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Adam J Singer,
Henry C Thode,
W Frank Peacock,
Judd E Hollander, Deborah Diercks,
Robert Birkhahn,
Nathan Shapiro,
Ted Glynn,
Richard Nowack,
Basmah Safdar,
Chadwick Miller,
Elizabeth Lewandrowski,
John Nagurney
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ABSTRACT: BACKGROUND: Regular exercise is thought to be protective against coronary artery disease. As a result, some physicians believe that the likelihood of acute coronary syndrome (ACS) in patients with acute chest pain is reduced in those who exercise regularly. We studied the association between self-reported frequency of exercising and the likelihood of ACS in patients presenting to the Emergency Department (ED) with chest pain. METHODS: A multi-center prospective, descriptive, cohort study design was used in ED patients to determine whether the risk of ACS was reduced in patients who self-reported regular exercise. RESULTS: There were 1093 patients enrolled. Median (interquartile range) age was 57 (48-67) years; 506 (45.7%) were female. ACS was diagnosed in 248 (22.7%) patients. Patients who did not exercise at least monthly were more likely to be diagnosed with ACS than those who did (129/466 [27.7%] vs. 119/627 [19.0%]; odds ratio 1.63, 95% CI 1.23-2.17). After adjusting for age, gender, body mass index, smoking, and prior history, limited exercise was still associated with ACS (adjusted odds ratio 1.52, 95% CI 1.10-2.10). There was no apparent association between frequency and intensity of exercise and risk of ACS. CONCLUSION: Although self-reported frequency of exercise was significantly associated with a decrease in ACS in ED patients with chest pain, it should not be used to exclude ACS in symptomatic ED patients.
Journal of Emergency Medicine 10/2012; · 1.31 Impact Factor
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W Frank Peacock,
John Nagurney,
Robert Birkhahn,
Adam Singer,
Nathan Shapiro,
Judd Hollander,
Ted Glynn,
Richard Nowak,
Basmah Safdar,
Chadwick Miller, [......],
Francis Counselman,
Abhinav Chandra,
Joshua Kosowsky,
James Neuenschwander,
Jon Schrock,
Stephen Plantholt,
Elizabeth Lewandrowski,
Vance Wong,
Ken Kupfer, Deborah Diercks
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ABSTRACT: Myeloperoxidase (MPO) is proposed for risk stratification in patients with suspected acute coronary syndromes (ACSs). We determined if MPO has diagnostic value in patients being evaluated for ACS.
MIDAS was an 18-center prospective study enrolling suspected ACS emergency department patients who presented <8 hours after symptom onset and in whom serial cardiac markers and objective cardiac perfusion testing were planned. Blinded MPO (Biosite, Inc, San Diego, CA) and troponin I (Triage Cardio 3; Biosite, Inc) were drawn at arrival, and Troponin I (TnI) was measured at 90, 180, and 360 minutes. Final diagnoses were adjudicated by the local investigator blinded to study assay.
Of 1,018 patients, 54% were male, 26% black, with a mean age of 58 ± 13 years. Diagnoses were ACS in 288 (23%) and noncardiac chest pain (NCCP) in 788 (77%). Of patients with ACS, 94 (9.2%) had a myocardial infarction (MI) at presentation (69 non-ST-elevation MI, 25 ST-elevation MI), and 136 had unstable angina. Using a cutpoint of 210 ng/mL to provide 90% specificity, MPO had a sensitivity of 0.18; negative predictive value, 0.69; positive predictive value, 0.47; negative likelihood ratio, 0.91; and a positive likelihood ratio of 1.83 to differentiate ACS and NCCP. Because of the large overlap of quartiles, MPO was not clinically useful to predict serial TnI changes. The C statistics ± 95% CI for MPO differentiating ACS from NCCP and for AMI versus NCCP were 0.629 ± 0.04 and 0.666 ± 0.06, respectively.
Myeloperoxidase has insufficient accuracy for decision making in patients with suspected ACS.
American heart journal 11/2011; 162(5):893-9. · 4.65 Impact Factor
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Alan S Maisel,
W Frank Peacock,
Kevin S Shah,
Paul Clopton, Deborah Diercks,
Brian Hiestand,
Michael C Kontos,
Christian Mueller,
Richard Nowak,
Wen Jone Chen,
Sean P Collins
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ABSTRACT: Dyspneic emergency department (ED) patients present a diagnostic dilemma. The S3, although highly specific for acute heart failure (AHF) and predicting death and readmission, is often difficult to auscultate. The HEart failure and Audicor technology for Rapid Diagnosis and Initial Treatment (HEARD-IT) multinational trial evaluated the S3 via acoustic cardiography (Audicor). Our goal in this secondary analysis was to determine if the strength of the S3 can provide diagnostic/prognostic information in problematic heart failure subgroups.
Dyspneic ED patients older than 40 years and not on dialysis were prospectively enrolled. A gold standard AHF diagnosis was determined by 2 cardiologists blinded to acoustic cardiography results. The S3 strength parameter was delineated on a scale of 0 to 10. This secondary analysis of subgroups from the HEARD-IT database used univariate/multivariate regression to determine the diagnostic/prognostic ability of the S3 strength.
In the 995 patients enrolled, S3 strength was a significant prognosticator in univariate analysis for adverse events but not in a multivariable model. In patients with "gray zone" B-type natriuretic peptide (BNP) levels (100-499 pg/mL), acoustic cardiography increased diagnostic accuracy of AHF from 47% to 69%. Acoustic cardiography improved S3 detection sensitivity in obese patients when compared to auscultation.
The strength of the S3 gallop provides rapid results that assist with identification of AHF in selected populations. S3 detection complements the use of BNP in the gray zone, and its diagnostic/prognostic ability is largely unaffected by body mass index and renal function. S3 strength shows promise as a diagnostic and prognostic tool in problematic HF subgroups.
The American journal of emergency medicine 10/2011; 29(8):924-31. · 1.54 Impact Factor
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Nolan McMullin,
Christopher J Lindsell,
Lei Lei,
John Mafi,
Preeti Jois-Bilowich,
Venkataraman Anantharaman,
Charles V Pollack,
Judd E Hollander,
W Brian Gibler,
James W Hoekestra, Deborah Diercks,
W Frank Peacock
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ABSTRACT: Troponin concentrations rising above an institutional cutpoint are used to define acute myocardial necrosis, yet it is uncertain what outcomes are associated with fluctuations in troponin that do not exceed this level. We evaluate the association between troponin fluctuations below an institutional upper limit of normal and acute coronary syndrome (ACS).
This was a post hoc analysis of the Internet tracking registry of ACS (i*trACS), which describes patients presenting to emergency departments (EDs) with suspected ACS across the spectrum of risk. Patients were included in this registry if they were at least 18 years old and had suspected ACS at the time of their ED visit. Inclusions in this analysis required that patients had at least 1 cardiac marker (creatine kinase-MB [CK-MB], troponin T, or troponin I) drawn twice within 6 hours of presentation, with both measures being below the institution's upper limit of normal. A marker change was defined as either an increase or decrease that exceeded 15% of the institutional upper limit of normal. Acute coronary syndrome was defined as a positive stress test, documented myocardial infarction, coronary revascularization, or death within 30 days of their ED admission.
Of 17,713 patient visits, 2162 met inclusion and exclusion criteria. There were 1872 patient visits with 2 troponin results and 1312 with 2 CK-MB results. Patient visits with increasing troponin had increased odds of ACS compared with those with stable troponin levels (odds ratio, 3.6; 95% confidence interval, 1.4-9.2). Changing CK-MB and decreasing troponin were not associated with increased odds of ACS.
Small increases in troponin concentration below the upper limit of normal are associated with increased odds of ACS.
The American journal of emergency medicine 02/2011; 29(2):162-7. · 1.54 Impact Factor
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Ezra A Amsterdam,
J Douglas Kirk,
David A Bluemke, Deborah Diercks,
Michael E Farkouh,
J Lee Garvey,
Michael C Kontos,
James McCord,
Todd D Miller,
Anthony Morise,
L Kristin Newby,
Frederick L Ruberg,
Kristine Anne Scordo,
Paul D Thompson
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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. · 14.74 Impact Factor
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ABSTRACT: Clinical trials are the foundation underlying clinical decision-making. However, stringent inclusion and exclusion criteria may reduce the generalizability of their results, especially for patients seen in the emergency department (ED). Guideline recommendations, based on clinical trials and pertinent registries, apply to broad populations, but not all patients cared for at the bedside fit the predefined categories that make guidelines practical. Furthermore, these documents may not incorporate the latest evidence. As a result, other factors (eg, individual patient characteristics, clinician experience, cost, regulatory labels, expert opinions) often result in clinical decision-making that varies from strict adherence to guideline recommendations.
These challenges demonstrate a need to integrate clinical data and guidelines advice with actual ED practice in a manner that will be consistent with decisions made later in the continuum of care.
In recognition of these issues, a roundtable was convened in New York City on June 5, 2009, to discuss the implications of recent trials involving patients with non-ST-segment elevation acute coronary syndromes. Eight physicians, representing both emergency medicine and cardiology, shared information on advances and clinical trial results in antiplatelet treatment, guidelines, and other developments in patient care. This article is based on transcripts of their presentations and the ensuing discussions that were of particular importance for emergency physicians.
Although guidelines and clinical registries can provide broad direction for practice, there is no substitute for a prospective, multidisciplinary, institution-specific, consistent, evidence-based approach to patient management.
The American journal of emergency medicine 10/2010; 29(9):1203-16. · 1.54 Impact Factor
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Brian J O'Neil,
James Hoekstra,
Yuri B Pride,
Cedric Lefebvre, Deborah Diercks,
W Frank Peacock,
Gregory J Fermann,
C Michael Gibson,
Duane Pinto,
James F Giglio,
Abhinav Chandra,
Charles B Cairns,
Carol Clark,
Joe Massaro,
Mitchell Krucoff
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ABSTRACT: The initial 12-lead (12L) electrocardiogram (ECG) has low sensitivity to detect myocardial infarction (MI) and acute coronary syndromes (ACS) in the emergency department (ED). Yet, early therapies in these patients have been shown to improve outcomes.
The Optimal Cardiovascular Diagnostic Evaluation Enabling Faster Treatment of Myocardial Infarction (OCCULT-MI) trial was a multicenter trial comparing a novel 80-lead mapping system (80L) to standard 12L ECG in patients with chest pain and presumed ACS. This secondary analysis analyzed the incremental value of the 80L over the 12L in the detection of high-risk ECG abnormalities (ST-segment elevation or ST depression) in patients with MI and ACS, after eliminating all patients diagnosed with ST-elevation MI (STEMI) by 12L ECG.
Chest pain patients presenting to one of 12 academic EDs were diagnosed and treated according to the standard care of that site and its clinicians; the clinicians were blinded to 80L results. MI was defined by discharge diagnosis of non-ST-elevation MI (NSTEMI) or unstable angina (UA) with an elevated troponin. ACS was defined as discharge diagnosis of NSTEMI or UA with at least one positive test result (troponin, stress test, angiogram) or revascularization procedure.
Of the 1,830 patients enrolled in the trial, 91 patients with physician-diagnosed STEMI and 225 patients with missing 80L or 12L data were eliminated from the analysis; no discharge diagnosis was available for one additional patient. Of the remaining 1,513 patients, 408 had ACS, 206 had MI, and one had missing status. The sensitivity of the 80L was significantly higher than that of the 12L for detecting MI (19.4% vs. 10.4%, p = 0.0014) and ACS (12.3% vs. 7.1%, p = 0.0025). Specificities remained high for both tests, but were somewhat lower for 80L than for 12L for detecting both MI and ACS. Negative and positive likelihood ratios (LR) were not statistically different between groups. In patients with severe disease (defined by stenosis > 70% at catheterization, percutaneous coronary intervention, coronary artery bypass graft, or death from any cause), the 80L had significantly higher sensitivity for detecting MI (with equivalent specificity), but not ACS.
Among patients without ST elevation on the 12L ECG, the 80L body surface mapping technology detects more patients with MI or ACS than the 12L, while maintaining a high degree of specificity.
Academic Emergency Medicine 09/2010; 17(9):932-9. · 1.86 Impact Factor
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W Frank Peacock,
Eugene Braunwald,
William Abraham,
Nancy Albert,
John Burnett,
Rob Christenson,
Sean Collins, Deborah Diercks,
Greg Fonarow,
Judd Hollander, [......],
Phil Levy,
Alan Maisel,
Barry M Massie,
Christopher O'Connor,
Peter Pang,
Monica Shah,
George Sopko,
Lynne Stevenson,
Alan Storrow,
John Teerlink
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ABSTRACT: This paper details the substance and recommendations arising from a meeting convened by the National Heart, Lung, and Blood Institute in August 2009, to assess the challenges and opportunities of emergency department management of acute heart failure syndrome (AHFS). The assembled faculty represented a large cross section of medical professionals spanning the medical management continuum of patients presenting with acute heart failure and included heart failure cardiologists, emergency physicians, laboratory medicine specialists, nurses, and bench scientists. Their recommendations include proposals regarding the design and conduct of emergency department-based clinical trials, suggestions regarding the development of improved methods for early detection and monitoring of AHFS, and potential needs for expanding translational and applied AHFS focused research and biotechnology. We anticipate that this review will serve as a starting point for future investigations across the spectrum of funding sources.
Journal of the American College of Cardiology 07/2010; 56(5):343-51. · 14.16 Impact Factor
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ABSTRACT: Financial conflicts of interest have come under increasing scrutiny in medicine, but their impact has not been quantified. Our objective was to use the results of a national survey of academic emergency medicine (EM) faculty to determine if an association between money and personal opinion exists.
We conducted a web-based survey of EM faculty. Opinion questions were analyzed with regard to whether the respondent had either 1) received research grant money or 2) received money from industry as a speaker, consultant, or advisor. Responses were unweighted, and tests of differences in proportions were made using Chi-squared tests, with p<0.05 set for significance.
We received responses from 430 members; 98 (23%) received research grants from industry, while 145 (34%) reported fee-for-service money. Respondents with research money were more likely to be comfortable accepting gifts (40% vs. 29%) and acting as paid consultants (50% vs. 37%). They had a more favorable attitude with regard to societal interactions with industry and felt that industry-sponsored lectures could be fair and unbiased (52% vs. 29%). Faculty with fee-for-service money mirrored those with research money. They were also more likely to believe that industry-sponsored research produces fair and unbiased results (61% vs. 45%) and less likely to believe that honoraria biased speakers (49% vs. 69%).
Accepting money for either service or research identified a distinct population defined by their opinions. Faculty engaged in industry-sponsored research benefitted socially (collaborations), academically (publications), and financially from the relationship.
The western journal of emergency medicine 05/2010; 11(2):126-32.
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ABSTRACT: Risk-stratification in acute heart failure syndromes (AHFS) is problematic. A recent set of recommendations describes emergency department (ED) patients with AHFS who do not fulfill high-risk criteria and may be good candidates for observation unit (OU) management. The goal of this analysis was to report on the outcomes experienced by ED patients with AHFS who do not have any of these high-risk criteria.
We performed a secondary analysis of the HEart failure and Audicor technology for Rapid Diagnosis and Initial Treatment (HEARD-IT) multinational study. HEARD-IT was a multicenter study designed to test the impact of acoustic cardiography on ED decision making in patients with possible AHFS. For the purposes of the current analysis we identified a subset of HEARD-IT patients who did not fulfill any high-risk criteria based on published data. The proportion of these patients who experienced an adverse outcome was determined.
The 201 subjects who fulfilled the inclusion criteria had a mean age of 64 years (SD: 13), 61% were male, 34% were Caucasian, and 55% were black. There were a total of 25 (12.4%) cardiac events, including 1 death due to AHFS. The majority of the cardiac events were 30-day readmissions related to AHFS (16/25, 64.0%).
AHFS patients at low-risk for subsequent morbidity and mortality based on recent consensus guidelines may be good candidates for early discharge after a brief period of observation in the OU or ED. Additional prospective research is needed to determine the impact of implementation of these criteria in ED patients with AHFS.
Critical pathways in cardiology 10/2009; 8(3):99-103.
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ABSTRACT: Introduction. Prehospital electrocardiograms (ECGs) have been recommended to facilitate early diagnosis of ST-segment elevation myocardial infarction (STEMI). However, prehospital ECGs can also be used to triage patients with non-ST-segment elevation acute coronary syndromes, who comprise a majority of patients with ischemic events presenting by ambulance to overcrowded emergency departments. Objective. We assessed the frequency of non-ST-segment elevation injury patterns on prehospital ECGs in patients with a chief complaint of chest pain evaluated by the emergency medical services (EMS) system. Methods. We analyzed prehospital ECGs of patients with the chief complaint of chest pain during a nine-month period. The ECGs were divided into three categories: injury pattern; no injury pattern; and technically uninterpretable. Injury pattern criteria were as follows: 1) regional ST depression >/=1.0 mm; 2) regional T-wave inversion (TWI) >/=3 mm; 3) left bundle branch block (LBBB); and 4) regional ST-segment elevation >/=1.0 mm. Descriptive statistics with 95% confidence intervals (CIs) are presented. Results. Prehospital ECGs were obtained for 322 of 340 chest pain patients: 72% were men; the average age was 60 years (range 18-96 years). Seventy-seven ECGs (24%, 95% CI 19.3-28.9%) met the criteria for injury pattern, 230 (71%) did not show injury, and 15 (5%) were uninterpretable. Of the 77 ECGs that exhibited an injury pattern, 39 (51%) showed ST depression, seven (9%) TWI, seven (9%) LBBB, and 24 (31%) ST-segment elevation. Thus, non-ST-segment elevation injury patterns (ST depression/TWI/LBBB) accounted for 53 (17%, 95% CI 12.6-20.9) of the total 322 prehospital ECGs. Conclusion. Our findings demonstrate a relatively high frequency (17%) of non-ST-segment elevation injury patterns on prehospital ECGs of patients who summon EMS because of chest pain. These results suggest the potential of prehospital ECGs to facilitate early triage in these high-risk chest pain patients who present to overcrowded emergency departments.
Prehospital Emergency Care 08/2009; · 1.78 Impact Factor
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ABSTRACT: The acute coronary syndromes include ST elevation myocardial infarction, non-ST elevation myocardial infarction, and unstable
angina. The latter two conditions are distinguished by evidence of myocardial infarction based on the elevation of cardiac
injury markers. The underlying pathophysiology in the great majority of patients with ACS is atherothrombosis, which encompasses
chronic coronary atherosclerotic disease and superimposed acute thrombotic occlusion. Rupture of a coronary atherosclerotic
plaque initiates platelet activation and thrombotic coronary occlusion as well as a cascade of clotting mechanisms and inflammatory
agents that contribute to myocardial ischemia and necrosis. Patients typically present with chest discomfort but a variety
of ischemic equivalents may also predominate (dyspnea, lightheadedness, and cardiac failure). Typically, total coronary occlusion
is associated with ST-segment elevation and elevation of injury markers of necrosis. With partial occlusion, there are usually
ST and/or T wave abnormalities. All ACS patients are treated with intensive antithrombotic and anticoagulation therapy, as
well management of associated problems such as ischemia heart failure and arrhythmias. Optimal treatment of ST elevation infarction
is urgent coronary reperfusion, preferably by percutaneous coronary intervention (PCI). Non-ST elevation ACS patients receive
comprehensive medical therapy and the majority undergo invasive evaluation within 48 hours of admission to determine their
suitability for revascularization by PCI (˜90% of patients) or coronary bypass surgery (˜10% of patients). Of importance is
the finding that, although mortality and morbidity of ST elevation infarction are higher than with non-ST elevation ACS during
the acute phase, long-term prognosis is worse with non-ST elevation ACS. Therefore, intensive, acute, and long-term management
of all patients with ACS is crucial and includes antithrombotic therapy, management of coronary risk factors, and treatment
of associated cardiac conditions.
KeywordsAcute coronary syndromes–Atherothrombosis–Plaque rupture–Platelet activation–Thrombosis–Coronary occlusion–Antithrombotic therapy–Percutaneous coronary intervention–Coronary bypass surgery
06/2009: pages 55-65;
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ABSTRACT: Optimizing heart failure management begins in the emergency department. Prompt recognition and treatment of underlying pathophysiology can improve patient outcomes. A review of therapeutic options is provided, with the goal of providing best practices in patient care.
Heart Failure Clinics 02/2009; 5(1):37-42, vi.
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ABSTRACT: The authors surveyed the membership of the Society for Academic Emergency Medicine (SAEM) about their associations with industry and predictors of those associations.
A national Web-based survey inviting faculty from the active member list of SAEM was conducted. Follow-up requests for participation were sent weekly for 3 weeks. Information was collected on respondents' personal and practice characteristics, industry interactions, and personal opinions regarding these interactions. Raw response rates were reported and a logistic regression was used to generate descriptive statistics.
Responses were received from 430 members, representing 14% of the 3,183 active members. Respondents were 83% male and 86% white, with 96% holding an MD degree (24% with an additional postdoctoral degree). Most were at the assistant (37%) or associate (25%) professor rank, with 51% holding at least one leadership position. Most respondents (82%) reported some type of industry interaction, most commonly the acceptance of food or beverages (67%). Respondents at the associate professor rank or higher were more likely to receive payments from industry (51% vs. 22%, odds ratio [OR] = 3.7).
This survey suggests that interactions between industry and academic EM faculty are common and increase with academic rank, but not with years in practice or leadership influence. The number and type of interactions are consistent with those reported by a national sampling of other physician specialties.
Academic Emergency Medicine 10/2008; 15(9):819-24. · 1.86 Impact Factor
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ABSTRACT: Cardiac troponin provides diagnostic and prognostic information in acute coronary syndromes, but its role in acute decompensated heart failure is unclear. The purpose of our study was to describe the association between elevated cardiac troponin levels and adverse events in hospitalized patients with acute decompensated heart failure.
We analyzed hospitalizations for acute decompensated heart failure between October 2001 and January 2004 that were recorded in the Acute Decompensated Heart Failure National Registry (ADHERE). Entry criteria included a troponin level that was obtained at the time of hospitalization in patients with a serum creatinine level of less than 2.0 mg per deciliter (177 micromol per liter). A positive troponin test was defined as a cardiac troponin I level of 1.0 microg per liter or higher or a cardiac troponin T level of 0.1 microg per liter or higher.
Troponin was measured at the time of admission in 84,872 of 105,388 patients (80.5%) who were hospitalized for acute decompensated heart failure. Of these patients, 67,924 had a creatinine level of less than 2.0 mg per deciliter. Cardiac troponin I was measured in 61,379 patients, and cardiac troponin T in 7880 patients (both proteins were measured in 1335 patients). Overall, 4240 patients (6.2%) were positive for troponin. Patients who were positive for troponin had lower systolic blood pressure on admission, a lower ejection fraction, and higher in-hospital mortality (8.0% vs. 2.7%, P<0.001) than those who were negative for troponin. The adjusted odds ratio for death in the group of patients with a positive troponin test was 2.55 (95% confidence interval, 2.24 to 2.89; P<0.001 by the Wald test).
In patients with acute decompensated heart failure, a positive cardiac troponin test is associated with higher in-hospital mortality, independently of other predictive variables. (ClinicalTrials.gov number, NCT00366639 [ClinicalTrials.gov].).
New England Journal of Medicine 05/2008; 358(20):2117-26. · 53.30 Impact Factor
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ABSTRACT: Venous thromboembolism (VTE) is a concerning problem for hospitalized heart failure (HF) patients. Current recommendations are that all hospitalized New York Heart Association Class III or IV HF patients should receive VTE prophylaxis. Our purpose was to describe the rate of use and the characteristics of patients receiving VTE prophylaxis in the Acute Decompensated Heart Failure National Registry (ADHERE).
HF hospitalization episodes in ADHERE were analyzed. Patients were excluded from analysis if they were receiving Coumadin or intravenous heparin, had elevated troponin levels, underwent cardiac catheterization or dialysis before or during hospitalization, or were initially admitted to the intensive care unit. VTE prophylaxis was defined as low-molecular-weight or subcutaneous unfractionated heparin administered at any time during hospitalization and intravenous vasoactive therapy was defined as any inotrope, inodilator, or vasodilator. Chi-square, analysis of variance, and Wilcoxon tests were used for univariate and multivariate analyses. Logistic regression was used to evaluate outcomes. A total of 155,073 entries were evaluated, with 71,376 eligible for VTE prophylaxis; 21,847 (31%) received VTE prophylaxis. VTE prophylaxis patients were more often African American (28% versus 21%) or admitted from the emergency department (84% versus 79%), compared with those who did not receive VTE prophylaxis (both P < .0001). Medical history and initial presentation characteristics were similar, except edema, which was more likely in VTE prophylaxis patients (71% versus 66%, P < .0001). Patients receiving VTE prophylaxis more often received an intravenous vasoactive agent (23% versus 18%), angiotensin-converting enzyme inhibitor (61% versus 54%), or beta-blocker (63% versus 58%) during their hospitalization and were more likely discharged on an angiotensin-converting enzyme inhibitor (53% versus 49%) or beta-blocker (57% versus 54%) than non-VTE prophylaxis patients, all P < .0001. VTE prophylaxis patients were more often admitted to the intensive care unit (4.8% versus 2.5%, P < .0001) and had longer median hospital stays (4.2 versus 3.8 days, P < .0001). Mortality was similar between cohorts (3.0% versus 2.9%, P = .69).
Despite recommendations that all hospitalized New York Heart Association III and IV CHF patients receive venous thromboembolic disease prophylaxis, less than one third of eligible patients receive this guideline recommended therapy.
Journal of cardiac failure 04/2008; 14(2):127-32. · 3.25 Impact Factor
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ABSTRACT: We sought to determine U.S. physicians' knowledge and perspectives regarding the 2004 American College of Cardiology/American Heart Association guidelines for management of patients who have ST-segment-elevation myocardial infarction (STEMI). We invited 45,998 physicians from the American Medical Association's roster to take an Internet survey of U.S. cardiologists and emergency physicians who were hospital-based or who had hospital-admitting privileges. To represent individual and combined populations, data were weighted on the basis of years in practice, sex, and geographic region. Of 505 cardiologists and 509 emergency physicians who completed the survey, 90% worked in an urban or suburban setting and 82% at hospitals with a cardiac catheterization laboratory. Sampling error was +/-3.4%. Most respondents (61%) believed that overall myocardial infarction treatment needed a "great deal" or "fair amount" of improvement; 24% were "somewhat" or "not at all" familiar with the guidelines. Although 84% knew the recommended STEMI treatments for a patient who presents within 3 hours of symptom onset without contraindications to reperfusion or delay to invasive treatment, only 11% knew that there is no preferred approach. If percutaneous coronary intervention proved impossible within 90 minutes of presentation, 21% reported that eligible patients--assuming early presentation, confirmed STEMI diagnosis, and no high-risk STEMI or contraindications to fibrinolysis--would "rarely" or "never" receive guideline-recommended fibrinolysis. Many cardiologists and emergency physicians are unfamiliar with the guidelines and with the uncertainty that surrounds therapeutic approaches, which suggests the need for increased education on effective treatments to expedite myocardial reperfusion in STEMI.
Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital 02/2008; 35(2):152-61. · 0.65 Impact Factor
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Critical pathways in cardiology 07/2007; 6(2):64-6.
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Christopher J Lindsell,
Venkataraman Anantharaman, Deborah Diercks,
Jin Ho Han,
James W Hoekstra,
Judd E Hollander,
J Douglas Kirk,
Swee-Han Lim,
W Frank Peacock,
Brian Tiffany,
Eric K Wilke,
W Brian Gibler,
Charles V Pollack
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ABSTRACT: Observational studies of well-described patient populations presenting to emergency departments (EDs) with suspicion of acute coronary syndrome are necessary to understand the relationships between patients' signs and symptoms, cardiac risk profile, test results, practice patterns, and outcomes. We describe the methods for data collection and the ED population enrolled in a multicenter registry of patients with chest pain.
Patients older than 18 years, presenting to one of 8 EDs in the United States or 1 ED in Singapore, and with possible acute coronary syndrome were enrolled in the Internet Tracking Registry of Acute Coronary Syndromes between June 1999 and August 2001. Prospective data, including presenting signs and symptoms, ECG findings, and the ED physician's initial impression of risk, were systematically collected. Medical record review or daily follow-up was used to obtain cardiac biomarker results, invasive and noninvasive testing, treatments, procedures, and inhospital outcomes. Thirty-day outcomes were determined by telephone follow-up and medical record review.
The registry includes 15,608 patients, with 17,713 visits. Chest pain was the chief complaint in 71% of visits. The ECG was diagnostic of ischemia or infarction in 10.1% and positive cardiac biomarkers were observed in 10% of visits. Forty-three percent of patients were sent home directly from the ED. Of admitted patients, 5% died by 30 days, and 3% had documented coronary artery disease or had undergone percutaneous coronary intervention or coronary artery bypass grafting within 30 days. For patients discharged directly from the ED, 0.4% died or had a documented myocardial infarction within 30 days. Coronary artery bypass graft surgery, percutaneous coronary intervention, or a diagnosis of coronary artery disease was found in 0.5% of discharged patients.
A unique description of undifferentiated ED chest pain patients with suspected acute coronary syndrome is provided. The data set can be used to generate and explore hypotheses to improve understanding of the complex relationships between presentation, treatment, testing, intervention and outcomes.
Annals of emergency medicine 01/2007; 48(6):666-77, 677.e1-9. · 4.23 Impact Factor
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ABSTRACT: Studies have shown that the addition of right precordial and left posterior leads to the standard 12-lead electrocardiogram (ECG) can significantly improve the sensitivity of exercise treadmill testing (ETT) for the diagnosis of myocardial ischemia.
The objective of this study was to determine the value of adding 2 rightsided (RV3, RV4) and 2 left posterior (V8, V9) auxiliary leads to enhance detection of myocardial ischemia in patients with chest pain identified as low risk.
The authors conducted a prospective study of all patients undergoing ETT as part of their management in a chest pain evaluation unit (CPEU) at a tertiary medical center from November 1999 to November 2001. Patients were considered low risk for acute coronary syndrome based on the clinical presentation to the CPEU, absence of ischemia on resting ECG, and negative initial cardiac markers. Diagnosis of coronary artery disease (CAD) was based on confirmatory testing, which included coronary angiography, myocardial stress scintigraphy, exercise echocardiography, or 30-day follow-up period.
The study cohort comprised 705 patients who underwent 16-lead ETT. Of these, 70 (10%) had positive ETT and CAD was confirmed by further evaluation in 26. ECG changes positive for ischemia were demonstrated on the standard 12-lead exercise ECG in 68 patients. An additional 2 patients had positive ECG alterations only in the 4 auxiliary leads on the 16-lead ECG. There was no significant difference in the sensitivity or positive predictive value between the 12- and 16-lead exercise ECG.
Electrocardiographic changes in auxiliary leads did not change the diagnostic use of the ETT and therefore may provide only a minimal contribution to the assessment of the low-risk CPEU population.
Critical pathways in cardiology 07/2006; 5(2):123-6.
