Publications by authors named "Simon A Mahler"

63 Publications

RACE-IT - Rapid Acute Coronary Syndrome Exclusion using the Beckman Coulter Access high-sensitivity cardiac troponin I: A stepped-wedge cluster randomized trial.

Contemp Clin Trials Commun 2021 Jun 23;22:100773. Epub 2021 Apr 23.

Henry Ford Health System, Detroit, MI, USA.

Background: Protocols utilizing high-sensitivity cardiac troponin (hs-cTn) assays for the evaluation of suspected acute coronary syndrome (ACS) in the emergency department (ED) have been gaining popularity across the US and the world. These protocols more rapidly rule-out ACS and more accurately identify the presence of acute myocardial injury. At this time, few randomized trials have evaluated the safety and operational impact of these assays, resulting in limited evidence to guide the use and implementation of hs-cTn in the ED.

Objective: The main study objective is to test the effectiveness of a rapid ACS rule-out pathway using hs-cTnI in safely discharging patients from the ED for whom clinical suspicion for ACS exists.

Design: This prospective, implementation trial (n = 11,070) will utilize a stepped wedge cluster randomized trial design. The design will allow for all participating sites to capture benefit from the implementation of the hs-cTnI pathway while providing data evaluating the effectiveness in providing safe and rapid evaluation of patients with clinical suspicion for ACS.

Summary: Demonstrating that clinical pathways using hs-cTnI can be effectively implemented to rapidly rule-out ACS while conserving costly hospital resources has significant implications for the care of patients with possible acute cardiac conditions in EDs across the US.

Clinicaltrialsgov Identifier: NCT04488913.
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http://dx.doi.org/10.1016/j.conctc.2021.100773DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8114080PMC
June 2021

EMS blood collection from patients with acute chest pain reduces emergency department length of stay.

Am J Emerg Med 2021 Apr 26;47:248-252. Epub 2021 Apr 26.

Department of Emergency Medicine, Wake Forest School of Medicine, USA.

Background: Expediting the measurement of serum troponin by leveraging EMS blood collection could reduce the diagnostic time for patients with acute chest pain and help address Emergency Department (ED) overcrowding. However, this practice has not been examined among an ED chest pain patient population in the United States.

Methods: A prospective observational cohort study of adults with non-traumatic chest pain without ST-segment elevation myocardial infarction was conducted in three EMS agencies between 12/2016-4/2018. During transport, paramedics obtained a patient blood sample that was sent directly to the hospital core lab for troponin measurement. On ED arrival HEART Pathway assessments were completed by ED providers as part of standard care. ED providers were blinded to troponin results from EMS blood samples. To evaluate the potential impact on length of stay (LOS), the time difference between EMS blood draw and first clinical ED draw was calculated. To determine the safety of using troponin measures from EMS blood samples, the diagnostic performance of the HEART Pathway for 30-day major adverse cardiac events (MACE: composite of cardiac death, myocardial infarction (MI), coronary revascularization) was determined using EMS troponin plus arrival ED troponin and EMS troponin plus a serial 3-h ED troponin.

Results: The use of EMS blood samples for troponin measures among 401 patients presenting with acute chest pain resulted in a mean potential reduction in LOS of 72.5 ± SD 35.7 min. MACE at 30 days occurred in 21.0% (84/401), with 1 cardiac death, 78 MIs, and 5 revascularizations without MI. Use of the HEART Pathway with EMS and ED arrival troponin measures yielded a NPV of 98.0% (95% CI: 89.6-100). NPV improved to 100% (95% CI: 92.9-100) when using the EMS and 3-h ED troponin measures.

Conclusions: EMS blood collection used for core lab ED troponin measures could significantly reduce ED LOS and appears safe when integrated into the HEART Pathway.
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http://dx.doi.org/10.1016/j.ajem.2021.04.073DOI Listing
April 2021

A Model Research Curriculum for Emergency Medicine Residency: A Modified Delphi Consensus.

AEM Educ Train 2021 Apr 17;5(2):e10484. Epub 2020 Jul 17.

Wake Forest School of Medicine Winston-Salem NC USA.

Background: Research training is important for all resident physicians to be able to interpret and critically appraise scientific literature. It is particularly important for those desiring future careers in academics or research. However, there is limited literature on research training in residency. The ideal scope and content of a model curriculum for research in emergency medicine (EM) residency programs has not been recently defined.

Methods: We used a modified Delphi method to achieve expert consensus as to what content should be included in a model research curriculum for EM residents as well as for those who choose to undertake an elective in EM research.

Results: Eight experts in EM clinical and education research participated in the modified Delphi process with two rounds of responses. Cronbach's alpha was 0.82 for round 1 and 0.95 for round 2. A curricular outline of 44 items was produced by this consensus process.

Conclusions: A model curriculum for EM research is proposed here, along with references to assist residencies in building curricular components.
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http://dx.doi.org/10.1002/aet2.10484DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8019147PMC
April 2021

The Impact of Accelerated Diagnostic Protocol Implementation on Chest Pain Observation Unit Utilization.

Crit Pathw Cardiol 2021 Feb 2. Epub 2021 Feb 2.

Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.

Background: Data evaluating the impact of the History, ECG, Age, Risk factors, and Troponin (HEART) Pathway on Observation Unit (OU) use is limited. The objective of this study is to determine how HEART Pathway implementation affects OU use.

Methods: An analysis of OU registry data from 10/2012-10/2016, 2 years before and after HEART Pathway implementation at an academic medical center, was conducted. Adult patients placed in the OU for chest pain were included. The proportion of patients placed in the OU chest pain protocol per total OU volume and hospitalization and myocardial infarction (MI) rates were determined. Proportions before vs after implementation were compared using Chi-Squared Tests and age was compared using a Mann-Whitney U Test.

Results: During the study period, 1,688 patients with chest pain before HEART Pathway implementation and 1,692 after were included. The proportion of chest pain patients in the OU per total OU volume decreased following implementation from (57% [1,688/2968] to 43.6% [1,692/3,882]; p<0. 001). Before HEART Pathway implementation the hospitalization rate was 10.4% (175/1688) versus 12.4% (210/1692) after (p=0.07). More patients were diagnosed with MI following implementation (0.8% [14/1,665] vs. 2.0% [33/1686]; p=0. 008). Median age was older post-implementation (52 years [IQR: 45-59 years] vs 54 years [IQR: 48-64 years]; p<0. 001).

Conclusion: HEART Pathway implementation resulted in management of higher risk patients in the OU. Following implementation, OU chest pain patients were older and were more likely to be hospitalized or diagnosed with MI.
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http://dx.doi.org/10.1097/HPC.0000000000000254DOI Listing
February 2021

In reply.

Ann Emerg Med 2021 02;77(2):278-279

Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC.

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http://dx.doi.org/10.1016/j.annemergmed.2020.09.440DOI Listing
February 2021

Diagnostic Performance of High-Sensitivity Cardiac Troponin T Strategies and Clinical Variables in a Multisite US Cohort.

Circulation 2021 Apr 21;143(17):1659-1672. Epub 2021 Jan 21.

Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (J.P.S., S.A.M.).

Background: European data support the use of low high-sensitivity troponin (hs-cTn) measurements or a 0/1-hour (0/1-h) algorithm for myocardial infarction to exclude major adverse cardiac events (MACEs) among patients in the emergency department with possible acute coronary syndrome. However, modest US data exist to validate these strategies. This study evaluated the diagnostic performance of an initial hs-cTnT measure below the limit of quantification (LOQ: 6 ng/L), a 0/1-h algorithm, and their combination with history, ECG, age, risk factors, and initial troponin (HEART) scores for excluding MACE in a multisite US cohort.

Methods: A prospective cohort study was conducted at 8 US sites, enrolling adult patients in the emergency department with symptoms suggestive of acute coronary syndrome and without ST-elevation on ECG. Baseline and 1-hour blood samples were collected, and hs-cTnT (Roche; Basel, Switzerland) was measured. Treating providers blinded to hs-cTnT results prospectively calculated HEART scores. MACE (cardiac death, myocardial infarction, and coronary revascularization) at 30 days was adjudicated. The proportion of patients with initial hs-cTnT measures below the LOQ and risk according to a 0/1-h algorithm was determined. The negative predictive value (NPV) was calculated for both strategies when used alone or with a HEART score.

Results: Among 1462 participants with initial hs-cTnT measures, 46.4% (678 of 1462) were women and 37.1% (542 of 1462) were Black with an age of 57.6±12.9 (mean±SD) years. MACEs at 30 days occurred in 14.4% (210 of 1462) of participants. Initial hs-cTnT measures below the LOQ occurred in 32.8% (479 of 1462), yielding an NPV of 98.3% (95% CI, 96.7-99.3) for 30-day MACEs. A low-risk HEART score with an initial hs-cTnT below the LOQ occurred in 20.1% (294 of 1462), yielding an NPV of 99.0% (95% CI, 97.0-99.8) for 30-day MACEs. A 0/1-h algorithm was complete in 1430 patients, ruling out 57.8% (826 of 1430) with an NPV of 97.2% (95% CI, 95.9-98.2) for 30-day MACEs. Adding a low HEART score to the 0/1-h algorithm ruled out 30.8% (441 of 1430) with an NPV of 98.4% (95% CI, 96.8-99.4) for 30-day MACEs.

Conclusions: In a prospective multisite US cohort, an initial hs-cTnT below the LOQ combined with a low-risk HEART score has a 99% NPV for 30-day MACEs. The 0/1-h hs-cTnT algorithm did not achieve an NPV >99% for 30-day MACEs when used alone or with a HEART score. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02984436.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.049298DOI Listing
April 2021

Sex and race differences in safety and effectiveness of the HEART pathway accelerated diagnostic protocol for acute chest pain.

Am Heart J 2021 02 6;232:125-136. Epub 2020 Nov 6.

Department of Emergency Medicine, Wake Forest School of Medicine (WFSOM), Winston-Salem, NC; Departments of Implementation Science and Epidemiology and Prevention, WFSOM, Winston-Salem, NC.

Background: The HEART Pathway is an accelerated diagnostic protocol for Emergency Department patients with possible acute coronary syndrome. The objective was to compare the safety and effectiveness of the HEART Pathway among women vs men and whites vs non-whites.

Methods: A subgroup analysis of the HEART Pathway Implementation Study was conducted. Adults with chest pain were accrued from November 2013 to January 2016 from 3 Emergency Departments in North Carolina. The primary outcomes were death and myocardial infarction (MI) and hospitalization rates at 30 days. Logistic regression evaluated for interactions of accelerated diagnostic protocol implementation with sex or race and changes in outcomes within subgroups.

Results: A total of 8,474 patients were accrued, of which 53.6% were female and 34.0% were non-white. The HEART Pathway identified 32.6% of females as low-risk vs 28.5% of males (P = 002) and 35.6% of non-whites as low-risk vs 28.0% of whites (P < .0001). Among low-risk patients, death or MI at 30 days occurred in 0.4% of females vs 0.5% of males (P = .70) and 0.5% of non-whites vs 0.3% of whites (P = .69). Hospitalization at 30 days was reduced by 6.6% in females (aOR: 0.74, 95% CI: 0.64-0.85), 5.1% in males (aOR: 0.87, 95% CI: 0.75-1.02), 8.6% in non-whites (aOR: 0.72, 95% CI: 0.60-0.86), and 4.5% in whites (aOR: 0.83, 95% CI: 0.73-0.94). Interactions were not significant.

Conclusion: Women and non-whites are more likely to be classified as low-risk by the HEART Pathway. HEART Pathway implementation is associated with decreased hospitalizations and a very low death and MI rate among low-risk patients regardless of sex or race.
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http://dx.doi.org/10.1016/j.ahj.2020.11.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952042PMC
February 2021

The disutility of stress testing in low-risk HEART Pathway patients.

Am J Emerg Med 2020 Aug 15. Epub 2020 Aug 15.

Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States.

Background: The HEART Pathway identifies low-risk chest pain patients for discharge from the Emergency Department without stress testing. However, HEART Pathway recommendations are not always followed. The objective of this study is to determine the frequency and diagnostic yield of stress testing among low-risk patients.

Methods: An academic hospital's chest pain registry was analyzed for low-risk HEART Pathway patients (HEAR score ≤ 3 with non-elevated troponins) from 1/2017 to 7/2018. Stress tests were reviewed for inducible ischemia. Diagnostic yield was defined as the rate of obstructive CAD among patients with positive stress testing. T-test or Fisher's exact test was used to test the univariate association of age, sex, race/ethnicity, and HEAR score with stress testing. Multivariate logistic regression was used to determine the association of age, sex, race/ethnicity, and HEAR score with stress testing.

Results: There were 4743 HEART Pathway assessments, with 43.7% (2074/4743) being low-risk. Stress testing was performed on 4.1% (84/2074). Of the 84 low-risk patients who underwent testing, 8.3% (7/84) had non-diagnostic studies and 2.6% (2/84) had positive studies. Among the 2 patients with positive studies, angiography revealed that 1 had widely patent coronary arteries and the other had multivessel obstructive coronary artery disease, making the diagnostic yield of stress testing 1.2% (1/84). Each one-point increase in HEAR score (aOR 2.17, 95% CI 1.45-3.24) and being male (aOR 1.59, 95% CI 1.02-2.49) were associated with testing.

Conclusions: Stress testing among low-risk HEART Pathway patients was uncommon, low yield, and more likely in males and those with a higher HEAR score.
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http://dx.doi.org/10.1016/j.ajem.2020.08.032DOI Listing
August 2020

Identification of very low-risk acute chest pain patients without troponin testing.

Emerg Med J 2020 Nov 4;37(11):690-695. Epub 2020 Aug 4.

Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.

Background: The HEART Pathway combines a History ECG Age Risk factor (HEAR) score and serial troponins to risk stratify patients with acute chest pain. However, it is unclear whether patients with HEAR scores of 1 require troponin testing. The objective of this study is to measure the major adverse cardiac event (MACE) rate among patients with 1 HEAR scores and determine whether serial troponin testing is needed to achieve a miss rate <1%.

Methods: A secondary analysis of the HEART Pathway Implementation Study was conducted. HEART Pathway risk assessments (HEAR scores and serial troponin testing at 0 and 3 hours) were completed by the providers on adult patients with chest pain from three US sites between November 2014 and January 2016. MACE (composite of death, myocardial infarction (MI) and coronary revascularisation) at 30 days was determined. The proportion of patients with HEAR scores of 1 diagnosed with MACE within 30 days was calculated. The impact of troponin testing on patients with HEAR scores of 1 was determined using Net Reclassification Improvement Index (NRI).

Results: Providers completed HEAR assessments on 4979 patients and HEAR scores<1 occurred in 9.0% (447/4979) of patients. Among these patients, MACE at 30 days occurred in 0.9% (4/447; 95% CI 0.2% to 2.3%) with two deaths, two MIs and 0 revascularisations. The sensitivity and negative predictive value for MACE in the HEAR 1 was 97.8% (95%CI 94.5% to 99.4%) and 99.1% (95% CI 97.7% to 99.8%), respectively, and were not improved by troponin testing. Troponin testing in patients with HEAR 1 correctly reclassified two patients diagnosed with MACE, and was elevated among seven patients without MACE yielding an NRI of 0.9% (95%CI -0.7 to 2.4%).

Conclusion: These data suggest that patients with HEAR scores of 0 and 1 represent a very low-risk group that may not require troponin testing to achieve a missed MACE rate <1%. NCT02056964.
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http://dx.doi.org/10.1136/emermed-2020-209698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952041PMC
November 2020

HEART Pathway Implementation Safely Reduces Hospitalizations at One Year in Patients With Acute Chest Pain.

Ann Emerg Med 2020 11 28;76(5):555-565. Epub 2020 Jul 28.

Departments of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC; Implementation Science and Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC.

Study Objective: We determine whether implementation of the HEART (History, ECG, Age, Risk Factors, Troponin) Pathway is safe and effective in emergency department (ED) patients with possible acute coronary syndrome through 1 year of follow-up.

Methods: A preplanned analysis of 1-year follow-up data from a prospective pre-post study of 8,474 adult ED patients with possible acute coronary syndrome from 3 US sites was conducted. Patients included were aged 21 years or older, evaluated for possible acute coronary syndrome, and without ST-segment elevation myocardial infarction. Accrual occurred for 12 months before and after HEART Pathway implementation, from November 2013 to January 2016. The HEART Pathway was integrated into the electronic health record at each site as an interactive clinical decision support tool. After integration, ED providers prospectively used the HEART Pathway to identify patients with possible acute coronary syndrome as low risk (appropriate for early discharge without stress testing or angiography) or nonlow risk (appropriate for further inhospital evaluation). Safety (all-cause death and myocardial infarction) and effectiveness (hospitalization) at 1 year were determined from health records, insurance claims, and death index data.

Results: Preimplementation and postimplementation cohorts included 3,713 and 4,761 patients, respectively. The HEART Pathway identified 30.7% of patients as low risk; 97.5% of them were free of death and myocardial infarction within 1 year. Hospitalization at 1 year was reduced by 7.0% in the postimplementation versus preimplementation cohort (62.1% versus 69.1%; adjusted odds ratio 0.70; 95% confidence interval 0.63 to 0.78). Rates of death or myocardial infarction at 1 year were similar (11.6% versus 12.4%; adjusted odds ratio 1.00; 95% confidence interval 0.87 to 1.16).

Conclusion: HEART Pathway implementation was associated with decreased hospitalizations and low adverse event rates among low-risk patients at 1-year follow-up.
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http://dx.doi.org/10.1016/j.annemergmed.2020.05.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7988839PMC
November 2020

Comparison of accelerated diagnostic pathways for acute chest pain risk stratification.

Heart 2020 07 8;106(13):977-984. Epub 2020 Apr 8.

Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.

Background: The History Electrocardiogram Age Risk factor Troponin (HEART) Pathway and Emergency Department Assessment of Chest pain Score (EDACS) are validated accelerated diagnostic pathways designed to risk stratify patients presenting to the emergency department with chest pain. Data from large multisite prospective studies comparing these accelerated diagnostic pathways are limited.

Methods: The HEART Pathway Implementation is a prospective three-site cohort study, which accrued adults with symptoms concerning for acute coronary syndrome. Physicians completed electronic health record HEART Pathway and EDACS risk assessments on participants. Major adverse cardiac events (death, myocardial infarction and coronary revascularisation) at 30 days were determined using electronic health record, insurance claims and death index data. Test characteristics for detection of major adverse cardiac events were calculated for both accelerated diagnostic pathways and McNemar's tests were used for comparisons.

Results: 5799 patients presenting to the emergency department were accrued, of which HEART Pathway and EDACS assessments were completed on 4399. Major adverse cardiac events at 30 days occurred in 449/4399 (10.2%). The HEART Pathway identified 38.4% (95% CI 37.0% to 39.9%) of patients as low-risk compared with 58.1% (95% CI 56.6% to 59.6%) identified as low-risk by EDACS (p<0.001). Major adverse cardiac events occurred in 0.4% (95% CI 0.2% to 0.9%) of patients classified as low-risk by the HEART Pathway compared with 1.0% (95% CI 0.7% to 1.5%) of patients identified as low-risk by EDACS (p<0.001). Thus, the HEART Pathway had a negative predictive value of 99.6% (95% CI 99.1% to 99.8%) for major adverse cardiac events compared with a negative predictive value of 99.0% (95% CI 98.5% to 99.3%) for EDACS.

Conclusions: EDACS identifies a larger proportion of patients as low-risk than the HEART Pathway, but has a higher missed major adverse cardiac events rate at 30 days. Physicians will need to consider their risk tolerance when deciding whether to adopt the HEART Pathway or EDACS accelerated diagnostic pathway.

Trial Registration Number: NCT02056964.
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http://dx.doi.org/10.1136/heartjnl-2019-316426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7962144PMC
July 2020

Point-of-Care Troponin Testing during Ambulance Transport to Detect Acute Myocardial Infarction.

Prehosp Emerg Care 2020 Nov-Dec;24(6):751-759. Epub 2020 Mar 3.

Use of point-of-care (POC) troponin (cTn) testing in the Emergency Department (ED) is well established. However, data examining POC cTn measurement in the prehospital setting, during ambulance transport, are limited. The objective of this study was to prospectively test the performance of POC cTn measurement by paramedics to detect myocardial infarction (MI) among patients transported to the ED for acute chest pain. A prospective cohort study of adults with non-traumatic chest pain was conducted in three Emergency Medical Services agencies (December 2016 to January 2018). Patients with ST-elevation MI on ECG were excluded. During ambulance transport paramedics initiated intravenous access, collected blood, and used a POC device (i-STAT; Abbott Laboratories) to measure cTn. Following ED arrival, participants received standard evaluations including clinical blood draws for cTn measurement in the hospital central lab (AccuTnI +3 assay; Beckman Coulter, or cTnI-Ultra assay; Siemens). Blood collected during ambulance transport was also analyzed for cTn in the central lab. Index visit MI was adjudicated by 3 experts using central lab cTn measures from the patient's clinical blood draws. Test characteristics (sensitivity, specificity, and predictive values) for detection of MI were calculated for POC and central lab cTn measurement of prehospital blood and compared with McNemar's test. During the study period prehospital POC cTn results were obtained on 421 patients, of which 5.0% (21/421) had results >99th percentile upper reference limit. MI was adjudicated in 16.2% (68/421) during the index visit. The specificity and positive predictive value of the POC cTn measurement were 99.2% (95% CI 97.5-99.8%) and 85.7% (95% CI 63.7-97.0%) for MI. However, the sensitivity and NPV of prehospital POC cTn were 26.5% (95% CI 16.5-38.6%) and 87.5% (95% CI 83.9-90.6%). Compared to POC cTn, the central lab cTn measurement of prehospital blood resulted in a higher sensitivity of 67.9% (95% CI 53.7-80.1%,  < 0.0001), but lower specificity of 92.4% (95% CI 88.4-95.4%,  = 0.0001). Prehospital POC i-STAT cTn measurement in patients transported with acute chest pain was highly specific for MI but had low sensitivity. This suggests that prehospital i-STAT POC cTn could be useful to rule-in MI, but should not be used to exclude MI.
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http://dx.doi.org/10.1080/10903127.2020.1721740DOI Listing
May 2021

Evaluating Suspected Acute MI in the Emergency Department: What Is and What Should Never Be.

J Am Coll Cardiol 2019 07;74(4):495-497

Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina.

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http://dx.doi.org/10.1016/j.jacc.2019.05.047DOI Listing
July 2019

News From Lake Wobegon … Clinician Gestalt Debunked?

Acad Emerg Med 2020 01 11;27(1):80-82. Epub 2019 Aug 11.

Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.

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http://dx.doi.org/10.1111/acem.13837DOI Listing
January 2020

Recommendations for Institutions Transitioning to High-Sensitivity Troponin Testing: JACC Scientific Expert Panel.

J Am Coll Cardiol 2019 03 21;73(9):1059-1077. Epub 2019 Feb 21.

Cardiology Department and Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.

High-sensitivity cardiac troponin (hs-cTn) I or T methods have been in use in certain regions for years but are now increasingly globally adopted, including in the United States. Accordingly, inevitable challenges are created for institutions transitioning from conventional cardiac troponin (cTn) assays. hs-cTn assays have higher analytic precision at lower concentrations, yielding greater clinical sensitivity for myocardial injury and allowing accurate recognition of small changes in troponin concentration (rise or fall) within a short time frame. Although much of the knowledge regarding troponin biology that was applicable with older troponin assays still holds true, considerable education regarding the differences between conventional cTn and hs-cTn is needed before medical systems convert to the newer methods. This includes a basic understanding of how hs-cTn testing differs from conventional cTn testing and how it is best deployed in different settings, such as the emergency department and inpatient services. This Expert Panel will review important concepts for institutional transition to hs-cTn methodology, providing recommendations useful for education before implementation.
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http://dx.doi.org/10.1016/j.jacc.2018.12.046DOI Listing
March 2019

ACES (Accelerated Chest Pain Evaluation With Stress Imaging) Protocols Eliminate Testing Disparities in Patients With Chest Pain.

Crit Pathw Cardiol 2019 03;18(1):5-9

Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC.

Background: Patients from racial and ethnic minority groups presenting to the Emergency Department (ED) with chest pain experience lower odds of receiving stress testing compared with nonminorities. Studies have demonstrated that care pathways administered within the ED can reduce health disparities, but this has yet to be studied as a strategy to increase stress testing equity.

Methods: A secondary analysis from 3 randomized clinical trials involving ED patients with acute chest pain was performed to determine whether a care pathway, ACES (Accelerated Chest pain Evaluation with Stress imaging), reduces the racial disparity in index visit cardiac testing between African American (AA) and White patients. Three hundred thirty-four participants with symptoms and findings indicating intermediate to high risk for acute coronary syndrome were enrolled in 3 clinical trials. Major exclusions were ST-segment elevation, initial troponin elevation, and hemodynamic instability. Participants were randomly assigned to receive usual inpatient care, or ACES. The ACES care pathway includes placement in observation for serial cardiac markers, with an expectation for stress imaging. The primary outcome was index visit objective cardiac testing, compared among AA and White participants.

Results: AA participants represented 111/329 (34%) of the study population, 80/220 (36%) of the ACES group and 31/109 (28%) of the usual care group. In usual care, objective testing occurred less frequently among AA (22/31, 71%) than among White (69/78, 88%, P = 0.027) participants, primarily driven by cardiac catheterization (3% vs. 24%; P = 0.012). In ACES, testing rates did not differ by race [AA 78/80 (98%) vs. White 138/140 (99%); P = 0.623]. At 90 days, death, MI, and revascularization did not differ in either group between AA and White participants.

Conclusions: A care pathway with the expectation for stress imaging eliminates the racial disparity among AA and White participants with chest pain in the acquisition of index-visit cardiovascular testing.
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http://dx.doi.org/10.1097/HPC.0000000000000161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6375104PMC
March 2019

Safely Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge.

Circulation 2018 11;138(22):2456-2468

Department of Emergency Medicine (S.A.M., B.C.H., C.D.M.), Wake Forest School of Medicine, Winston-Salem, NC.

Background: The HEART Pathway (history, ECG, age, risk factors, and initial troponin) is an accelerated diagnostic protocol designed to identify low-risk emergency department patients with chest pain for early discharge without stress testing or angiography. The objective of this study was to determine whether implementation of the HEART Pathway is safe (30-day death and myocardial infarction rate <1% in low-risk patients) and effective (reduces 30-day hospitalizations) in emergency department patients with possible acute coronary syndrome.

Methods: A prospective pre-post study was conducted at 3 US sites among 8474 adult emergency department patients with possible acute coronary syndrome. Patients included were ≥21 years old, investigated for possible acute coronary syndrome, and had no evidence of ST-segment-elevation myocardial infarction on ECG. Accrual occurred for 12 months before and after HEART Pathway implementation from November 2013 to January 2016. The HEART Pathway accelerated diagnostic protocol was integrated into the electronic health record at each site as an interactive clinical decision support tool. After accelerated diagnostic protocol integration, ED providers prospectively used the HEART Pathway to identify patients with possible acute coronary syndrome as low risk (appropriate for early discharge without stress testing or angiography) or non-low risk (appropriate for further in-hospital evaluation). The primary safety and effectiveness outcomes, death, and myocardial infarction (MI) and hospitalization rates at 30 days were determined from health records, insurance claims, and death index data.

Results: Preimplementation and postimplementation cohorts included 3713 and 4761 patients, respectively. The HEART Pathway identified 30.7% as low risk; 0.4% of these patients experienced death or MI within 30 days. Hospitalization at 30 days was reduced by 6% in the postimplementation versus preimplementation cohort (55.6% versus 61.6%; adjusted odds ratio, 0.79; 95% CI, 0.71-0.87). During the index visit, more MIs were detected in the postimplementation cohort (6.6% versus 5.7%; adjusted odds ratio, 1.36; 95% CI, 1.12-1.65). Rates of death or MI during follow-up were similar (1.1% versus 1.3%; adjusted odds ratio, 0.88; 95% CI, 0.58-1.33).

Conclusions: HEART Pathway implementation was associated with decreased hospitalizations, increased identification of index visit MIs, and a very low death and MI rate among low-risk patients. These findings support use of the HEART Pathway to identify low-risk patients who can be safely discharged without stress testing or angiography.

Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT02056964.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.118.036528DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309794PMC
November 2018

Implementation of the HEART Pathway: Using the Consolidated Framework for Implementation Research.

Crit Pathw Cardiol 2018 12;17(4):191-200

Departments of Emergency Medicine, Implementation Science, and Epidemiology and Prevention, Wake Forest School of Medicine, One Medical Center Boulevard, Winston-Salem, NC.

Objective: The HEART Pathway is an evidence-based decision tool for identifying emergency department (ED) patients with acute chest pain who are candidates for early discharge, to reduce unhelpful and potentially harmful hospitalizations. Guided by the Consolidated Framework for Implementation Research, we sought to identify important barriers and facilitators to implementation of the HEART Pathway.

Study Setting: Data were collected at 4 academic medical centers.

Study Design: We conducted semi-structured interviews with 25 key stakeholders (e.g., health system leaders, ED physicians). We conducted interviews before implementation of the HEART Pathway tool to identify potential barriers and facilitators to successful adoption at other regional academic medical centers. We also conducted postimplementation interviews at 1 medical center, to understand factors that contributed to successful adoption.

Data Collection: Interviews were recorded and transcribed verbatim. We used a Consolidated Framework for Implementation Research framework-driven deductive approach for coding and analysis.

Principal Findings: Potential barriers to implementation include time and resource burden, challenges specific to the electronic health record, sustained communication with and engagement of stakeholders, and patient concerns. Facilitators to implementation include strength of evidence for reduced length of stay and unnecessary testing and iatrogenic complications, ease of use, and supportive provider climate for evidence-based decision tools.

Conclusions: Successful dissemination of the HEART Pathway will require addressing institution-specific barriers, which includes engaging clinical and financial stakeholders. New SMART-FHIR technologies, compatible with many electronic health record systems, can overcome barriers to health systems with limited information technology resources.
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http://dx.doi.org/10.1097/HPC.0000000000000154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6234854PMC
December 2018

Usefulness of Serial 12-Lead Electrocardiograms in Predicting 30-Day Outcomes in Patients With Undifferentiated Chest Pain (the ASAP CATH Study).

Am J Cardiol 2018 08 1;122(3):374-380. Epub 2018 May 1.

Department of Emergency Medicine, Wake Forest Baptist Health, Cincinnati, Ohio.

An initial electrocardiogram (ECG) and serial troponin measurements are both independently and incrementally predictive of acute coronary syndrome in patients presenting with undifferentiated chest pain in the Emergency Department (ED). However, it is unclear if serial (ECGs) add significant to the contemporary diagnostic evaluation of this patient group. The ASAP CATH study was a single center, prospective study that enrolled patients presenting to an ED with undifferentiated chest pain. In addition to standard clinical evaluation, serial ECGs were performed at 90-minute intervals to evaluate whether serial changes suggestive of ischemia developed (Q waves, ST elevation or depression, or T-wave inversion). Total 365 subjects were enrolled from March 2014 to May 2015. Serial ECG changes developed in 6.6% (n = 24 of 365), the most common being the development of T-wave inversion (66.7%, n = 16 of 24). The sensitivity and positive predictive value of serial ECG changes were poor (<30%), with a less areas under the curve (0.55) compared with serial troponins alone (0.83). The addition of serial ECG changes to Thrombolysis In Myocardial Infarction risk scoring showed a decrease in the net reclassification index for major adverse cardiovascular events (-0.04, p <0.1) and was not significant for the prediction of major adverse cardiovascular events and/or acute coronary syndrome in 30 days (-0.003, p = 0.94). In conclusion, routine serial ECG evaluation for patients presenting with undifferentiated chest pain in the ED may not significantly improved diagnostic prognosis beyond current standard evaluation modalities.
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http://dx.doi.org/10.1016/j.amjcard.2018.04.031DOI Listing
August 2018

The HEART Pathway Randomized Controlled Trial One-year Outcomes.

Acad Emerg Med 2019 01 19;26(1):41-50. Epub 2018 Jul 19.

Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.

Objective: The objective was to determine the impact of the HEART Pathway on health care utilization and safety outcomes at 1 year in patients with acute chest pain.

Methods: Adult emergency department (ED) patients with chest pain (N = 282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, ED providers used the HEART score and troponin measures (0 and 3 hours) to risk stratify patients. Usual care was based on American College of Cardiology/American Heart Association guidelines. Major adverse cardiac events (MACE-cardiac death, myocardial infarction [MI], or coronary revascularization), objective testing (stress testing or coronary angiography), and cardiac hospitalizations and ED visits were assessed at 1 year. Randomization arm outcomes were compared using Fisher's exact tests.

Results: A total of 282 patients were enrolled, with 141 randomized to each arm. MACE at 1 year occurred in 10.6% (30/282): 9.9% in the HEART Pathway arm (14/141; 10 MIs, four revascularizations without MI) versus 11.3% in usual care (16/141; one cardiac death, 13 MIs, two revascularizations without MI; p = 0.85). Among low-risk HEART Pathway patients, 0% (0/66) had MACE, with a negative predictive value (NPV) of 100% (95% confidence interval = 93%-100%). Objective testing through 1 year occurred in 63.1% (89/141) of HEART Pathway patients compared to 71.6% (101/141) in usual care (p = 0.16). Nonindex cardiac-related hospitalizations and ED visits occurred in 14.9% (21/141) and 21.3% (30/141) of patients in the HEART Pathway versus 10.6% (15/141) and 16.3% (23/141) in usual care (p = 0.37, p = 0.36).

Conclusions: The HEART Pathway had a 100% NPV for 1-year safety outcomes (MACE) without increasing downstream hospitalizations or ED visits. Reduction in 1-year objective testing was not significant.
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http://dx.doi.org/10.1111/acem.13504DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6934171PMC
January 2019

Monocyte Chemoattractant Protein-1 as a Predictor of Coronary Atherosclerosis in Patients Receiving Coronary Angiography.

Crit Pathw Cardiol 2018 06;17(2):105-110

From the Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.

Background: Animal studies suggest that monocyte chemoattractant protein-1 (MCP-1) is a promising biomarker for coronary artery atherosclerosis (CAA), but human studies have been inconclusive.

Objective: To determine potential relationships between plasma MCP-1 and CAA in patients with acute chest pain.

Methods: A secondary analysis of 150 patients enrolled in emergency department chest pain risk stratification clinical investigations was conducted. Participants with stored blood and known coronary phenotypes (determined by coronary angiography) were selected using stratified randomization such that 50 patients were included into 3 groups: (1) no angiographic evidence of CAA, (2) nonobstructive CAA, and (3) obstructive CAA (stenosis ≥ 70%). Plasma MCP-1 levels were determined by enzyme-linked immunosorbent assay. The association between MCP-1 and obstructive CAA or any CAA was modeled using logistic regression. Variables in the unreduced model included age, sex, race, prior diagnosis of CAA or acute coronary syndrome, hyperlipidemia, hypertension, diabetes, smoking, and cardiac troponin I measurement.

Results: Among the 150 participants, 65.3% (98/150) had invasive coronary angiography and 34.7% (52/150) had coronary computed tomographic angiography. Myocardial infarction occurred in 27.3% (41/150) and coronary revascularization occurred in 26% (39/150) of the participants. Each 10 pg/mL increase in MCP-1 measurement was associated with an odds ratio of 1.12 (95% confidence interval, 1.06-1.19) for obstructive CAA. MCP-1 remained a significant predictor of obstructive CAA and any CAA after adjustment for age, sex, race, traditional cardiac risk factors, and cardiac troponin I.

Conclusions: MCP-1 is independently associated with CAA among emergency department patients with chest pain.
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http://dx.doi.org/10.1097/HPC.0000000000000140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5959046PMC
June 2018

3 for the Price of 1: Teaching Chest Pain Risk Stratification in a Multidisciplinary, Problem-based Learning Workshop.

West J Emerg Med 2018 May 8;19(3):613-618. Epub 2018 Mar 8.

Wake Forest School of Medicine, Department of Emergency Medicine, Winston-Salem, North Carolina.

Introduction: Chest pain is a common chief complaint among patients presenting to health systems and often leads to complex and intensive evaluations. While these patients are often cared for by a multidisciplinary team (primary care, emergency medicine, and cardiology), medical students usually learn about the care of these patients in a fragmented, single-specialty paradigm. The present and future care of patients with chest pain is multidisciplinary, and the education of medical students on the subject should be as well. Our objective was to evaluate the effectiveness of a multidisciplinary, problem-based learning workshop to teach third-year medical students about risk assessment for patients presenting with chest pain, specifically focusing on acute coronary syndromes.

Methods: To create an educational experience consistent with multidisciplinary team-based care, we designed a multidisciplinary, problem-based learning workshop to provide medical students with an understanding of how patients with chest pain are cared for in a systems-based manner to improve outcomes. Participants included third-year medical students (n=219) at a single, tertiary care, academic medical center. Knowledge acquisition was tested in a pre-/post-retention test study design.

Results: Following the workshop, students achieved a 19.7% (95% confidence interval [CI] [17.3-22.2%]) absolute increase in scores on post-testing as compared to pre-testing. In addition, students maintained an 11.1% (95% CI [7.2-15.0%]) increase on a retention test vs. the pre-test.

Conclusion: A multidisciplinary, problem-based learning workshop is an effective method of producing lasting gains in student knowledge about chest pain risk stratification.
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http://dx.doi.org/10.5811/westjem.2017.12.36444DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5942033PMC
May 2018

Prehospital Modified HEART Score Predictive of 30-Day Adverse Cardiac Events.

Prehosp Disaster Med 2018 Feb 10;33(1):58-62. Epub 2018 Jan 10.

1Wake Forest School of Medicine,Winston-Salem,North CarolinaUSA.

Introduction The History, Electrocardiogram (ECG), Age, Risk Factors, and Troponin (HEART) score is a decision aid designed to risk stratify emergency department (ED) patients with acute chest pain. It has been validated for ED use, but it has yet to be evaluated in a prehospital setting. Hypothesis A prehospital modified HEART score can predict major adverse cardiac events (MACE) among undifferentiated chest pain patients transported to the ED.

Methods: A retrospective cohort study of patients with chest pain transported by two county-based Emergency Medical Service (EMS) agencies to a tertiary care center was conducted. Adults without ST-elevation myocardial infarction (STEMI) were included. Inter-facility transfers and those without a prehospital 12-lead ECG or an ED troponin measurement were excluded. Modified HEART scores were calculated by study investigators using a standardized data collection tool for each patient. All MACE (death, myocardial infarction [MI], or coronary revascularization) were determined by record review at 30 days. The sensitivity and negative predictive values (NPVs) for MACE at 30 days were calculated.

Results: Over the study period, 794 patients met inclusion criteria. A MACE at 30 days was present in 10.7% (85/794) of patients with 12 deaths (1.5%), 66 MIs (8.3%), and 12 coronary revascularizations without MI (1.5%). The modified HEART score identified 33.2% (264/794) of patients as low risk. Among low-risk patients, 1.9% (5/264) had MACE (two MIs and three revascularizations without MI). The sensitivity and NPV for 30-day MACE was 94.1% (95% CI, 86.8-98.1) and 98.1% (95% CI, 95.6-99.4), respectively.

Conclusions: Prehospital modified HEART scores have a high NPV for MACE at 30 days. A study in which prehospital providers prospectively apply this decision aid is warranted. Stopyra JP , Harper WS , Higgins TJ , Prokesova JV , Winslow JE , Nelson RD , Alson RL , Davis CA , Russell GB , Miller CD , Mahler SA . Prehospital modified HEART score predictive of 30-day adverse cardiac events. Prehosp Disaster Med. 2018;33(1):58-62.
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http://dx.doi.org/10.1017/S1049023X17007154DOI Listing
February 2018

In Reply.

Acad Emerg Med 2017 09 31;24(9):1171-1172. Epub 2017 Jul 31.

Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC.

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http://dx.doi.org/10.1111/acem.13239DOI Listing
September 2017

Validation of the No Objective Testing Rule and Comparison to the HEART Pathway.

Acad Emerg Med 2017 09 8;24(9):1165-1168. Epub 2017 Aug 8.

Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.

Background: The no objective testing rule (NOTR) is a decision aid designed to safely identify emergency department (ED) patients with chest pain who do not require objective testing for coronary artery disease.

Objectives: The objective was to validate the NOTR in a cohort of U.S. ED patients with acute chest pain and compare its performance to the HEART Pathway.

Methods: A secondary analysis of 282 participants enrolled in the HEART Pathway randomized controlled trial was conducted. Each patient was classified as low risk or at risk by the NOTR. Sensitivity for major adverse cardiac events (MACE) at 30 days was calculated in the entire study population. NOTR and HEART Pathways were compared among patients randomized to the HEART Pathway in the parent trial using McNemar's test and the net reclassification improvement (NRI).

Results: Major adverse cardiac events occurred in 22/282 (7.8%) participants, including no deaths, 16/282 (5.6%) with myocardial infarction (MI), and 6/282 (2.1%) with coronary revascularization without MI. NOTR was 100% (95% confidence interval [CI] = 84.6%-100%) sensitive for MACE and identified 78/282 patients (27.7%, 95% = CI 22.5-33.3%) as low risk. In the HEART Pathway arm (n = 141), both NOTR and HEART Pathway identified all patients with MACE as at risk. Compared to NOTR, the HEART Pathway was able to correctly reclassify 27 patients without MACE as low risk, yielding a NRI of 20.8% (95% CI = 11.3%-30.2%).

Conclusions: Within a U.S. cohort of ED patients with chest pain, the NOTR and HEART Pathway were 100% sensitive for MACE at 30 days. However, the HEART Pathway identified more patients suitable for early discharge than the NOTR.
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http://dx.doi.org/10.1111/acem.13221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5600651PMC
September 2017

The Fast and the Furious: Low-Risk Chest Pain and the Rapid Rule-Out Protocol.

West J Emerg Med 2017 Apr 27;18(3):474-478. Epub 2017 Feb 27.

University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland.

Accelerated diagnostic pathways (ADP) have been designed to identify low-risk chest pain patients in the emergency department. This review article discusses the Asia-Pacific Evaluation of Chest Pain Trial (ASPECT) score, the Accelerated Diagnostic Protocol for Chest Pain Trial (ADAPT) score, the Emergency Department Assessment of Chest Pain Score (EDACS), the HEARTScore and the HEART pathway. These ADPs have been validated in various studies and aid the emergency provider with identifying the low-risk chest pain patient who is appropriate for discharge home, while at the same time highlighting those patients who would benefit from further in-patient work up. These approaches should be paired with patient input and shared decision-making strategies.
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http://dx.doi.org/10.5811/westjem.2016.12.32676DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5391898PMC
April 2017

Use of the HEART Pathway with high sensitivity cardiac troponins: A secondary analysis.

Clin Biochem 2017 May 10;50(7-8):401-407. Epub 2017 Jan 10.

Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.

Objectives: The HEART Pathway combines a decision aid and serial contemporary cardiac troponin I (cTnI) measures to achieve >99% sensitivity for major adverse cardiac events (MACE) at 30days and early discharge rates >20%. However, the impact of integrating high-sensitivity troponin (hs-cTn) measures into the HEART Pathway has yet to be determined. In this analysis we compare test characteristics of the HEART Pathway using hs-cTnI, hs-cTnT, or cTnI.

Design & Methods: A secondary analysis of participants enrolled in the HEART Pathway RCT was conducted. Each patient was risk stratified by the cTn-HEART Pathway (Siemens TnI-Ultra at 0- and 3-h) and a hs-cTn-HEART Pathway using hs-cTnI (Abbott) or hs-cTnT (Roche) at 3-h. The early discharge rate, sensitivity, specificity, and negative predictive value (NPV) for MACE (death, myocardial infarction, or coronary revascularization) at 30days were calculated.

Results: hs-cTnI measures were available on 133 patients. MACE occurred in 11/133 (8%) of these patients. Test characteristics for the HEART Pathway using serial cTnI vs 3hour hs-cTnI were the same: sensitivity (100%, 95%CI: 72-100%), specificity (49%, 95%CI: 40-58%), NPV (100%, 95%CI: 94-100%), and early discharge rate (45%, 95%CI: 37-54%). The HEART Pathway using hs-cTnT missed one MACE event (myocardial infarction): sensitivity (91%, 95%CI: 59-100%), specificity (48%, 95%CI: 39-57%), NPV (98%, 95%CI: 91-100%), and early discharge rate (45%, 95%CI: 37-54%).

Conclusions: There was no difference in the test characteristics of the HEART Pathway whether using cTnI or hs-cTnI, with both achieving 100% sensitivity and NPV. Use of hs-cTnT with the HEART Pathway was associated with one missed MACE.
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http://dx.doi.org/10.1016/j.clinbiochem.2017.01.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5446796PMC
May 2017

Association Between Hospital Practices and Door-in-door-out Time in ST-segment Elevation Myocardial Infarction.

Crit Pathw Cardiol 2016 12;15(4):165-168

From the *Department of Emergency Medicine, University of California Davis, Sacramento, CA; †San Juan Bautista School of Medicine, Caguas, Puerto Rico; ‡Department of Emergency Medicine, Wake Forest Baptist Health, Winston-Salem, NC; §Division of Cardiology, Virginia Commonwealth University, Richmond, VA; and ¶Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX.

Background: Current guidelines suggest a "door-in-door-out" (DIDO) time of 30 minutes or shorter for patients with ST-segment elevation myocardial infarction (STEMI) who arrive at a STEMI referral hospital and are transferred to a STEMI-receiving center for primary percutaneous coronary intervention. Experts previously identified 18 system practices as critical for reducing DIDO times. The objective of this study was to describe how frequently these critical practices are used and to determine whether their use was associated with shorter DIDO times.

Methods: We surveyed 18 STEMI referral hospitals for 4 STEMI-receiving centers regarding their use of these 18 practices. The median number used was 14 practices (interquartile range 12-15). We then evaluated their association with DIDO times in all patients (n = 93) transferred from these STEMI referral hospitals to the 4 STEMI-receiving centers for primary percutaneous coronary intervention.

Results: In univariate linear regression analyses, system-wide quality improvement programs with leaders in the emergency medical services agencies and STEMI referral hospitals were associated with shorter DIDO times (P < 0.001 for all). Overall use of system practices was not associated with DIDO times (P = 0.143). The majority (76%, 95% confidence interval: 66%-85%) of DIDO times did not meet the 30-minute goal.

Conclusions: These findings highlight the difficulty in achieving the 30-minute DIDO goal and the need for continued focus on strategies for reducing DIDO time, including system-wide quality improvement programs.
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http://dx.doi.org/10.1097/HPC.0000000000000093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5119653PMC
December 2016