Alan B. Storrow

B-type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure: analysis from Breathing Not Properly (BNP) Multinational Study.

Background—We sought to determine the degree to which B-type natriuretic peptide (BNP) adds to clinical judgment in the diagnosis of congestive heart failure (CHF). Methods and Results—The Breathing Not Properly Multinational Study was a prospective diagnostic test evaluation study conducted in 7 centers. Of 1586 participants who presented with acute dyspnea, 1538 (97%) had clinical certainty of CHF determined by the attending physician in the emergency department. Participants underwent routine care and had BNP measured in a blinded fashion. The reference standard for CHF was adjudicated by 2 independent cardiologists, also blinded to BNP results. The final diagnosis was CHF in 722 (47%) participants. At an 80% cutoff level of certainty of CHF, clinical judgment had a sensitivity of 49% and specificity of 96%. At 100 pg/mL, BNP had a sensitivity of 90% and specificity of 73%. In determining the correct diagnosis (CHF versus no CHF), adding BNP to clinical judgment would have enhanced diagnostic accuracy from 74% to 81%. In those participants with an intermediate (21% to 79%) probability of CHF, BNP at a cutoff of 100 pg/mL correctly classified 74% of the cases. The areas under the receiver operating characteristic curve were 0.86 (95% CI 0.84 to 0.88), 0.90 (95% CI 0.88 to 0.91), and 0.93 (95% CI 0.92 to 0.94) for clinical judgment, for BNP at a cutoff of 100 pg/mL, and for the 2 in combination, respectively (P <0.0001 for all pairwise comparisons). Conclusions—The evaluation of acute dyspnea would be improved with the addition of BNP testing to clinical judgment in the emergency department.

Society of Chest Pain Centers recommendations for the evaluation and management of the observation stay acute heart failure patient-parts 1-6.

Making the definitive diagnosis of heart failure in the acute care setting can be difficult. In the emergency department this needs to be done rapidly, frequently, and accurately, without access to a patient’s health records and while simultaneously initiating the appropriate diagnostic and therapeutic interventions. This section reviews the diagnostic strategies available to the physician confronted with a patient in whom the differential diagnosis includes acute heart failure. (Crit Pathways in Cardiol 2008;7: 91–95) Making the Diagnosis of Heart Failure When Patients Present With Symptoms Possibly Related to Acute Heart Failure Making the definitive diagnosis of heart failure (HF) in the acute care setting can be difficult. In the emergency department (ED) this needs to be done rapidly, frequently without access to a patient’s health records while simultaneously initiating the appropriate diagnostic and therapeutic interventions. The physician must determine the etiology of symptoms in patients with suspected HF based on the initial history, physical examination, diagnostic studies (laboratory data, electrocardiogram, and radiography), as well as response to empiric therapy. PubMed was searched in a systematic manner using a combination of search terms relevant to each topic specific to early diagnosis available in the emergency department setting. References from articles and guidelines so identified were also evaluated for additional pertinent literature. The Initial History and Physical Examination The most common symptom of HF is dyspnea. However, dyspnea is also common in the general population. Even in well persons, a lack of physical fitness may result in exertional dyspnea. Multiple other medical conditions also produce dyspnea, including chronic obstructive pulmonary disease (COPD), asthma, pneumonia, and myocardial ischemia (Table 1). In several studies and registries of presumed HF, up to 40% of patients had a history of COPD. Therefore, in the acute care setting, a chief complaint of dyspnea is very nonspecific. Other components of a complete history include assessment of abdominal distention, paroxysmal nocturnal dyspnea, orthopnea, fatigue, weakness, nausea, and vomiting. The presence of paroxysmal nocturnal dyspnea, orthopnea, or dyspnea on exertion increases the likelihood of HF, whereas their absence decreases its likelihood. One of the more reliable indicators that dyspnea is due to an acute exacerbation of HF is a previous history of HF. However, approximately 20% of patients admitted with acute heart failure have a history of COPD. A history is most beneficial when combined with other information but by itself will make the accurate diagnosis of HF challenging. Auscultation for an S3 gallop, assessment for jugular venous distension (JVD), auscultation for pulmonary rales, and assessment for leg edema should be part of the initial evaluation of a patient with suspected HF, and the presence of these signs increases the likelihood of HF. The absence of rales, edema, or JVD lowers the probability of HF. An S3 is difficult to detect in the emergency department. Electronic identification of an S3 should improve detection and diagnosis of HF, although studies have yet to show an effect on patient outcome.

The Impact of Race on the Acute Management of Chest Pain

OBJECTIVESnAfrican Americans with acute coronary syndromes receive cardiac catheterization less frequently than whites. The objective was to determine if such disparities extend to acute evaluation and non interventional treatment.nnnMETHODSnData on adults with chest pain (N = 7,935) presenting to eight emergency departments (EDs) were evaluated from the Internet Tracking Registry of Acute Coronary Syndromes. Groups were selected from final ED diagnosis: 1) acute myocardial infarction (AMI), n = 400; 2) unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI), n = 1,153; and 3) nonacute coronary syndrome chest pain (non-ACS CP), n = 6,382. American College of Cardiology/American Heart Association guidelines for AMI and UA/NSTEMI were used to evaluate racial disparities with logistic regression models. Odds ratios (ORs) were adjusted for age, gender, guideline publication, and insurance status. Non-ACS CP patients were assessed by comparing electrocardiographic (ECG)/laboratory evaluation, medical treatment, admission rates, and invasive and noninvasive testing for coronary artery disease (CAD).nnnRESULTSnAfrican Americans with UA/NSTEMI received glycoprotein IIb/IIIa receptor inhibitors less often than whites (OR, 0.41; 95% CI = 0.19 to 0.91). African Americans with non-ACS CP underwent ECG/laboratory evaluation, medical treatment, and invasive and noninvasive testing for CAD less often than whites (p < 0.05). Other nonwhites with non-ACS CP were admitted and received invasive testing for CAD less often than whites (p < 0.01). African Americans and other nonwhites with AMI underwent catheterization less frequently than whites (OR, 0.45; 95% CI = 0.29 to 0.71 and OR, 0.40; 95% CI = 0.17 to 0.92, respectively). A similar disparity in catheterization was noted in UA/NSTEMI therapy (OR, 0.53; 95% CI = 0.40 to 0.68 and OR, 0.68; 95% CI = 0.47 to 0.99).nnnCONCLUSIONSnRacial disparities in acute chest pain management extend beyond cardiac catheterization. Poor compliance with recommended treatments for ACS may be an explanation.

Identification of patients at risk by graded exercise testing in an emergency department chest pain center

The study applied a retrospective follow-up design to determine the prognostic effect of graded exercise testing (GXT) in patients with low- to moderate-risk chest pain evaluated in an emergency department 9-hour protocol chest pain center (CPC) from January 1, 1993 to August 1, 1996. The cohort of 1,209 patients were followed to the date of death or first adverse cardiac event up to 1 year after CPC admission. Cardiac events were defined as coronary artery bypass graft, percutaneous transluminal coronary angioplasty, cardiogenic shock, cardiac-related death, congestive heart failure admission, ventricular tachycardia/ventricular fibrillation arrest, and myocardial infarction. Patients with acute ST-segment elevation or depression of >1 mm, positive enzyme (creatine kinase myocardial band) testing, or unstable angina during their CPC evaluation were admitted without GXT testing. Statistical analysis included chi-square test for complication rates and Cox proportional-hazards modeling. Nine hundred fifty-eight of 1,209 patients underwent GXT testing. Patients with positive, inconclusive, and normal GXTs had complication rates of 36.8% (7 of 19), 3.4% (9 of 267), and 1.1% (5 of 456), respectively. After adjusting for age, sex, and race, the relative risk of complication was 38.9 (95% confidence interval 11.7 to 129.6) with a positive GXT, and 3.6 (95% confidence interval 1.2 to 10.7) with an inconclusive GXT compared with a normal GXT. The GXT is a good prognostic indicator of adverse cardiac events in low- to moderate-risk chest pain in patients evaluated in an emergency department CPC.

The role of cardiac markers in the emergency department

The emergency department (ED) evaluation of patients with potential acute coronary syndromes (ACS) has traditionally included initial cardiac marker testing for suspected acute myocardial infarction (AMI). While ED management decisions for patients with ACS have largely been based on history, physical examination, and a presenting 12-lead electrocardiogram (ECG), there is ample evidence that markers impact treatment decisions and provide risk stratification. Newer, more sensitive markers of myocardial necrosis have blurred the distinction between patients with and without classically defined AMI, and have focused attention on the continuum of ACS from angina to transmural Q-wave MI. Newer antiplatelet agents, the glycoprotein IIb/IIIa receptor blockers, are likely to receive increased ED utilization. This use will be partially driven by ED cardiac marker determination. Bedside, point-of-care testing is reliable technology that may shorten time to diagnosis and treatment of ACS in the emergency setting. The ED-based chest pain center (CPC) has become a popular tool to evaluate patients at low- to moderate-risk for ACS and a non-diagnostic ECG. Such centers use serial cardiac marker testing as a mainstay for evaluation and risk stratification. Cost issues have driven many diagnostic patient evaluations from the inpatient setting to such ED observation units. As this becomes more common for low- to moderate-risk patients with chest pain, serial assessment of cardiac markers, and their interpretation by emergency physicians, will become essential.

Continuous and bilevel positive airway pressure in the treatment of acute cardiogenic pulmonary edema.

Patients with acute cardiogenic pulmonary edema (ACPE) are commonly seen in the emergency department (ED). Although the majority of patients respond to conventional medical therapy, some patients require at least temporary ventilatory support. Traditionally, this has been accomplished via endotracheal intubation and mechanical ventilation, an approach that is associated with a small but significant rate of complications. The past 2 decades have witnessed increasing interest in methods of noninvasive ventilatory support (NVS), notably continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). We review the physiological consequences, clinical efficacy, and practical limitations of CPAP and BiPAP in the management of ACPE.

A randomized, placebo-controlled trial of early eptifibatide for non-ST-segment elevation acute coronary syndromes.

BACKGROUNDnThe acute benefits of platelet glycoprotein IIb/IIIa inhibitors for non-ST-segment elevation acute coronary syndromes (NSTE ACS) remain unclear.nnnMETHODSnIn this pilot trial, 311 patients with NSTE ACS were randomly assigned in the emergency department to double-blinded therapy with eptifibatide or placebo for 12 to 24 hours before crossover to open-label eptifibatide. Serial creatine-kinase MB (CK-MB) and quantitative cardiac troponin T levels were collected during the first 24 hours to assess the impact of early platelet glycoprotein IIb/IIIa blockade on infarct size as measured by cardiac markers.nnnRESULTSnMedian peak CK-MB (10.3 vs 11.8 ng/mL; P =.71) and peak quantitative cardiac troponin T levels (0.2 vs 0.3 ng/mL; P =.95) were similar between treatment groups, respectively. Median calculated peak CK-MB values (41 vs 40 ng/mL; P =.72) and area under the CK-MB curve measurements (980 vs 764 microg/min/L; P =.68) from curve-fitting analyses that could be performed in 106 of 311 patients were also similar.nnnCONCLUSIONSnIn this pilot trial, early administration of eptifibatide in the emergency department did not modulate serologic measurements of infarct size in patients with NSTE ACS.

Cocaine-associated chest pain in a chest pain center.

Chest pain is the most common cocaine-related complaint. The objective of this study was to describe an emergency department-based chest pain center for patients with cocaine-associated chest pain and to evaluate the safety of this protocol by assessing cardiac complications at 30 days.

Evaluation and management of acutely decompensated chronic heart failure in the emergency department.

A wide range of patients with symptomatic heart failure seek treatment in the emergency department. While there is no single approach to the diversity of patients with acutely decompensated heart failure, certain overarching principles apply. For patients with acute pulmonary edema or cardiogenic shock, the first priority must be rapid stabilization and treatment of reversible problems. For patients with less dramatic presentations, a more systematic search for precipitating factors may be required. Therapy, in general, is directed at reversing dyspnea and/or hypoxemia caused by pulmonary edema, improving systemic perfusion, and reducing myocardial oxygen demand. While morphine and diuretics still have their traditional roles, vasodilators and inotropic agents play an increasingly important part in the modern pharmacologic approach to decompensated heart failure in the emergency department. After evaluation and stabilization in the emergency department, most patients will require hospital admission, although a subset of low-risk patients may be appropriate for discharge to home following a period of observation. Strategies to optimize emergency department care are likely to have an impact upon patient outcomes and upon resource utilization. (c)2001 by CHF, Inc.

Emergency department prediction of heart failure by bedside physical examination

Study objectives: A variety of presenting symptoms and features of the bedside examination are all commonly used in the diagnosis and assessment of heart failure patients. We seek to determine the relative performance of presenting symptoms and features of the physical examination, including jugular venous distention (JVD), orthopnea, and computerized detection of abnormal heart sounds, in the emergency department (ED) for the diagnosis of heart failure. Methods: On presentation to the ED, and before treatment, patients with signs of heart failure had standardized reporting of symptoms and bedside examination (JVD, dyspnea, peripheral edema, paroxysmal nocturnal dyspnea, orthopnea), including a standard 12-lead ECG with acoustic signal recording for computerized detection of S3 using the validated AUDICOR algorithm (Inovise Medical, Inc.). Primary diagnosis of heart failure was based on hospital discharge diagnosis or ED diagnosis (if the patient was not admitted). Data were analyzed using logistic regression analysis. Wald values and P values are reported. Results: Of the 138 patients enrolled, 113 received full bedside examination and definitive diagnosis, 46 had a primary diagnosis of heart failure, and 67 had a non–heart failure diagnosis. Within the study population, there were 58.7% male patients in the heart failure group versus 44.8% male patients in the non–heart failure group, 67.4% black patients in the heart failure group versus 49.3% in the non–heart failure group, and the median age category was 66 to 70 years in the heart failure group versus 56 to 60 years in the non–heart failure group. Using a binary logistic regression model, features of bedside evaluation that were significant predictors of a primary diagnosis of heart failure ( R 2 =0.396) were the AUDICOR S3 heart sound (11.599, P =.001) and peripheral edema (9.784, P =.002). JVD (0.981, P =.322), dyspnea (3.001, P =.083), orthopnea (2.857, P =.091), and paroxysmal nocturnal dyspnea (0.208, P =.648) were not significant determinants of primary diagnosis of heart failure. Conclusion: For bedside diagnosis of heart failure, the third heart sound detected by the computerized AUDICOR algorithm and the presence of peripheral edema were the best predictors for a primary diagnosis of heart failure.