Frank D. Sites

Lack of utility of telemetry monitoring for identification of cardiac death and life-threatening ventricular dysrhythmias in low-risk patients with chest pain.

STUDY OBJECTIVE Low-risk patients with chest pain are often admitted to monitored beds; however, the use of telemetry beds in this cohort is not evidence based. We tested the hypothesis that monitoring admitted low-risk patients with chest pain for dysrhythmia is low yield (<1% detection of life-threatening dysrhythmias requiring treatment). METHODS We conducted a prospective cohort study of emergency department (ED) patients with chest pain with a Goldman risk score of less than 8%, a normal initial creatine kinase-MB level, and a negative initial troponin I level admitted to non-ICU monitored beds. Investigators followed the hospital course daily. The main outcome was cardiovascular death and life-threatening ventricular dysrhythmia during telemetry. RESULTS Of 3,681 patients with chest pain who presented to the ED, 1,750 patients were admitted to non-ICU monitored beds. Of these, 1,029 patients had a Goldman risk score of less than 8%, a troponin I level of less than 0.3 ng/mL, and a creatine kinase-MB level of less than 5 ng/mL (accounting for 59% of all chest pain telemetry admissions). During hospitalization, there were no patients with sustained ventricular tachycardia/ventricular fibrillation requiring treatment on the telemetry service (0%; 95% confidence interval [CI] 0% to 0.3%). There were 2 deaths: neither was cardiovascular in nature or preventable by monitoring (cardiovascular preventable death rate=0%; 95% CI 0.0% to 0.3%). CONCLUSION The routine use of telemetry monitoring for low-risk patients with chest pain is of limited utility. Admission to nonmonitored beds might help alleviate ED crowding without increasing risk of adverse events caused by dysrhythmia in patients with a Goldman risk of less than 8%, an initial troponin I level of less than 0.3 ng/mL, and a creatine kinase-MB level of less than 5 ng/mL.

Impact of stress testing on 30-day cardiovascular outcomes for low-risk patients with chest pain admitted to floor telemetry beds

The role of immediate stress testing in low-risk patients with a potential acute coronary syndrome has not been rigorously evaluated with respect to impact on 30-day cardiovascular events. We evaluated the impact of inpatient, outpatient, or no stress testing (ETT) on 30-day cardiovascular outcomes. We performed a prospective cohort study in which consecutive patients with chest pain were admitted to a non-intensive-care telemetry bed over 16 months. Patients were identified in the ED, followed daily through hospitalization, and contacted by telephone at 30 days. Patients were excluded if they were admitted to the coronary care unit, died during hospitalization, sustained an acute myocardial infarction (AMI), or received cardiac catheterization before ETT. Patients were stratified according to whether they received an ETT as an inpatient, outpatient, or no ETT. Main outcomes were 30-day cardiac death, AMI, percutaneous interventions (PCI), and coronary artery bypass graft surgery (CABG). Data are presented as percentages with 95% confidence intervals (CI) for main outcomes. A total of 832 patients were admitted 962 times. A total of 205 patients (21%) received an in-house ETT. Seventy-four patients (10%) without an inpatient ETT received an outpatient ETT. At baseline, the groups were similar with respect to likelihood of ischemia based on mean ACI-TIPI score and Goldman risk score. A total of 98% of patients had 30-day follow-up. The cardiovascular outcomes (with 95% confidence interval) for patients with inpatient ETT versus outpatient ETT versus no ETT were as follows: death, 0% (0-1.5%) vs 0% (0-4.1%) vs 1% (0.3-1.7%); AMI, 1% (0.1-2.4%) vs 1.4% (0.1-4.1%) vs 0.3% (0.1-0.7%); PCI, 0.5% (0.1-1.5%) vs 1.3% (0.1-4.1%) vs 0% (0-0.4%); and CABG, 0.5% (0.1-1.5%) vs 0% (0-4.1%) vs 0.2% (0.1-0.4%). There was no statistical difference in 30-day cardiovascular outcomes among patients who received inpatient, outpatient, or no ETT within 30 days. This suggests that patients with chest pain who are admitted to non-intensive-care telemetry (or observation unit) beds might not need stress testing before hospital release.

Prospective evaluation of Emergency Department patients with potential coronary syndromes using initial absolute CK-MB vs. CK-MB relative index

We compared the predictive properties of an initial absolute creatine kinase-MB (CK-MB) to creatine kinase-MB relative index (CK-MB RI) for detecting acute myocardial infarction (AMI), acute coronary syndromes (ACS), and serious cardiac events (SCE). Consecutive patients > 24 years of age with chest pain who received an electrocardiogram (EKG) as part of their Emergency Department (ED) evaluation had CK and CK-MB drawn at presentation. Patients were followed prospectively during their hospital course. The main outcome was AMI, ACS or SCE (death, AMI, dysrhythmias, CHF, PTCA/stent, CABG) within 30 days. The sensitivity, specificity, PPV and NPV of CK-MB and CK-MB RI to predict AMI, ACS, and SCE were calculated with 95% CIs. We enrolled 2028 patients. There were 105 patients (5.2%) with AMI, 266 (13.1%) with ACS, and 150 with SCE (7.4%). Absolute CK-MB had a higher sensitivity than CK-MB RI for AMI (52.0 vs. 46.9, respectively), ACS (23.5 vs. 20.8, respectively), and SCE (39.6 vs. 36.0, respectively), but a lower specificity than CK-MB RI for AMI (93.2 vs. 96.1, respectively), ACS (93.1 vs. 96.1, respectively) and SCE (93.3 vs. 96.3, respectively); and lower PPV for AMI (35.7 vs. 46.5, respectively), ACS (42.0 vs. 53.4, respectively) and SCE (38.5 vs. 50.5, respectively). The negative predictive values were similar for all outcomes. We conclude that the risk stratification of ED chest pain patients by absolute CK-MB has higher sensitivity, similar NPV, but a lower specificity and PPV than CK-MB relative index for detection of AMI, ACS, and SCE. The optimal test depends upon the relative importance of the sensitivity or specificity for clinical decision-making in an individual patient.

A randomized study of electronic mail versus telephone follow-up after emergency department visit

This study was conducted to determine whether electronic mail (e-mail) increases contact rates after patients are discharged from the emergency department (ED). Following discharge, patients were randomized to be contacted by telephone or e-mail. The main outcome was success of contact. Secondary outcome was the median time of response. There were 1561 patients initially screened. Of these, 444 had e-mail and were included in the study. Half were contacted by telephone and the rest via e-mail. Our telephone contact rate was 58% (129/222) after two calls in a 48-h period and our e-mail contact was 41% (90/222). The telephone was nearly two times better than e-mail. The median time of response was 48 h for e-mail and 18 h for telephone. It is concluded that the telephone is a better modality of contact than e-mail for patients discharged from the ED.

Congestive Heart Failure Patients with Chest Pain: Incidence and Predictors of Acute Coronary Syndrome

OBJECTIVE New diagnostic and treatment options for emergency department (ED) patients with congestive heart failure (CHF) may facilitate the ED discharge of some patients. However, some patients require admission to exclude concurrent acute coronary syndrome (ACS) as the precipitant of CHF. The objective of this study was to identify the incidence, clinical characteristics, and hospital course of CHF patients who present to the ED with and without concurrent ACS. METHODS This was a prospective cohort study of consecutive patients >23 years of age who presented to the ED with chest pain, received an electrocardiogram (ECG), and either had a known history of CHF or presented with new-onset CHF, between July 1999 and April 2001. The hospital course of each patient was followed daily, and telephone follow-up occurred at 30 days. The main outcomes were the incidence of ACS and comparisons of lengths of hospital stay (LOSs), rates of admission to the intensive care unit (ICU), intubations, and death rates among patients with and without ACS. RESULTS Two hundred ninety-eight CHF patients presented 380 times. The incidence of ACS in the 380 patient visits was 32% (95% CI = 27% to 36%). Compared with patients who did not have ACS, patients who had concurrent ACS were more likely to have known coronary artery disease (CAD) (67% vs. 42%; p < 0.0001) and hypercholesterolemia (36% vs. 18%; p = 0.0002). Patients with concurrent ACS were also more likely to be admitted to the hospital (97% vs 82%; p < 0.0001), had a longer LOS (5.2 [3.9-6.5] vs 3.2 [2.6-3.8] days; p = 0.006), had higher rates of ICU admission (44% vs. 13%; p < 0.0001), were more likely to be intubated (8% vs. 1%, p = 0.002), and were more likely to die (15 vs 7 deaths; p < 0.0001). CONCLUSIONS The incidence of ACS in ED CHF patients with chest pain was 32%. Patients with CHF complicated by ACS had more prolonged hospital stays, required higher levels of care, and had a higher incidence of death than those patients without ACS. Strategies tailored to early identification and management of these patients would be desirable.