William R. Lewis

Immediate exercise testing to evaluate low-risk patients presenting to the emergency department with chest pain

OBJECTIVES Our purpose was to determine the safety and accuracy of immediate exercise testing in low-risk patients presenting to the emergency department (ED) with chest pain suggestive of a cardiac etiology. BACKGROUND Safe, efficient management of low-risk patients presenting to the ED with chest pain is a continuing challenge. We have employed immediate exercise testing to evaluate a large, heterogeneous group of low-risk patients presenting with chest pain. METHODS Patients presenting to the ED with chest pain compatible with a cardiac origin and clinical evidence of low risk on initial assessment underwent immediate exercise treadmill testing in our chest pain evaluation unit. Indicators of low clinical risk included no evidence of hemodynamic instability, arrhythmias or electrocardiographic signs of ischemia. Serial measurements of cardiac injury markers were not obtained. RESULTS Exercise testing was performed to a sign- or symptom-limited end point in 1,000 patients (520 men, 480 women; age range 31 to 82 years) and was positive for ischemia in 13%, negative in 64% and nondiagnostic in 23% of patients. There were no adverse effects of exercise testing, and all patients with a negative exercise test were discharged directly from the ED. At 30-day follow-up there was no mortality in any of the three groups. Cardiac events in the three groups included: negative group, 1 non-Q-wave myocardial infarction (MI); positive group, 4 non-Q-wave MIs and 12 myocardial revascularizations; nondiagnostic group, 7 myocardial revascularizations. BACKGROUND Immediate exercise testing of patients presenting to the ED with chest pain and evidence of low clinical risk is safe and accurate for determining those who require admission and those who can be discharged to further outpatient evaluation.

Utility and safety of immediate exercise testing of low-risk patients admitted to the hospital for suspected acute myocardial infarction☆

More than 2 million patients are admitted to U.S. hospitals annually for clinical suspicion of acute myocardial infarction (AMI), and > 70% are found not to have had a cardiac event. This study evaluates the safety and efficacy of immediate exercise testing for patients admitted to the hospital for suspected AMI. Ninety-three nonconsecutive low-risk patients admitted to the hospital from the emergency department to rule out AMI underwent exercise treadmill testing using a modified Bruce protocol immediately on admission to the hospital (median time < 1 hour). Twelve patients had positive exercise electrocardiograms, 6 of whom had significant coronary narrowing by angiography. An uncomplicated non-Q-wave AMI was diagnosed in 1 patient. Fifty-nine patients had negative and 22 patients had nondiagnostic exercise electrocardiograms. Of these 81 patients, 44 were discharged immediately after exercise testing, 17 were discharged within 24 hours, and 20 were discharged after 24 hours of observation. There were no complications from exercise testing. There were 2 late noncardiac deaths and 1 late AMI. Thus, immediate exercise testing of low-risk patients with chest pain who are at sufficient risk to be designated for hospital admission is effective in further stratifying this group into those who can be safely discharged immediately and those who require hospitalization.

Cognitive Impairments in Chronic Heart Failure: A Case Controlled Study

BACKGROUND There are limited data describing the prevalence, type, and severity of cognitive impairments (CIs) in the general population with chronic heart failure (HF). The primary purpose of this study was to fill this gap in the literature by comparing the cognitive function of patients with chronic HF and community-dwelling control subjects. METHODS AND RESULTS A case controlled design was used. Fifty patients with HF were recruited and matched to 50 healthy control subjects on age (+/- 3 years), gender, and estimated intelligence (intelligence quotient +/- 1 standard deviation). In the patient sample, mean left ventricular ejection fraction was 27% +/- 14%, 22 patients had New York Heart Association (NYHA) class II, 23 patients had NYHA class III, and 5 patients had NYHA class IV heart disease. Neuropsychologic tests assessed cognitive outcomes in orientation, attention, memory, executive function, motor speed, and reaction times. Patients had significantly poorer scores than controls on 14 of 19 variables assessed. After standardization of the neuropsychologic test scores to T-scores (mean 50 +/- 10 SD), 23 patients (46%) had mild to severe CI and 8 of the control subjects had mild CI. Both patients and controls were impaired in 1 or more of the 4 memory outcomes assessed. Logistic regression analysis indicated CI was independently associated with HF (odds ratio = 4.47, confidence interval = 1.75-11.43, P < .002). Severity of CI was associated with depressed learning (P < .0001), previous myocardial infarction (MI) (P < .02), and the number of MIs (P < .01). CI severity was not associated with LVEF, HF duration, NYHA class, anxiety, depression, positive affect, social support, or physical functioning. Severity of MI (>or=2 MIs) was associated with deficits in early recall (P < .01), delayed recall (P < .03), and learning (P < .03). In contrast, patients with idiopathic or hypertensive cardiomyopathies without coronary artery disease when compared with patients with greater MI severity were not cognitively impaired on these outcome variables. CONCLUSION The prevalence, type, and severity of CI in the community-dwelling patients with HF are consistent with the results found in patients with end-stage HF awaiting heart transplantation. Patients with heart failure incur a more than 4-fold risk for CI compared with matched community controls. The relationship of MI severity to deficits in memory outcomes and learning suggests that ischemic cardiomyopathy may be a significant factor in the development of CI in heart failure.

Intravenous diltiazem for the treatment of patients with atrial fibrillation or flutter and moderate to severe congestive heart failure

The objective of this multicenter, randomized, double-blind, placebo-controlled study was to determine the safety and efficacy of intravenous diltiazem in the treatment of 37 patients with rapid (ventricular rate, mean +/- SD 142 +/- 17 beats/min) atrial fibrillation or flutter and moderate to severe congestive heart failure (ejection fraction, mean +/- SD 36 +/- 14%; New York Heart Association class III [23 patients], class IV [14 patients]). During the double-blind portion of the study, patients received either intravenous diltiazem, 0.25 mg/kg over 2 minutes, or placebo followed 15 minutes later by diltiazem or placebo, 0.35 mg/kg over 2 minutes, if the first dose was tolerated but ineffective. Placebo nonresponders were given open-label intravenous diltiazem in a similar fashion as in the double-blind portion of the study. In the double-blind part of the study, 21 (18 with 0.25 mg/kg, 3 with an additional 0.35 mg/kg) of the 22 patients (95%) responded to diltiazem, and 0 of 15 patients (0%) responded to placebo (p < 0.001). All 15 patients (13 with 0.25 mg/kg and 2 with an additional 0.35 mg/kg) who received placebo during the double-blind period had a therapeutic response to diltiazem during open-label therapy. Overall, 36 of 37 patients (97%) had a therapeutic response to intravenous diltiazem. Heart rate response to diltiazem after the 2-minute bolus infusions consisted of a > or = 20% decrease in heart rate from baseline in 36 patients; in addition, 17 patients also had heart rates decreased to < 100 beats/min, whereas no patient had conversion to sinus rhythm.(ABSTRACT TRUNCATED AT 250 WORDS)

Immediate exercise testing of low risk patients with known coronary artery disease presenting to the emergency department with chest pain

OBJECTIVES The purpose of this study was to demonstrate the safety and utility of immediate exercise treadmill testing (IETT) of low risk patients presenting to the emergency department with known coronary artery disease (CAD). BACKGROUND More than 70% of the two million patients admitted to U.S. hospitals annually for suspected acute myocardial infarction (AMI) are found not to have had a cardiac event. We have previously demonstrated the safety and efficacy of IETT of selected low risk patients without known CAD presenting to the emergency department with chest pain. This study extends this approach to selected patients with a history of CAD. METHODS One hundred patients evaluated by the chest pain emergency room to rule out AMI underwent IETT using a modified Bruce protocol upon admission to the hospital (median time <1 h). RESULTS Twenty-three patients (23%) had positive exercise electrocardiograms (ExECGs); an uncomplicated non-Q wave AMI was diagnosed in two patients. Thirty-eight patients (38%) had negative ExECGs and 39 patients (39%) had nondiagnostic ExECGs. Of these 100 patients, 64 were discharged immediately after IETT, 19 were discharged in less than 24 h after negative serial cardiac enzymes and stable electrocardiograms and 17 were discharged after further evaluation and treatment. There were no complications from exercise testing and no late deaths or AMI during six-month follow-up. CONCLUSIONS Immediate exercise treadmill testing of low risk patients with chest pain and known CAD is effective in further stratifying this group into patients who can be safely discharged and those who require hospital admission.

ACCF 2012 health policy statement on patient-centered care in cardiovascular medicine: a report of the American College of Cardiology Foundation Clinical Quality Committee.

Joseph P. Drozda, Jr, MD, FACC, Chair Joseph G. Cacchione, MD, FACC Blair D. Erb, Jr, MD, FACC Robert A. Harrington, MD, FACC Jerry D. Kennett, MD, FACC Harlan M. Krumholz, MD, SM, FACC Frederick A. Masoudi, MD, MSPH, FACC Eric D. Peterson, MD, MPH, FACC Athena Poppas, MD, FACC David J.

Health Policy StatementACCF 2012 Health Policy Statement on Patient-Centered Care in Cardiovascular Medicine: A Report of the American College of Cardiology Foundation Clinical Quality Committee

Joseph P. Drozda, Jr, MD, FACC, Chair Joseph G. Cacchione, MD, FACC Blair D. Erb, Jr, MD, FACC Robert A. Harrington, MD, FACC Jerry D. Kennett, MD, FACC Harlan M. Krumholz, MD, SM, FACC Frederick A. Masoudi, MD, MSPH, FACC Eric D. Peterson, MD, MPH, FACC Athena Poppas, MD, FACC David J.

Statins for Primary Prevention of Cardiovascular Mortality in Women: A Systematic Review and Meta‐Analysis

The benefits of statins on prevention of coronary heart disease in women without heart disease have not been clarified. The authors systematically reviewed all the published literature on primary prevention trials and found 6 primary prevention trials to date with sex-specific data on mortality and coronary heart disease events in women. The summary risk ratio for primary prevention of all-cause mortality was 0.90 (95% confidence interval, 0.60-1.35; P=.61) and for any coronary heart disease event was 0.78 (95% confidence interval, 0.64-0.96; P=.02). This review reveals that statin therapy along with diet and exercise in moderately hyperlipidemic women without a previous history of cardiovascular disease is of significant benefit in preventing coronary heart disease events but of no proven benefit in preventing all-cause mortality.

Acute ischemic syndromes: Chest pain center concept

CPCs have been developed to meet the clinical challenge posed by the diverse group of patients presenting to the ED with findings suggestive of a coronary event. Using a protocol-driven approach, high- and low-risk patients can be identified on presentation, facilitating urgent therapy in the former and triage of the latter to more deliberate management. Most CPCs focus on low-risk patients who are being increasingly managed by accelerated diagnostic protocols. These methods comprise systematic strategies that include innovative diagnostic approaches during a 6 to 12 hour period of observation with serial ECGs, continuous monitoring and cardiac biomarker measurements. A negative evaluation is usually followed by predischarge stress testing, and positive findings mandate admission. An essential aspect of the CPC strategy is continuity of care for patients with negative cardiac evaluations. Current data indicate that management of low-risk patients with chest pain in a CPC is safe accurate, and appears to be cost-effective.

Evaluation of the Patient With 'Rule Out Myocardial Infarction'

Evaluation in the emergency department of the patient with chest pain remains a common problem. Large numbers of patients are admitted to the hospital because of diagnostic uncertainty. Strategies dealing with this population include risk stratification by clinical presentation, serial cardiac enzyme assays to exclude myocardial infarction, and detection of myocardial ischemia with nuclear scintigraphy or echocardiography. Each of these strategies is rational with specific benefits and weaknesses. Bypassing these steps and performing immediate exercise testing is the newest approach that appears to be safe, timely, and cost-effective.