Alexander T. Limkakeng

Copeptin Helps in the Early Detection of Patients With Acute Myocardial Infarction Primary Results of the CHOPIN Trial (Copeptin Helps in the early detection Of Patients with acute myocardial INfarction)

OBJECTIVES The goal of this study was to demonstrate that copeptin levels <14 pmol/L allow ruling out acute myocardial infarction (AMI) when used in combination with cardiac troponin I (cTnI) <99 th percentile and a nondiagnostic electrocardiogram at the time of presentation to the emergency department (ED). BACKGROUND Copeptin is secreted from the pituitary early in the course of AMI. METHODS This was a 16-site study in 1,967 patients with chest pain presenting to an ED within 6 hours of pain onset. Baseline demographic characteristics and clinical data were collected prospectively. Copeptin levels and a contemporary sensitive cTnI (99 th percentile 40 ng/l; 10% coefficient of variation 0.03 μg/l) were measured in a core laboratory. Patients were followed up for 180 days. The primary outcome was diagnosis of AMI. Final diagnoses were adjudicated by 2 independent cardiologists blinded to copeptin results. RESULTS AMI was the final diagnosis in 156 patients (7.9%). A negative copeptin and cTnI at baseline ruled out AMI for 58% of patients, with a negative predictive value of 99.2% (95% confidence interval: 98.5 to 99.6). AMIs not detected by the initial cTnI alone were picked up with copeptin >14 pmol/l in 23 (72%) of 32 patients. Non-ST-segment elevation myocardial infarctions undetected by cTnI at 0 h were detected with copeptin >14 pmol/l in 10 (53%) of 19 patients. Projected average time-to-decision could be reduced by 43% (from 3.0 h to 1.8 h) by the early rule out of 58% of patients. Both abnormal copeptin and cTnI were predictors of death at 180 days (p < 0.0001 for both; c index 0.784 and 0.800, respectively). Both were independent of age and each other and provided additional predictive value (all p < 0.0001). CONCLUSIONS Adding copeptin to cTnI allowed safe rule out of AMI with a negative predictive value >99% in patients presenting with suspected acute coronary syndromes. This combination has the potential to rule out AMI in 58% of patients without serial blood draws.

High Exposure to Organophosphate Flame Retardants in Infants: Associations with Baby Products.

Infant products containing polyurethane foam are commonly treated with organophosphate flame retardants (PFRs), including tris(1,3-dichloro-2-propyl)phosphate (TDCIPP) and triphenyl phosphate (TPHP). Infants may have greater exposure due to greater contact with these products, yet little is known about levels of exposure or the factors contributing to higher exposure. We recruited children age 2-18 months from North Carolina to investigate PFR exposure (n = 43; recruited 2014-2015). Parents provided information on potential sources and modifiers of exposure, and reported whether they owned common infant products. We measured five PFR metabolites in urine samples collected from children. TDCIPP and TPHP metabolites (bis(1,3-dichloro-2-propyl) phosphate (BDCIPP) and diphenyl phosphate (DPHP)) were most commonly detected (>93% detect). Other metabolites were detected infrequently (<35% detect). Although we did not observe a clear age trend for infants, BDCIPP levels were substantially higher than those reported for adults (geometric mean = 7.3 ng/mL). The number of infant products owned was strongly associated with BDCIPP; children with >16 products had BDCIPP levels that were 6.8 times those with <13 (p = 0.02). Infants attending daycare centers also had higher BDCIPP levels (3.7 times those of others; p = 0.07), suggesting time spent in this microenvironment contributes to higher exposure. In contrast, DPHP levels were not related to products owned, time in different microenvironments, or behavior.

Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest

BACKGROUND Point-of-care ultrasound has been suggested to improve outcomes from advanced cardiac life support (ACLS), but no large studies have explored how it should be incorporated into ACLS. Our aim was to determine whether cardiac activity on ultrasound during ACLS is associated with improved survival. METHODS We conducted a non-randomized, prospective, protocol-driven observational study at 20 hospitals across United States and Canada. Patients presenting with out-of-hospital arrest or in-ED arrest with pulseless electrical activity or asystole were included. An ultrasound was performed at the beginning and end of ACLS. The primary outcome was survival to hospital admission. Secondary outcomes included survival to hospital discharge and return of spontaneous circulation. FINDINGS 793 patients were enrolled, 208 (26.2%) survived the initial resuscitation, 114 (14.4%) survived to hospital admission, and 13 (1.6%) survived to hospital discharge. Cardiac activity on US was the variable most associated with survival at all time points. On multivariate regression modeling, cardiac activity was associated with increased survival to hospital admission (OR 3.6, 2.2-5.9) and hospital discharge (OR 5.7, 1.5-21.9). No cardiac activity on US was associated with non-survival, but 0.6% (95% CI 0.3-2.3) survived to discharge. Ultrasound identified findings that responded to non-ACLS interventions. Patients with pericardial effusion and pericardiocentesis demonstrated higher survival rates (15.4%) compared to all others (1.3%). CONCLUSION Cardiac activity on ultrasound was the variable most associated with survival following cardiac arrest. Ultrasound during cardiac arrest identifies interventions outside of the standard ACLS algorithm.

Preferences for cardiac tests and procedures may partially explain sex but not race disparities

OBJECTIVE There are known race and sex differences in emergent cardiac care. Many feel these differences reflect a bias from the physician. We hypothesized these differences may be the result of patient preferences. METHODS Emergency department (ED) patients 40 years and older with a chief complaint of chest pain were surveyed from July 11 through December 9, 2005, at 2 academic EDs. This prospective survey study included demographics and prior cardiac test experience. Preferences for hypothetical cardiac tests and procedures were compared between race and sex using chi(2) or Fisher exact tests. RESULTS Two hundred sixteen patients were enrolled. The mean age was 55 +/- 12 years (43% men and 51% black). Blacks compared with whites preferred the electrocardiogram (ECG) to the technetium-99m sestamibi (MIBI) stress test. Blacks also preferred a percutaneous coronary intervention (PCI) compared with whites who were more likely to forego PCI. These racial differences disappeared when a physician recommended a procedure. There were no race preferences between PCI vs coronary artery bypass graft, whether or not a doctor recommended the procedure. For sex, there were no preferences between ECG vs MIBI stress test or cardiac catheterization, whether or not a doctor recommended the test or procedure. With regard to a choice between PCI and coronary artery bypass graft, women were more likely to decline the procedure than men. Even with a physician-recommended procedure, women were more likely to refuse than men, whereas men were more likely to accept it. CONCLUSIONS Blacks were more likely to prefer the less invasive stress test and wanted PCIs more, but these racial differences disappeared when a physician-recommended test was offered. Women were more likely to refuse the most invasive cardiac procedure compared with men. The sex-related preferences might partially explain why women receive fewer invasive cardiac procedures than men. However, race-related cardiac preferences suggest that other factors beyond patient preference account for fewer PCIs in black patients.

Validation of the modified Sgarbossa criteria for acute coronary occlusion in the setting of left bundle branch block: A retrospective case-control study

BACKGROUND The modified Sgarbossa criteria were proposed in a derivation study to be superior to the original criteria for diagnosing acute coronary occlusion (ACO) in left bundle branch block (LBBB). The new rule replaces the third criterion (5 mm of excessively discordant ST elevation [STE]) with a proportion (at least 1 mm STE and STE/S wave ≤-0.25). We sought to validate the modified criteria. METHODS This retrospective case-control study was performed by chart review in 2 tertiary care center emergency departments (EDs) and 1 regional referral center. A billing database was used at 1 site to identify all ED patients with LBBB and ischemic symptoms between May 2009 and June 2012. In addition, all 3 sites identified LBBB ACO patients who underwent emergent catheterization. We measured QRS amplitude and J-point deviation in all leads, blinded to outcomes. Acute coronary occlusion was determined by angiographic findings and cardiac biomarker levels, which were collected blinded to electrocardiograms. Diagnostic statistics of each rule were calculated and compared using McNemars test. RESULTS Our consecutive cohort search identified 258 patients: 9 had ACO, and 249 were controls. Among the 3 sites, an additional 36 cases of ACO were identified, for a total of 45 ACO cases and 249 controls. The modified criteria were significantly more sensitive than the original weighted criteria (80% vs 49%, P < .001) and unweighted criteria (80% vs 56%, P < .001). Specificity of the modified criteria was not statistically different from the original weighted criteria (99% vs 100%, P = .5) but was significantly greater than the original unweighted criteria (99% vs 94%, P = .004). CONCLUSIONS The modified Sgarbossa criteria were superior to the original criteria for identifying ACO in LBBB.

Emergency Physician High Pretest Probability for Acute Coronary Syndrome Correlates with Adverse Cardiovascular Outcomes

OBJECTIVES The value of unstructured physician estimate of risk for disease processes, other than acute coronary syndrome (ACS), has been demonstrated. The authors sought to evaluate the predictive value of unstructured physician estimate of risk for ACS in emergency department (ED) patients without obvious initial evidence of a cardiac event. METHODS This was a post hoc secondary analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospectively collected multicenter data registry of patients over the age of 18 years presenting to the ED with symptoms of ACS between 1999 and 2001. In this registry, following patient history, physical exam, and electrocardiogram (ECG), the unstructured treating physician estimate of risk was recorded. A 30-day follow-up and a medical record review were used to determine rates of adverse cardiac events, death, myocardial infarction (MI), or revascularization procedure. The analysis included all patients with nondiagnostic ECG changes, normal initial biomarkers, and a non-MI initial impression from the registry and excluded those without complete data or who were lost to follow-up. Data were stratified by unstructured physician risk estimate: noncardiac, low risk, high risk, or unstable angina. RESULTS Of 15,608 unique patients in the registry, 10,145 met inclusion/exclusion criteria. Patients were defined as having unstable angina in 6.0% of cases; high risk, 23.5% of cases; low risk, 44.2%; and noncardiac, 26.3% of cases. Adverse cardiac event rates had an inverse relationship, decreasing from 22.0% (95% confidence interval [CI] = 18.8% to 25.6%) for unstable angina, 10.2% (95% CI = 9.0% to 11.5%) for those stratified as high risk, 2.2% (95% CI = 1.8% to 2.6%) for low risk, and to 1.8% (95% CI = 1.4% to 2.4%) for noncardiac. The relative risk (RR) of an adverse cardiac event for those with an initial label of unstable angina compared to those with a low-risk designation was 10.2 (95% CI = 8.0 to 13.0). The RR of an event for those with a high-risk initial impression compared to those with a low-risk initial impression was 4.7 (95% CI = 3.8 to 5.9). The risk of an event among those with a low-risk initial impression was the same as for those with a noncardiac initial impression (RR = 0.83, 95% CI = 0.6 to 1.2). CONCLUSIONS In ED patients without obvious initial evidence of a cardiac event, unstructured emergency physician (EP) estimate of risk correlates with adverse cardiac outcomes.

A multicenter analysis of the ED diagnosis of pneumonia

OBJECTIVES The objective of this study was to describe the prevalence of pneumonia-like signs and symptoms in patients admitted from the emergency department (ED) with a diagnosis of community acquired pneumonia (CAP) but subsequently discharged from the hospital with a nonpneumonia diagnosis. METHODS A retrospective, structured, chart review of ED patients with CAP at 3 academic hospitals was performed by trained extractors on all adult patients admitted for CAP. Demographic data, Pneumonia Patient Outcomes Research Team scores, and discharge diagnosis data (International Classification of Diseases, Ninth Revision [ICD-9] codes) were extracted using a predetermined case report form. RESULTS A total of 800 patients were admitted from the ED with a diagnosis of CAP from the 3 hospitals, and 219 (27.3%; 95% confidence interval [CI], 24-31) ultimately had a nonpneumonia diagnosis upon discharge. Characteristics of this group included a mean age of 62.6 years, 50% female, and a history of congestive heart failure (CHF) (14%) or cancer (12%). After excluding patients with missing data, 123 patients (65%) had an abnormal chest x-ray, and 13% had abnormal oxygen saturation. Cough, sputum production, fever, tachypnea, or leukocytosis were present in 91.5% of this cohort, and 63.8% had at least 2 of these findings. Twenty alternate ICD-9s were identified, including non-CAP pulmonary disease (18%; 95% CI, 13-24), renal disease (16%; 95% CI, 13-19), other infections (9%; 95% CI, 7-11), cardiovascular diseases (3%; 95% CI, 2-4), and other miscellaneous diagnosis (28%; 95% CI, 25-31). CONCLUSIONS Our data suggest that the ED diagnosis of CAP frequently differs from the discharge diagnosis. This may be due to the fact that a diagnosis of CAP relies on a combination of potentially nonspecific clinical and radiographic features. New diagnostic approaches and tools with better specificity are needed to improve ED diagnosis of CAP.

An observation unit may help improve an institution's Press Ganey satisfaction score.

BACKGROUND : Hospitals measure patient satisfaction through Press Ganey (PG) surveys. The impact of an emergency department observation unit (EDOU) on patient satisfaction has not been reported to date. We hypothesize that an EDOU has a positive impact on patient satisfaction results as measured by PG surveys. METHODS : This is a retrospective observational analysis of PG scores collected for 8 quarters before the opening of a 13-bed EDOU in January 2002 and compared with 6 quarters post-EDOU opening, starting April 1, 2003, at a tertiary care, academic, urban hospital. The facility, physician staffing, nursing, and wait times all remained the same during this period. Mean values and a 95% confidence interval (CI) are reported and statistical significance is calculated using a t test. Significance is defined as a P < 0.05. RESULTS : The mean overall PG scores pre-EDOU was 75.2 (95% CI: 74.2-76.2) and post-EDOU was 80.2 (95% CI: 78.9-82.6), which is statistically significant (P = 0.00005). Of 9 scoring categories, 9 increased post-EDOU. Other than the category for physician scores, all other mean values were higher for the EDOU in the subcategories. CONCLUSION : The introduction of an observation unit appears to be associated with a statistical improvement in patient satisfaction scores as reported by PG, in the setting of same facility, physician staffing, and nursing staffing.

Cardiac Evaluation for Structural Abnormalities May Not Be Required in Patients Presenting With Syncope and a Normal ECG Result in an Observation Unit Setting

STUDY OBJECTIVE Patients with syncope are frequently managed in observation units and receive serial examinations, monitoring for arrhythmias, and structural analysis of the heart. The primary aim of this study is to determine the utility of structural analysis of the heart in syncope patients who are being managed in an observation unit and have a normal ECG result. METHODS This is a retrospective, observational chart review of all consecutive adult patients observed during 18 months at an urban, academic medical center. A case report form with demographics, ECG interpretations, and structural analysis of the heart data was generated and all variables were defined before data extraction. Subjects with an ECG demonstrating any arrhythmia, premature atrial contraction, premature ventricular contraction, pacing, second- and third-degree blocks, and left bundle branch block were excluded from the normal ECG group. An abnormal cardiac structure was defined as an ejection fraction less than 45%, severe hypertrophy, or severe valvular abnormality. Ten percent of cases were evaluated by a second extractor to verify accuracy. Descriptive statistics with confidence intervals (CIs) and interquartile ranges (IQRs; 25%, 75%) are used. RESULTS Three hundred twenty-three subjects were managed in the observation unit for syncope, 48% were men, and their median age was 66 years (25%, 75% IQR 52, 80). Two of 323 (0.6%; 95% CI 0.2% to 2.2%) had an arrhythmia; 1 of 323 had a non-ST-segment myocardial infarction (0.3%; 95% CI 0.1% to 1.7%). Of the 323 patients, 267 had a normal ECG result and 235 (88%) had their cardiac structure evaluated. Forty-eight percent of the normal ECG group were men, and the median age was 65 years (25%, 75% IQR 52, 79). Zero of 235 patients (0%; 95% CI 0% to 1.6%) had a structural abnormality identified on evaluation, and 2 of 18 (11%; 95% CI 3.1% to 32.8%) had an abnormal stress echocardiogram result. CONCLUSION Structural abnormalities are unlikely in syncope patients with a normal ECG result. Care should focus on excluding arrhythmias and acute coronary syndrome.

Efficacy of high-sensitivity troponin T in identifying very-low-risk patients with possible acute coronary syndrome

Importance Physicians need information on how to use the first available high-sensitivity troponin (hsTnT) assay in the United States to identify patients at very low risk for 30-day adverse cardiac events (ACE). Objective To determine whether a negative hsTnT assay at 0 and 3 hours following emergency department presentation could identify patients at less than 1% risk of a 30-day ACE. Design, Setting, and Participants A prospective, observational study at 15 emergency departments in the United States between 2011 and 2015 that included individuals 21 years and older, presenting to the emergency department with suspected acute coronary syndrome. Of 1690 eligible individuals, 15 (no cardiac troponin T measurement) and 320 (missing a 0-hour or 3-hour sample) were excluded from the analyses. Exposures Serial hsTnT measurements (fifth-generation Roche Elecsys hsTnT assay). Main Outcomes and Measures Serial blood samples from each patient were collected after emergency department presentation (once identified as a potential patient with acute coronary syndrome) and 3 hours, 6 to 9 hours, and 12 to 24 hours later. Adverse cardiac events were defined as myocardial infarction, urgent revascularization, or death. The upper reference level for the hsTnT assay, defined as the 99th percentile, was established as 19 ng/L in a separate healthy US cohort. Patients were considered ruled out for acute myocardial infarction if their hsTnT level at 0 hours and 3 hours was less than the upper reference level. Gold standard diagnoses were determined by a clinical end point committee. Evaluation of assay clinical performance for acute myocardial infarction rule-out was prespecified; the hypothesis regarding 30-day ACE was formulated after data collection. Results In 1301 healthy volunteers (50.4% women; median age, 48 years), the upper reference level was 19 ng/L. In 1600 patients with suspected acute coronary syndrome (48.4% women; median age, 55 years), a single hsTnTlevel less than 6 ng/L at baseline had a negative predictive value for AMI of 99.4%. In 974 patients (77.1%) with both 0-hour and 3-hour hsTnT levels of 19 ng/L or less, the negative predictive value for 30-day ACE was 99.3% (95% CI, 99.1-99.6). Using sex-specific cutpoints, C statistics for women (0.952) and men (0.962) were similar for acute myocardial infarction. Conclusions and Relevance A single hsTnT level less than 6 ng/L was associated with a markedly decreased risk of AMI, while serial levels at 19 ng/L or less identified patients at less than 1% risk of 30-day ACE.