for ST-segment-elevation myocardial infarction (STEMI) in women, minorities, and the elderly, relative to their counterparts. Regionalization has been shown to improve overall STEMI treatment times, but its impact on care differences among these important patient subgroups is unknown. The objective of this analysis was to assess the impact of a statewide system of STEMI care (The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments) on treatment times according to patient sex, race, and age. STEMI treatment times were determined before (July 2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of coordinated regional treatment protocols. Times in the pre- and postintervention periods were compared by mixed-effects models. A total of 2063 STEMI patients were analyzed: 1140 at percutaneous coronary intervention hospitals and 923 at non-percutaneous coronary intervention hospitals. The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments was associated with significant improvements in treatment times in women and the elderly, including door-to-ECG, door-to-device, door-in-door-out, and door-to-needle times (all P<0.05). Temporal improvements in treatment times at percutaneous coronary intervention hospitals were not significantly different in blacks than in whites. There was a reduction in baseline treatment disparities in door-to-ECG times in women versus men (4.4-minute reduction in difference; 95% CI, -8.1 to -0.4; P=0.03). After Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments, an age-treatment time gap persisted in the elderly, relative to younger patients. A statewide STEMI regionalization program was associated with comparable improvement in treatment times for female, black, and elderly patients compared with middle-aged, white male patients. Nevertheless, there remain opportunities to further narrow treatment differences, particularly among the elderly.
    Circulation Cardiovascular Quality and Outcomes 09/2010; 3(5):514-21. · 5.66 Impact Factor
  • Journal of The American College of Cardiology - J AMER COLL CARDIOL. 01/2010; 55(10).
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    ABSTRACT: The aim of this study was determine whether hospitals accredited by the Society of Chest Pain Centers hospitals (accredited chest pain centers [ACPCs]) are associated with better performance regarding Centers for Medicare and Medicaid Services core measures for acute myocardial infarction (AMI) than nonaccredited hospitals. The study was a retrospective, observational cohort study of hospitals reporting Centers for Medicare and Medicaid Services core measures for AMI from January 1, 2005, to December 31, 2005, on the basis of the presence or absence of Society of Chest Pain Centers accreditation. Data were obtained from the Web sites of the Centers for Medicare and Medicaid Services (Hospital Compare), Society of Chest Pain Centers listings, and the American Hospital Directory. Groups were compared in terms of demographics and mean percentage compliance with all 8 AMI core measures. Student's t test, chi-square analysis, and logistic regression were used to analyze bivariate relations. Multivariate logistic regression models used a propensity-score adjustment factor. Of the 4,197 hospitals that reported core measures for AMI, 178 (4%) were accredited and 4,019 (96%) were not. ACPCs had been accredited for an average of 12 months and were larger (378 vs 204 beds), more often teaching hospitals (52% vs 30%), and more often urban (95% vs 69%) (all p <0.0001). There were 395,250 patients with AMIs, of whom 55,418 (14%) presented to ACPCs and 339,832 (86%) presented to nonaccredited hospitals. There was significantly greater compliance with all 8 AMI core measures at ACPCs (p <0.0001), except for lytic therapy <30 minutes after arrival (p = 0.04), for which unadjusted performance was the same. In conclusion, ACPCs were associated with better compliance with Centers for Medicare and Medicaid Services core measures and saw a greater proportion of patients with AMIs.
    The American Journal of Cardiology 07/2008; 102(2):120-4. · 3.21 Impact Factor
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    ABSTRACT: Despite 2 decades of evidence demonstrating benefits from prompt coronary reperfusion, registries continue to show that many patients with ST-segment elevation myocardial infarction (STEMI) are treated too slowly or not at all. To establish a statewide system for reperfusion, as exists for trauma care, to overcome systematic barriers. A quality improvement study that examined the change in speed and rate of coronary reperfusion after system implementation in 5 regions in North Carolina involving 65 hospitals and associated emergency medical systems (10 percutaneous coronary intervention [PCI] hospitals and 55 non-PCI hospitals). A total of 1164 patients with STEMI (579 preintervention and 585 postintervention) eligible for reperfusion were treated at PCI hospitals (median age 61 years, 31% women, 4% Killip class III or IV). A total of 925 patients with STEMI (518 preintervention and 407 postintervention) were treated at non-PCI hospitals (median age 62 years, 32% women, 4% Killip class III or IV). Early diagnosis and the most expedient coronary reperfusion method at each point of care: emergency medical systems, emergency department, catheterization laboratory, and transfer. Within 5 regions, PCI hospitals agreed to provide single-call catheterization laboratory activation by emergency medical personnel, accept patients regardless of bed availability, and improve STEMI care for the entire region regardless of hospital affiliation. Reperfusion times and rates 3 months before (July to September 2005) and 3 months after (January to March 2007) a year-long implementation. Median reperfusion times significantly improved according to first door-to-device (presenting to PCI hospital 85 to 74 minutes, P < .001; transferred to PCI hospital 165 to 128 minutes, P < .001), door-to-needle in non-PCI hospitals (35 to 29 minutes, P = .002), and door-in to door-out for patients transferred from non-PCI hospitals (120 to 71 minutes, P < .001). Nonreperfusion rates were unchanged (15%) in non-PCI hospitals and decreased from 23% to 11% in the PCI hospitals. For patients presenting to or transferred to PCI hospitals, clinical outcomes including death, cardiac arrest, and cardiogenic shock did not significantly change following the intervention. A statewide program focused on regional systems for reperfusion for STEMI can significantly improve quality of care. Further research is needed to ensure that programs that result in improved application of reperfusion treatments will lead to reductions in mortality and morbidity from STEMI.
    JAMA The Journal of the American Medical Association 11/2007; 298(20):2371-80. · 29.98 Impact Factor
  • Annals of Emergency Medicine - ANN EMERG MED. 01/2007; 50(3).
  • Academic Emergency Medicine - ACAD EMERG MED. 01/2007; 14.
  • Alice M Mitchell, Joseph Lee Garvey, Jeffrey A Kline
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    ABSTRACT: To test novel markers of acute coronary syndrome (ACS), monocyte chemoattractant protein-1 (MCP), myeloperoxidase (MPO), C-reactive protein (CRP), and brain natriuretic peptide (BNP) in low-risk emergency department (ED) patients who were evaluated for ACS in a chest pain unit (CPU). A convenience sample of 414 patients underwent CPU evaluation, including provocative testing, and were followed prospectively for 45 days for ACS, which was defined as death, myocardial infarction (MI), revascularization, or >60% coronary artery stenosis prompting new medical treatment, adjudicated by three blinded reviewers. Published diagnostic thresholds were used to calculate diagnostic indices for each marker and for the multimarker panel. The prevalence of ACS was 7 in 414 (1.7%; 95% CI = 0.7% to 3.5%). Only MCP demonstrated a negative likelihood ratio [LR(-)] of less than 0.5, with a sensitivity of 85% (95% CI = 42% to 99%), specificity of 72% (95% CI = 67% to 76%), and LR(-) of 0.20 (95% CI = 0.04 to 0.71). For MPO, CRP, and BNP, LR(-) was 0.89 (95% CI = 0.26 to 2.05), 0.79 (95% CI = 0.40 to 1.01), and 0.90 (95% CI = 0.51 to 1.03), respectively. The sensitivity, specificity, and LR(-) of an abnormal multimarker panel were 86% (95% CI = 42% to 100%), 17% (95% CI = 13% to 21%), and 0.84 (95% CI = 0.15 to 3.12), respectively. The prevalence of ACS was very low but was similar to reports from other CPUs. BNP and CRP had high specificities, but had limited sensitivities, whereas MPO had a low specificity. Only MCP had a low LR(-) and should be studied further. The combined multimarker panel had an unexpectedly low sensitivity and specificity, yielding an LR(-) of 0.84, suggesting that the panel would not be an efficient screening test to decrease unnecessary CPU testing.
    Academic Emergency Medicine 07/2006; 13(7):803-6. · 1.76 Impact Factor
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    ABSTRACT: We compare the diagnostic accuracy of 3 methods--attribute matching, physician's written unstructured estimate, and a logistic regression formula (Acute Coronary Insufficiency-Time Insensitive Predictive Instrument, ACI-TIPI)--of estimating a very low pretest probability (< or = 2%) for acute coronary syndromes in emergency department (ED) patients evaluated in chest pain units. We prospectively studied 1,114 consecutive patients from 3 academic EDs, evaluated for acute coronary syndrome. Physicians collected data required for pretest probability assessment before protocol-driven chest pain unit testing. A pretest probability greater than 2% was considered "test positive." The criterion standard was the outcome of acute coronary syndrome (death, myocardial infarction, revascularization, or > 60% stenosis prompting new treatment) within 45 days, adjudicated by 3 independent reviewers. Fifty-one of 1,114 enrolled patients (4.5%; 95% confidence interval [CI] 3.4% to 6.0%) developed acute coronary syndrome within 45 days, including 4 of 991 (0.4%; 95% CI 0.1% to 1.0%) patients, discharged after a negative chest pain unit evaluation result, who developed acute coronary syndrome. Unstructured estimate identified 293 patients with pretest probability less than or equal to 2%, 2 had acute coronary syndrome, yielding sensitivity of 96.1% (95% CI 86.5% to 99.5%) and specificity of 27.4% (95% CI 24.7% to 30.2%). Attribute matching identified 304 patients with pretest probability less than or equal to 2%; 1 had acute coronary syndrome, yielding a sensitivity of 98.0% (95% CI 89.6% to 99.9%) and a specificity of 26.1% (95% CI 23.6% to 28.7%). ACI-TIPI identified 56 patients; none had acute coronary syndrome, yielding sensitivity of 100% (95% CI 93.0% to 100%) and specificity of 6.1% (95% CI 4.7% to 7.9%). In a low-risk ED population with symptoms suggestive of acute coronary syndrome, patients with a quantitative pretest probability less than or equal to 2%, determined by attribute matching, unstructured estimate, or logistic regression, may not require additional diagnostic testing.
    Annals of emergency medicine 05/2006; 47(5):447. · 4.23 Impact Factor
  • J Lee Garvey
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    ABSTRACT: The electrocardiogram (ECG) continues to be a critical component of the evaluation of patients who have signs and symptoms of emergency cardiac conditions. This tool is now approximately 100 years old and has been a standard in clinical practice for more than half a century. Application of new signal processing techniques and an expansion in the use of additional leads allows clinicians to extract more and more information from the cardiac electrical activity. An understanding of the technology inherent in the recording of ECGs allows one to more fully understand the benefits and limitation of electrocardiography.
    Emergency Medicine Clinics of North America 03/2006; 24(1):209-25, viii. · 0.83 Impact Factor

Publication Stats

582 Citations
169.65 Total Impact Points

Institutions

  • 2003–2014
    • Carolinas Medical Center University
      Charlotte, North Carolina, United States
  • 2013
    • Duke University
      Durham, North Carolina, United States
  • 2007–2013
    • Duke University Medical Center
      • • Duke Clinical Research Institute
      • • Division of Cardiology
      Durham, NC, United States
  • 2006–2008
    • University of North Carolina at Charlotte
      Charlotte, North Carolina, United States