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Verardi R, Iannopollo G, Casolari G, Nobile G, Capecchi A, Bruno M, Lanzilotti V, Casella G. Management of Acute Coronary Syndrome in Elderly Patients: A Narrative Review through Decisional Crossroads. J Clin Med 2024; 13:6034. [PMID: 39457985 PMCID: PMC11508245 DOI: 10.3390/jcm13206034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2024] [Revised: 10/01/2024] [Accepted: 10/02/2024] [Indexed: 10/28/2024] Open
Abstract
Diagnosis and treatment of acute coronary syndrome (ACS) pose particular challenges in elderly patients. When high troponin levels are detected, the distinction between non-ischemic myocardial injury (NIMI), type 1, and type 2 myocardial infarction (MI) is the necessary first step to guide further care. However, the assessment of signs of ischemia is hindered in older patients, and no simple clinical or laboratory tool proved useful in this discrimination task. Current evidence suggests a benefit of an invasive vs. conservative approach in terms of recurrence of MI, with no significant impact on mortality. In patients with multivessel disease in which the culprit lesion has been treated, a physiology-guided complete percutaneous revascularization significantly reduced major events. The management of ACS in elderly patients is an example of the actual need for a multimodal, thorough clinical approach, coupled with shared decision-making, in order to ensure the best treatment and avoid futility. Such a need will likely grow throughout the next decades, with the aging of the world population. In this narrative review, we address pivotal yet common questions arising in clinical practice while caring for elderly patients with ACS.
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Affiliation(s)
- Roberto Verardi
- Ospedale Maggiore Carlo Alberto Pizzardi, Largo Nigrisoli 2, 40133 Bologna, Italy; (G.I.); (G.N.); (A.C.); (M.B.); (V.L.); (G.C.)
| | - Gianmarco Iannopollo
- Ospedale Maggiore Carlo Alberto Pizzardi, Largo Nigrisoli 2, 40133 Bologna, Italy; (G.I.); (G.N.); (A.C.); (M.B.); (V.L.); (G.C.)
| | - Giulia Casolari
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro 8, 44124 Cona, Italy
| | - Giampiero Nobile
- Ospedale Maggiore Carlo Alberto Pizzardi, Largo Nigrisoli 2, 40133 Bologna, Italy; (G.I.); (G.N.); (A.C.); (M.B.); (V.L.); (G.C.)
| | - Alessandro Capecchi
- Ospedale Maggiore Carlo Alberto Pizzardi, Largo Nigrisoli 2, 40133 Bologna, Italy; (G.I.); (G.N.); (A.C.); (M.B.); (V.L.); (G.C.)
| | - Matteo Bruno
- Ospedale Maggiore Carlo Alberto Pizzardi, Largo Nigrisoli 2, 40133 Bologna, Italy; (G.I.); (G.N.); (A.C.); (M.B.); (V.L.); (G.C.)
| | - Valerio Lanzilotti
- Ospedale Maggiore Carlo Alberto Pizzardi, Largo Nigrisoli 2, 40133 Bologna, Italy; (G.I.); (G.N.); (A.C.); (M.B.); (V.L.); (G.C.)
| | - Gianni Casella
- Ospedale Maggiore Carlo Alberto Pizzardi, Largo Nigrisoli 2, 40133 Bologna, Italy; (G.I.); (G.N.); (A.C.); (M.B.); (V.L.); (G.C.)
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Wang AZ, Hunter BR. Troponin or not troponin, what is the (clinical) question? Acad Emerg Med 2024; 31:944-946. [PMID: 38511483 DOI: 10.1111/acem.14900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 03/22/2024]
Affiliation(s)
- Alfred Z Wang
- West Sound Emergency Physicians, Seattle, Washington, USA
| | - Benton R Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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3
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Espejo T, Terhalle L, Malinovska A, Riedel HB, Arntz L, Hafner L, Delport-Lehnen K, Zuppinger J, Geigy N, Leuppi J, Somasundaram R, Bingisser R, Nickel CH. Diagnostic and prognostic value of cardiac troponins in emergency department patients presenting after a fall: A prospective, multicenter study. Acad Emerg Med 2024; 31:860-869. [PMID: 38532263 DOI: 10.1111/acem.14897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/04/2024] [Accepted: 01/23/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Emergency department (ED) presentations after a ground-level fall (GLF) are common. Falls were suggested to be another possible presenting feature of a myocardial infarction (MI), as unrecognized MIs are common in older adults. Elevated high-sensitivity cardiac troponin (hs-cTn) concentrations could help determine the etiology of a GLF in ED. We investigated the prevalence of both MI and elevated high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI), as well as the diagnostic accuracy of hs-cTnT and hs-cTnI regarding MI, and their prognostic value in older ED patients presenting after a GLF. METHODS This was a prospective, international, multicenter, cohort study with a follow-up of up to 1 year. Patients aged 65 years or older presenting to the ED after a GLF were prospectively enrolled. Two outcome assessors independently reviewed all discharge records to ascertain final gold standard diagnoses. Hs-cTnT and hs-cTnI levels were determined from thawed samples for every patient. RESULTS In total, 558 patients were included. Median (IQR) age was 83 (77-89) years, and 67.7% were female. Elevated hs-cTnT levels were found in 384 (68.8%) patients, and elevated hs-cTnI levels in 86 (15.4%) patients. Three patients (0.5%) were ascertained the gold standard diagnosis MI. Within 30 days, 18 (3.2%) patients had died. Nonsurvivors had higher hs-cTnT and hs-cTnI levels compared with survivors (hs-cTnT 40 [23-85] ng/L in nonsurvivors and 20 [13-33] ng/L in survivors; hs-cTnI 25 [14-54] ng/L in nonsurvivors and 8 [4-16] ng/L in survivors; p < 0.001 for both). CONCLUSIONS A majority of patients (n = 364, 68.8%) presenting to the ED after a fall had elevated hs-cTnT levels and 86 (15.4%) elevated hs-cTnI levels. However, the incidence of MI in these patients was low (n = 3, 0.5%). Our data do not support the opinion that falls may be a common presenting feature of MI. We discourage routine troponin testing in this population. However, hs-cTnT and hs-cTnI were both found to have prognostic properties for mortality prediction up to 1 year.
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Affiliation(s)
- Tanguy Espejo
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Lukas Terhalle
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alexandra Malinovska
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Henk B Riedel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Laura Arntz
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Livia Hafner
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Joanna Zuppinger
- Emergency Department, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Nicolas Geigy
- Emergency Department, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Jörg Leuppi
- Medical Faculty University of Basel and Cantonal Hospital Baselland, Liestal, Switzerland
| | - Rajan Somasundaram
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
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4
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Narendren A, Whitehead N, Burrell LM, Yudi MB, Yeoh J, Jones N, Weinberg L, Miles LF, Lim HS, Clark DJ, Al-Fiadh A, Farouque O, Koshy AN. Management of Acute Coronary Syndromes in Older People: Comprehensive Review and Multidisciplinary Practice-Based Recommendations. J Clin Med 2024; 13:4416. [PMID: 39124683 PMCID: PMC11312870 DOI: 10.3390/jcm13154416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024] Open
Abstract
Managing health care for older adults aged 75 years and older can pose unique challenges stemming from age-related physiological differences and comorbidities, along with elevated risk of delirium, frailty, disability, and polypharmacy. This review is aimed at providing a comprehensive analysis of the management of acute coronary syndromes (ACS) in older patients, a demographic substantially underrepresented in major clinical trials. Because older patients often exhibit atypical ACS symptoms, a nuanced diagnostic and risk stratification approach is necessary. We aim to address diagnostic challenges for older populations and highlight the diminished sensitivity of traditional symptoms with age, and the importance of biomarkers and imaging techniques tailored for older patients. Additionally, we review the efficacy and safety of pharmacological agents for ACS management in older people, emphasizing the need for a personalized and shared decision-making approach to treatment. This review also explores revascularization strategies, considering the implications of invasive procedures in older people, and weighing the potential benefits against the heightened procedural risks, particularly with surgical revascularization techniques. We explore the perioperative management of older patients experiencing myocardial infarction in the setting of noncardiac surgeries, including preoperative risk stratification and postoperative care considerations. Furthermore, we highlight the critical role of a multidisciplinary approach involving cardiologists, geriatricians, general and internal medicine physicians, primary care physicians, and allied health, to ensure a holistic care pathway in this patient cohort.
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Affiliation(s)
- Ahthavan Narendren
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Cardiology, Northern Health, Epping, VIC 3076, Australia
| | - Natalie Whitehead
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
| | - Louise M. Burrell
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Matias B. Yudi
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
| | - Julian Yeoh
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
| | - Nicholas Jones
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Laurence Weinberg
- Department of Critical Care, The University of Melbourne, Melbourne, VIC 3010, Australia; (L.W.); (L.F.M.)
- Department of Anaesthesia, Austin Health, Heidelberg, VIC 3084, Australia
| | - Lachlan F. Miles
- Department of Critical Care, The University of Melbourne, Melbourne, VIC 3010, Australia; (L.W.); (L.F.M.)
- Department of Anaesthesia, Austin Health, Heidelberg, VIC 3084, Australia
| | - Han S. Lim
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Cardiology, Northern Health, Epping, VIC 3076, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - David J. Clark
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Ali Al-Fiadh
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Anoop N. Koshy
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Parkville, VIC 3052, Australia
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Thonon H, Van Nieuwenhove M, Thachil J, Lippi G, Hardy M, Mullier F. Hemostasis Testing in the Emergency Department: A Narrative Review. Semin Thromb Hemost 2024. [PMID: 38897223 DOI: 10.1055/s-0044-1787661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Routine laboratory screening is typically performed at initial evaluation of the vast majority of presentations to the emergency department (ED). These laboratory results are crucial to the diagnostic process, as they may influence up to 70% of clinical decisions. However, despite the usefulness of biological assessments, many tests performed are inappropriate or of doubtful clinical relevance. This overutilization rate of laboratory testing in hospitals, which represents a significant medical-economic burden, ranges from 20 to 67%, with coagulation tests at the top of the list. While reviews frequently focus on nonintensive care units, there are few published assessments of emergency-specific interventions or guidelines/guidance to date. The aim of this review is to highlight current recommendations for hemostasis evaluation in the emergency setting with a specific analysis of common situations leading to ED admissions, such as suspected venous thrombosis or severe bleeding. We revisit the evidence related to the assessment of patient's hemostatic capacity based on comprehensive history taking and physical examination as well as best practice recommendations for blood sample collection to ensure the reliability of results. This review also includes an examination of various currently available point of care tests and a comprehensive discussion on indications, limitations, and interpretation of these tests.
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Affiliation(s)
- Henri Thonon
- Emergency Department, Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Yvoir, Belgium
| | | | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, United Kingdom
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Michael Hardy
- Department of Anesthesiology, Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Yvoir, Belgium
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Hematology Laboratory, Yvoir, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle Mont, Université catholique de Louvain (UCLouvain), Yvoir, Belgium
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Ticinesi A, Nouvenne A, Cerundolo N, Prati B, Parise A, Tana C, Rendo M, Guerra A, Meschi T. Accounting for frailty and multimorbidity when interpreting high-sensitivity troponin I tests in oldest old. J Am Geriatr Soc 2021; 70:549-559. [PMID: 34792185 PMCID: PMC9299120 DOI: 10.1111/jgs.17566] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 12/17/2022]
Abstract
Background Older patients evaluated in Emergency Departments (ED) for suspect Myocardial Infarction (MI) frequently exhibit unspecific elevations of serum high‐sensitivity troponin I (hs‐TnI), making interpretation particularly challenging for emergency physicians. The aim of this longitudinal study was to identify the interaction of multimorbidity and frailty with hs‐TnI levels in older patients seeking emergency care. Methods A group of patients aged≥75 with suspected MI was enrolled in our acute geriatric ward immediately after ED visit. Multimorbidity and frailty were measured with Cumulative Illness Rating Scale (CIRS) and Clinical Frailty Scale (CFS), respectively. The association of hs‐TnI with MI (main endpoint) was assessed by calculation of the Area Under the Receiver‐Operating Characteristic Curve (AUROC), deriving population‐specific cut‐offs with Youden test. The factors associated with hs‐TnI categories, including MI, CFS and CIRS, were determined with stepwise multinomial logistic regression. The association of hs‐TnI with 3‐month mortality (secondary endpoint) was also investigated with stepwise logistic regression. Results Among 268 participants (147 F, median age 85, IQR 80–89), hs‐TnI elevation was found in 191 cases (71%, median 23 ng/L, IQR 11–65), but MI was present in only 12 cases (4.5%). hs‐TnI was significantly associated with MI (AUROC 0.751, 95% CI 0.580–0.922, p = 0.003), with an optimal cut‐off of 141 ng/L. hs‐TnI levels ≥141 ng/L were significantly associated with CFS (OR 1.58, 95% CI 1.15–2.18, p = 0.005), while levels <141 ng/L were associated with the cardiac subscore of CIRS (OR 1.36, 95% CI 1.07–1.71, p = 0.011). CFS, but not hs‐TnI levels, predicted 3‐month mortality. Conclusions In geriatric patients with suspected MI, frailty and cardiovascular multimorbidity should be carefully considered when interpreting emergency hs‐TnI testing.
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Affiliation(s)
- Andrea Ticinesi
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Antonio Nouvenne
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Nicoletta Cerundolo
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Beatrice Prati
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Alberto Parise
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Claudio Tana
- Internal Medicine Unit and Geriatrics Clinic, SS Annunziata Hospital, Chieti, Italy
| | - Martina Rendo
- Primary Care Department, Parma District, Azienda Unità Sanitaria Locale di Parma, Parma, Italy
| | - Angela Guerra
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Tiziana Meschi
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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7
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Samara I, Tsiara S, Papafaklis MI, Pappas K, Kolios G, Vryzas N, Michalis LK, Bairaktari ET, Katsouras CS. Elderly patients with non-cardiac admissions and elevated high-sensitivity troponin: the prognostic value of renal function. World J Cardiol 2021; 13:566-573. [PMID: 34754401 PMCID: PMC8554362 DOI: 10.4330/wjc.v13.i10.566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 06/27/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND High-sensitivity cardiac troponin (hs-cTn) levels are frequently elevated in elderly patients presenting to the emergency department for non-cardiac events. However, most studies on the role of elevated hs-cTn in elderly populations have investigated the prognostic value of hs-cTn in patients with a specific diagnosis or have assessed the relationship between hs-cTn and comorbidities. AIM To investigate the in-hospital prognosis of consecutive elderly patients admitted to the Internal Medicine Department with acute non-cardiac events and increased hs-cTnI levels. METHODS In this retrospective study, we selected patients who were aged ≥ 65 years and admitted to the Internal Medicine Department of our hospital between January 2019 and December 2019 for non-cardiac reasons. Eligible patients were those who had hs-cTnI concentrations ≥ 100 ng/L. We investigated the independent predictors of in-hospital mortality by multivariable logistic regression analysis. RESULTS One hundred and forty-six patients (59% female) were selected with an age range from 65 to 100 (mean ± SD: 85.4 ± 7.61) years. The median hs-cTnI value was 284.2 ng/L. For 72 (49%) patients the diagnosis of hospitalization was an infectious disease. The overall in-hospital mortality was 32% (47 patients). Individuals who died did not have higher hs-cTnI levels compared with those who were discharged alive (median: 314.8 vs 282.5 ng/L; P = 0.565). There was no difference in mortality in patients with infectious vs non-infectious disease (29% vs 35%). Multivariable analysis showed that age (OR 1.062 per 1 year increase, 95%CI: 1.000-1.127; P = 0.048) and creatinine levels (OR 2.065 per 1 mg/dL increase, 95%CI: 1.383-3.085; P < 0.001) were the only independent predictors of death. Mortality was 49% in patients with eGFR < 30 mL/min/1.73 m2. CONCLUSION Myocardial injury is a malignant condition in elderly patients admitted to the hospital for non-cardiac reasons. The presence of severe renal impairment is a marker of extremely high in-hospital mortality.
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Affiliation(s)
- Ioanna Samara
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina 45110, Greece
| | - Stavroula Tsiara
- Second Department of Internal Medicine, University Hospital of Ioannina, Ioannina 45110, Greece
| | - Michail I Papafaklis
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina 45110, Greece
| | - Konstantinos Pappas
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina 45110, Greece
| | - Georgios Kolios
- Laboratory of Biochemistry, University Hospital of Ioannina, Ioannina 45110, Greece
| | - Nikolaos Vryzas
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina 45110, Greece
| | - Lampros K Michalis
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina 45110, Greece
| | - Eleni T Bairaktari
- Laboratory of Clinical Chemistry, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina 45110, Greece
| | - Christos S Katsouras
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina 45110, Greece.
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8
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Allen R, Cai AG, Tepler P, deSouza IS. The "NUTS" statistic: Applying an EBM disease model to defensive medicine. J Healthc Risk Manag 2021; 41:9-12. [PMID: 34528329 DOI: 10.1002/jhrm.21486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/11/2021] [Accepted: 08/20/2021] [Indexed: 12/28/2022]
Abstract
Physicians believe that malpractice concerns result in unnecessary testing, and many emergency physicians state that avoiding malpractice is a contributing factor to ordering medically unnecessary tests. Unfortunately, defensive medicine does not come without possible harm to patients who may be subject to non-beneficial, downstream testing, procedures, and hospitalizations. We submit a novel statistic, "NUTS" or "Number of Unnecessary Tests to avoid one Suit. " We calculated a NUTS of 4737 for troponin testing in ED patients with suspected myocardial infarction, meaning a clinician will need to order 4737 medically unnecessary troponin tests to avoid one missed myocardial infarction lawsuit. The NUTS framework offers us an evidence-based lens to examine defensive medicine less superstitiously and more based on currently available data.
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Affiliation(s)
- Robert Allen
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, USA.,Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, New York, USA
| | - Angela G Cai
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, USA.,Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, New York, USA
| | - Peter Tepler
- Department of Emergency Medicine, Jackson South Medical Center, Miami, Florida, USA
| | - Ian S deSouza
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, USA.,Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, New York, USA
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9
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Abstract
When older adults experience acute coronary syndrome (ACS), they often present with what are considered "atypical" symptoms. Because their symptoms less often match the expected presentation of ACS, older patients can have delayed time to assessment, to performance of an electrocardiogram, to diagnosis, and to definitive management. Unfortunately, it is this very group of patients who are at the highest risk for having ACS and for complications from ACS. This article aims to outline presentation, outcomes, and potential solutions of underrecognition of ACS in the older adult population.
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10
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Bylund WE, Cole PM, Lloyd ML, Mercer AA, Osit AK, Hussain SW, Lawrence MW, Gaspary MJ. Effect of Implementation of HEART Chest Pain Protocol on Emergency Department Disposition, Testing and Cost. West J Emerg Med 2021; 22:308-318. [PMID: 33856317 PMCID: PMC7972363 DOI: 10.5811/westjem.2020.9.48903] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/25/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Symptoms concerning for acute coronary syndromes (ACS) such as chest pain and dyspnea are some of the most common reasons for presenting to an emergency department (ED). The HEART score (history, electrocardiogram, age, risk factors and troponin) was developed and has been externally validated in an emergency setting to determine which patients with chest pain are at increased risk for poor outcomes. Our hospital adopted a HEART score-based protocol in late 2015 to facilitate the management and disposition of these patients. In this study we aimed to analyze the effects of the adoption of this protocol. Prior studies have included only patients with chest pain. We included both patients with chest pain and patients with only atypical symptoms. METHODS This was a retrospective chart review of two cohorts. We identified ED charts from six-month periods prior to and after adoption of our HEART score-based protocol. Patients in whom an electrocardiogram and troponin were ordered were eligible for inclusion. We analyzed data for patients with typical symptoms (chest pain) and atypical symptoms both together and separately. RESULTS We identified 1546 charts in the pre-adoption cohort and 1623 in the post-adoption cohort that met criteria. We analyzed the first 900 charts in each group. Discharges from the ED increased (odds ratio [OR[1.56, P<.001), and admissions for cardiac workup decreased (OR 0.46, P <.001). ED length of stay was 17 minutes shorter (P = .01). Stress testing decreased (OR 0.47, P<.001). We estimate a cost savings for our hospital system of over $4.5 million annually. There was no significant difference in inpatient length of stay or catheterization rate. When analyzing typical and atypical patients separately, these results held true. CONCLUSION After adoption of a HEART score-based protocol, discharges from the ED increased with a corresponding decrease in admissions for cardiac evaluations as well as cost. These effects were similar in patients presenting without chest pain but with presentations concerning for ACS.
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Affiliation(s)
- William E Bylund
- Naval Medical Center Portsmouth, Department of Emergency Department, Portsmouth, Virginia
| | - Peter M Cole
- Naval Medical Center Portsmouth, Department of Emergency Department, Portsmouth, Virginia
| | - Michael L Lloyd
- Naval Medical Center Portsmouth, Department of Emergency Department, Portsmouth, Virginia
| | - Anastasia A Mercer
- Naval Medical Center Portsmouth, Department of Emergency Department, Portsmouth, Virginia
| | - Amanda K Osit
- Naval Medical Center Portsmouth, Department of Emergency Department, Portsmouth, Virginia
| | - Sarah W Hussain
- Naval Medical Center Portsmouth, Department of Emergency Department, Portsmouth, Virginia
| | - Matthew W Lawrence
- Naval Medical Center Portsmouth, Department of Emergency Department, Portsmouth, Virginia
| | - Micah J Gaspary
- Naval Medical Center Portsmouth, Department of Emergency Department, Portsmouth, Virginia
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Tscherny K, Kienbacher C, Fuhrmann V, Schreiber W, Herkner H, Roth D. Early identification of patients with chest pain at very low risk of acute myocardial infarction using clinical information and ECG only. Int J Clin Pract 2020; 74:e13526. [PMID: 32383504 PMCID: PMC7507208 DOI: 10.1111/ijcp.13526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/02/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND A considerable proportion of patients with angina-like symptoms in an emergency department have very low pretest probability for acute myocardial infarction (AMI). Numerous algorithms exist for the exclusion of AMI, usually including laboratory tests. We aimed to investigate whether patients with very low risk can safely be identified by ECG and clinical information without biomarker testing, contributing to saving time and costs. METHODS Prospective diagnostic test accuracy study. We included all consecutive patients presenting with angina at the department of emergency medicine of a tertiary care hospital during a 1-year period. Using clinical information without biomarker testing and ECG, the "Mini-GRACE score," based on the well-established GRACE-score without using laboratory parameters was calculated. In a cohort design we compared the index test Mini-GRACE to AMI as reference standard in the final diagnosis using standard measures of diagnostic test accuracy. RESULTS We included 2755 patients (44% female, age 44 ± 17 years). AMI was diagnosed in 103 (4%) patients, among those 44% with STEMI. Overall 2562 patients (93%) had a negative "Mini-GRACE," four (0.2%) of these patients had myocardial infarction, and this results in a sensitivity of 96.1% (95% CI 90.4%-98.9%), specificity 96.5% (95.7%-97.1%), positive predictive value 51.3% (46.3%-56.3%) and negative predictive value 99.8% (99.6%-99.9%). Model performance according to C statistic (0.90) and Brier score (0.0045) was excellent. In rule-out patients 30-day mortality was 0.3% and 1-year mortality was 0.8%. CONCLUSIONS Patients with very low risk of AMI can be identified with high certainty using clinical information without biomarker testing and ECG. Cardiac biomarkers might be avoided in such cases, potentially leading to a significant cost reduction.
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Affiliation(s)
- Katharina Tscherny
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| | - Calvin Kienbacher
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| | - Verena Fuhrmann
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| | - Wolfgang Schreiber
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| | - Harald Herkner
- Department of Emergency MedicineMedical University of ViennaViennaAustria
| | - Dominik Roth
- Department of Emergency MedicineMedical University of ViennaViennaAustria
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Raane M, Eberl M, Möbius J, Umgelter A. Second Look: The Predictive Value of Elevated Cardiac Troponins Often Depends on Retesting. Acad Emerg Med 2020; 27:644-645. [PMID: 32412107 DOI: 10.1111/acem.14011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/04/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Maximilian Raane
- Vivantes Humboldt Klinikum, Zentrale Notfallversorgung, Berlin, Germany
| | - Marcel Eberl
- Vivantes Humboldt Klinikum, Zentrale Notfallversorgung, Berlin, Germany
| | - Julia Möbius
- Vivantes Humboldt Klinikum, Zentrale Notfallversorgung, Berlin, Germany
| | - Andreas Umgelter
- Vivantes Humboldt Klinikum, Zentrale Notfallversorgung, Berlin, Germany.,Medizinische Klinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
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Wexler Y, Nussinovitch U. The Diagnostic Value of Mir-133a in ST Elevation and Non-ST Elevation Myocardial Infarction: A Meta-Analysis. Cells 2020; 9:cells9040793. [PMID: 32218383 PMCID: PMC7226415 DOI: 10.3390/cells9040793] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/20/2020] [Accepted: 03/23/2020] [Indexed: 12/27/2022] Open
Abstract
Numerous studies have reported correlations between plasma microRNA signatures and cardiovascular disease. MicroRNA-133a (Mir-133a) has been researched extensively for its diagnostic value in acute myocardial infarction (AMI). While initial results seemed promising, more recent studies cast doubt on the diagnostic utility of Mir-133a, calling its clinical prospects into question. Here, the diagnostic potential of Mir-133a was analyzed using data from multiple papers. Medline, Embase, and Web of Science were systematically searched for publications containing “Cardiovascular Disease”, “MicroRNA”, “Mir-133a” and their synonyms. Diagnostic performance was assessed using area under the summary receiver operator characteristic curve (AUC), while examining the impact of age, sex, final diagnosis, and time. Of the 753 identified publications, 9 were included in the quantitative analysis. The pooled AUC for Mir-133a was 0.73. Analyses performed separately on studies using healthy vs. symptomatic controls yielded pooled AUCs of 0.89 and 0.68, respectively. Age and sex were not found to significantly affect diagnostic performance. Our findings indicate that control characteristics and methodological inconsistencies are likely the causes of incongruent reports, and that Mir-133a may have limited use in distinguishing symptomatic patients from those suffering AMI. Lastly, we hypothesized that Mir-133a may find a new use as a risk stratification biomarker in patients with specific subsets of non-ST elevation myocardial infarction (NSTEMI).
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Affiliation(s)
- Yehuda Wexler
- Rappaport Faculty of Medicine and Research Institute, Technion - Israel Institute of Technology, POB 9649, Haifa 3109601, Israel;
| | - Udi Nussinovitch
- Applicative Cardiovascular Research Center (ACRC) and Department of Cardiology, Meir Medical Center, Kfar Saba 44281, Israel
- Correspondence: ; Tel.: +972-53-526-8535
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