Arvin Lamanna

2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial.

OBJECTIVES The purpose of this study was to determine whether a new accelerated diagnostic protocol (ADP) for possible cardiac chest pain could identify low-risk patients suitable for early discharge (with follow-up shortly after discharge). BACKGROUND Patients presenting with possible acute coronary syndrome (ACS), who have a low short-term risk of adverse cardiac events may be suitable for early discharge and shorter hospital stays. METHODS This prospective observational study tested an ADP that included pre-test probability scoring by the Thrombolysis In Myocardial Infarction (TIMI) score, electrocardiography, and 0 + 2 h values of laboratory troponin I as the sole biomarker. Patients presenting with chest pain due to suspected ACS were included. The primary endpoint was major adverse cardiac event (MACE) within 30 days. RESULTS Of 1,975 patients, 302 (15.3%) had a MACE. The ADP classified 392 patients (20%) as low risk. One (0.25%) of these patients had a MACE, giving the ADP a sensitivity of 99.7% (95% confidence interval [CI]: 98.1% to 99.9%), negative predictive value of 99.7% (95% CI: 98.6% to 100.0%), specificity of 23.4% (95% CI: 21.4% to 25.4%), and positive predictive value of 19.0% (95% CI: 17.2% to 21.0%). Many ADP negative patients had further investigations (74.1%), and therapeutic (18.3%) or procedural (2.0%) interventions during the initial hospital attendance and/or 30-day follow-up. CONCLUSIONS Using the ADP, a large group of patients was successfully identified as at low short-term risk of a MACE and therefore suitable for rapid discharge from the emergency department with early follow-up. This approach could decrease the observation period required for some patients with chest pain. (An observational study of the diagnostic utility of an accelerated diagnostic protocol using contemporary central laboratory cardiac troponin in the assessment of patients presenting to two Australasian hospitals with chest pain of possible cardiac origin; ACTRN12611001069943).

The new Vancouver Chest Pain Rule using troponin as the only biomarker: an external validation study

OBJECTIVES To externally evaluate the accuracy of the new Vancouver Chest Pain Rule and to assess the diagnostic accuracy using either sensitive or highly sensitive troponin assays. METHODS Prospectively collected data from 2 emergency departments (EDs) in Australia and New Zealand were analysed. Based on the new Vancouver Chest Pain Rule, low-risk patients were identified using electrocardiogram results, cardiac history, nitrate use, age, pain characteristics and troponin results at 2 hours after presentation. The primary outcome was 30-day diagnosis of acute coronary syndrome (ACS), including acute myocardial infarction, and unstable angina. Sensitivity, specificity, positive predictive values and negative predictive values were calculated to assess the accuracy of the new Vancouver Chest Pain Rule using either sensitive or highly sensitive troponin assay results. RESULTS Of the 1635 patients, 20.4% had an ACS diagnosis at 30 days. Using the highly sensitive troponin assay, 212 (13.0%) patients were eligible for early discharge with 3 patients (1.4%) diagnosed with ACS. Sensitivity was 99.1% (95% CI 97.4-99.7), specificity was 16.1 (95% CI 14.2-18.2), positive predictive values was 23.3 (95% CI 21.1-25.5) and negative predictive values was 98.6 (95% CI 95.9-99.5). The diagnostic accuracy of the rule was similar using the sensitive troponin assay. CONCLUSIONS The new Vancouver Chest Pain Rule should be used for the identification of low risk patients presenting to EDs with symptoms of possible ACS, and will reduce the proportion of patients requiring lengthy assessment; however we recommend further outpatient investigation for coronary artery disease in patients identified as low risk.

Comparison of Three Risk Stratification Rules for Predicting Patients With Acute Coronary Syndrome Presenting to an Australian Emergency Department

OBJECTIVES To compare the predictive ability of three risk stratification tools used to assess patients presenting to the ED with potential acute coronary syndrome. DESIGN Pre-planned analysis of an observational study. SETTING A single tertiary referral hospital. PARTICIPANTS 1495 patients presented with chest pain. 948 patients were screened and enrolled. Patients with at least 5 min of chest pain suggestive of ACS were eligible. INTERVENTIONS Subjects were risk categorised using the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines (HFA/CSANZ), the TIMI score and the GRACE score. Three strata of the TIMI and GRACE score were used to compare to the HFA/CSANZ risk categories. MAIN OUTCOME MEASUREMENT 30-Day cardiac event rates including cardiac death, acute myocardial infarction and unstable angina. RESULTS There were 152 events in 91 patients (9.6%). The discriminatory ability of the scores determined by the AUC was 0.83 (95% CI 0.79-0.87) for the GRACE score, 0.79 (95% CI 0.74-0.83) for TIMI score and 0.75 (95% CI 0.70-0.80) for HFA/CSANZ. The AUCs with three strata of the GRACE and TIMI scores were 0.76 (95% CI 0.72-0.81) and 0.68 (95% CI 0.62-0.73) respectively. CONCLUSIONS All three scores were similar in performance in quantifying risk in ED patients with possible ACS. The GRACE score identified a sizable low risk cohort with high sensitivity and NPV but complexity of this tool may limit its utility. Improved scores are needed to allow early identification of low- and high-risk patients to support improvements in patient flow and ED overcrowding.

Valvular and Aortic Diseases in Osteogenesis Imperfecta

Osteogenesis imperfecta (OI) is an inheritable connective tissue disorder caused by defective collagen synthesis with the principal manifestations of bone fragility. OI has been associated with left sided valvular regurgitation and aortic dilation. Valve and aortic surgery are technically feasible in patients with OI but are inherently high risk due to the underlying connective tissue defect. This report reviews the valvular and aortic pathology associated with OI and their management. We describe two cases of patients with OI who have significant aortic and mitral valve regurgitation, one of whom has been managed conservatively and the other who has undergone successful mitral valve repair and aortic valve replacement. The latter case represents the fifth case of mitral valve repair in a patient with OI reported in the medical literature.

Comparison of early biomarker strategies with the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for risk stratification of emergency department patients with chest pain.

To compare cardiac risk stratification using a 0 and 2 h point‐of‐care (POC) cardiac troponin (cTn), 0 and 2 h POC multi‐biomarkers against the 0 and 6 h laboratory cTn reference standard.

Limited utility of exercise stress testing in the evaluation of suspected acute coronary syndrome in patients aged less than 40 years with intermediate risk features.

National guidelines for management of intermediate risk patients with suspected acute coronary syndrome, in whom AMI has been excluded, advocate provocative testing to final risk stratify these patients into low risk (negative testing) or high risk (positive testing suggestive of unstable angina). Adults less than 40 years have a low pretest probability of acute coronary syndrome. The utility of exercise stress testing in young adults with chest pain suspected of acute coronary syndrome who have National Heart Foundation intermediate risk features was evaluated.

Performance of Risk Stratification for Acute Coronary Syndrome with Two-hour Sensitive Troponin Assay Results

BACKGROUND Risk stratification processes for patients with possible acute coronary syndrome (ACS) recommend the use of serial sensitive troponin testing over at least 6h. Troponin assays vary in their analytical performance. Utility in accurate risk stratification at 2h post-presentation is unknown. METHODS A diagnostic accuracy study of patients presenting to the emergency department (ED) with symptoms of ACS was performed. Troponin was measured at 0, 2 and 6h post-presentation. Acute myocardial infarction (AMI) was adjudicated by cardiologists and incorporated the 0 and 6h troponin values measured by a sensitive troponin assay. Results were described using standard measures of test accuracy. RESULTS Of the 685 patients, 51 (7.4%) had 30-day AMI or cardiac death, and 76 (11.1%) had secondary outcomes (all cause death, ACS and revascularisation procedures). There was no significant difference in the diagnostic accuracy of early versus late biomarker strategies when used with the current risk stratification processes. Incorporation of a significant delta did not improve the stratification at 2h post-presentation. CONCLUSIONS Accelerated risk stratification of patients with ACS symptoms may occur at 2h post-presentation using troponin results measured by a sensitive assay. Incorporation of such a strategy could support improvements in patient flow within EDs.

Excessive Daytime Sleepiness and Sleep Disordered Breathing in Stable Heart Failure Patients

considered preventable. Readmission monitoring is a key performance indicator for Heart Failure Management Programmes (HF-MPs). Aim: To investigate the underlying causes, contributing factors and incidence of unplanned hospital readmissions for HF patients. Methods:A sixmonth prospective studywas performed at the PrincessAlexandraHospital, a tertiary referral facility. A convenience sample of 50 adult patientsmanaged by theHF-MPwas recruited.Health literacywas assessed.All unplanned admissions were investigated with admission interview andworksheet. At six months hospital readmissions were verified by patients, patient medical records and electronic databases. Results: Participants mean age was 70 (±11.6), 38 (76%) were male, 11 (22%) had inadequate health literacy. Of the 45 (90%) patients with systolic HF, 35 (78%) had an ejection fraction (EF)≤ 30%. There were 46 unplanned readmissions during six month follow-up, 28 were HF related and involved 17 patients (HF readmissions 34%). Six of these patients had >1 readmission and six (12%) patients died. Of the patients readmitted for HF, 82% had systolic HF with EF≤ 30%, and an average length of stay of seven (±5.7) days. Thirty days readmission rate was 12%. Eighty-six percent of patients readmitted with HF were on optimal medical therapy including beta blocker, ACE inhibitor/Angiotensin II receptor antagonist and mineralocorticoid receptor antagonist. All patients received self-care education and early follow-up from multi-disciplinary HF clinicians. Conclusion:Unplanned HF readmissions in this cohort of patients with severe systolic HF are common despite optimal medical therapy and intensive HF-MPs. http://dx.doi.org/10.1016/j.hlc.2013.05.182

Comparison of early biomarker strategies with the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for risk stratification of emergency department patients with chest pain: Early biomarker strategies

To compare cardiac risk stratification using a 0 and 2 h point‐of‐care (POC) cardiac troponin (cTn), 0 and 2 h POC multi‐biomarkers against the 0 and 6 h laboratory cTn reference standard.

Comparison of early biomarker strategies with the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for risk stratification of ED patients with chest pain

To compare cardiac risk stratification using a 0 and 2 h point‐of‐care (POC) cardiac troponin (cTn), 0 and 2 h POC multi‐biomarkers against the 0 and 6 h laboratory cTn reference standard.