Factors Affecting Cardiac Catheterization Rates in Elders with Acute Coronary Syndromes

Background: Elder patients with acute coronary syndromes (ACS) are less likely to receive cardiac catheterization. The reasons for this are unclear.
Objectives: To assess whether elder patients who had a documented history of dementia, lived in extended care facilities, or had do not intubate–do not resuscitate (DNR-DNI) advance directives were less likely to receive cardiac catheterization, despite having ACS with high-risk features.
Methods: This was a medical record review conducted at an urban teaching hospital. DNR-DNI status before hospitalization, extended care facility (nursing home or assisted living) residence, and a previous diagnosis of dementia were obtained from the medical record. Patients 65 years and older who presented to the emergency department with acute myocardial infarction or with unstable angina with ST segment deviation were included. Univariate and multivariate logistic regression were performed, and odds ratios (ORs) were reported with their 95% confidence intervals (CIs).
Results: Of the 201 eligible patients, 66 (32.8%) patients did not undergo cardiac catheterization. In the univariate analysis, patients who had dementia, resided in extended care facilities, or were DNR-DNI were less likely to receive cardiac catheterization. Only extended care facility residence (OR, 0.18; 95% CI = 0.04 to 0.83) and DNR-DNI status (OR, 0.19; 95% CI = 0.04 to 0.92) remained significantly associated with decreased cardiac catheterization in the multivariate analysis.
Conclusions: Elder patients with ACS residing in extended care facilities or who are DNR-DNI are less likely to receive cardiac catheterization. Future studies concerning the quality of ACS care for elders should take these variables into account.     

Improving the Care of Patients with Non-ST-elevation Acute Coronary Syndromes in the Emergency Department: The CRUSADE Initiative

Although acute coronary syndromes (ACS) represent a well-recognized source of morbidity and mortality for patients with cardiovascular disease, evidence-based therapies shown to improve outcomes for ACS are frequently underused in appropriate patients, especially in the emergency department (ED). Despite dissemination of expert recommendations from the American College of Cardiology/American Heart Association (ACC/AHA) and ED-focused recapitulation of them in the emergency medicine literature, significant barriers continue to limit the adoption of guidelines in clinical practice and appear to hinder the use of beneficial therapies and interventions in the ED. Unique and creative approaches are therefore needed to stimulate better adherence to practice guidelines and improve the quality of care for patients with non-ST-elevation myocardial infarction (NSTE) ACS. The CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines) quality improvement and educational initiative provides an innovative and multifaceted approach to the education of emergency physicians and cardiologists in the care of patients with NSTE ACS. The CRUSADE initiative is a multidisciplinary cooperative effort involving over 400 EDs and medical centers. It includes an ACS registry designed to characterize demographic patterns and risk stratification results in patients who meet diagnostic criteria for high-risk NSTE ACS. It also measures the use of ED treatment modalities including aspirin, heparin, beta-blockers, and platelet inhibitors as recommended in the ACC/AHA guidelines. The results of a given institution's treatment patterns will be reported back to the practitioners, with comparisons with national norms. These reports can be used as quality improvement tools to improve care at participating institutions. Beyond a static registry, these reports are coupled with educational efforts by the CRUSADE steering committee, scientific publications of risk stratification practice and success, as well as ED patterns of care, and tailored educational interventions, to reinforce compliance with the ACC/AHA guidelines. This initiative represents a truly innovative approach to improving care for ACS patients in the ED as well as on the cardiology service. This article describes the CRUSADE initiative and its implications for the practicing emergency physician. It is the intent of CRUSADE to improve patient care in the ED by tracking and encouraging compliance with evidence-based guidelines for the evaluation and management of NSTE ACS.     

冠状动脉内注射替罗非班在急性冠状动脉综合征介入治疗中的安全性和疗效

目的 探讨冠状动脉内注射替罗非班应用于急性冠状动脉综合征(ACS)患者经皮冠状动脉介入治疗术(PCI)中的安全性及有效性.方法 将58例ACS患者按随机数字表法分为2组:对照组30例,PCI术前6 h内嚼服阿司匹林300 mg和口服氯吡格雷600 mg;替罗非班组28例,在对照组治疗的基础上应用替罗非班10 μg·kg-1原药稀释1倍后通过指引导管于冠状动脉内给药,2 min注射完毕,并以0.1 μg·kg-1·min-1速度维持静脉泵入24 h.2组PCI术后均皮下注射低分子肝素钠4 000 U 5～7 d及其他药物治疗.对2组患者PCI术后的TIMI血流情况、出血事件及术后3个月的不良心脏事件(MACE)进行比较.结果 PCI术后替罗非班组靶血管前向血流TIMI 3级获得率为92.9%,对照组靶血管前向血流TIMI 3级获得率为70.0%,2组比较差异有统计学意义(P＜0.05);替罗非班组出血并发症发生率为14.3%,对照组出血并发症发生率为10.0%,2组比较差异无统计学意义(P＞0.05);替罗非班组术后3个月MACE发生率为3.6%,对照组为13.3%,2组比较差异有统计学意义(P＜0.05).结论 PCI术中冠状动脉内注射替罗非班可以明显改善PCI术后的冠状动脉血流和临床预后,且无明显不良反应.     

Impact of Point-of-care Testing in the Emergency Department Evaluation and Treatment of Patients with Suspected Acute Coronary Syndromes

Objectives:  To assess the impact of point-of-care testing (POCT) for troponin I (cTnI) measurement on the time to anti-ischemic therapy (TAIT) for patients with suspected non–ST-segment elevation acute coronary syndrome (NSTE-ACS) presenting to the emergency department (ED).
Methods:  This was an open-label, randomized, single-center trial conducted in a university-affiliated hospital. cTnI measurement of patients with suspicion of NSTE-ACS coming to the ED was randomly allocated to POCT or central hospital laboratory testing (CHLT). The authors compared patients' baseline characteristics, time to anti-ischemic therapy, and medical outcomes between the randomized groups, in all study participants and in high-risk NSTE-ACS (cTnI level ≥ 0.10 μg/mL), and in those with low suspicion ACS (no chest pain and no ST deviation).
Results:  Of the 860 patients enrolled, 113 were high-risk NSTE-ACS patients, including 53 (46.9%) allocated to POCT and 60 (53.1%) to CHLT. POCT was associated with decreased time to anti-ischemic therapy of about three-quarters of an hour, which was due to a shorter time to physician notification of cTnI level, in both all and subgroup participants. In contrast, neither ED length of stay nor medical outcomes differed between study groups.
Conclusions:  Point-of-care testing for cTnI measurement might be clinically relevant for ED patients with a suspicion of NSTE-ACS, particularly for high-risk patients with a low suspicion of ACS.     

Predictive Value of T-wave Abnormalities at the Time of Emergency Department Presentation in Patients with Potential Acute Coronary Syndromes

Objectives: T‐wave abnormalities on electrocardiograms (ECGs) are common, but their ability to predict 30‐day cardiovascular outcomes at the time of emergency department (ED) presentation is unknown. The authors determined the association between T‐wave abnormalities on the presenting ECG and cardiovascular outcomes within 30 days of presentation in patients with potential acute coronary syndromes (ACSs). Methods: This was a secondary analysis of a prospective cohort study of ED patients that presented with a potential ACS. Patients were excluded if they had a prior myocardial infarction, ST‐segment elevation or depressions, right or left bundle branch block, or Q‐waves on the initial ECG. Data included demographics, medical and cardiac history, and ECG findings including the presence or absence of T‐wave flattening, inversions of 1–5 mm, and inversions >5 mm. Investigators followed the hospital course for admitted patients, and 30‐day follow‐up was performed on all patients. The main outcome was a composite of death, acute myocardial infarction, revascularization, coronary stenosis greater than 50%, or a stress test with reversible ischemia. Results: Of 8,298 patient visits, 5,582 met criteria for inclusion: 4,166 (74.6%) had no T‐wave abnormalities, 721 (12.9%) had T‐wave flattening in two or more leads, 659 (11.8%) had T‐wave inversions of 1–5 mm, and 36 (0.64%) had T‐wave inversions >5 mm. The composite endpoint was more common in patients with T‐wave flattening (8.2% vs. 5.7%; p = 0.0001; relative risk [RR] = 1.4; 95% confidence interval [CI] = 1.1 to 1.9), T‐wave inversions 1–5 mm (13.2% vs. 5.7%; p = 0.0001; RR = 2.4; 95% CI = 1.8 to 3.1), and T‐wave inversions >5 mm (19.4% vs. 5.7%; p = 0.0001; RR = 3.4; 95% CI = 1.7 to 6.1), or any T‐wave abnormality (10.8% vs. 5.7%; p = 0.0001; RR = 1.9; 95% CI = 1.6 to 2.3), even after adjustment for initial troponin. This association also existed in the subset of patients without known coronary artery disease. Conclusions: In patients with potential ACS presenting to the ED, T‐wave abnormalities are associated with higher rates of 30‐day cardiovascular events.     

Targeting the Unstable Plaque in Acute Coronary Syndromes

Background

Rupture or erosion of an unstable atherosclerotic plaque is the typical pathology and usual cause of acute coronary syndromes. Despite detailed understanding of the processes of lipid accumulation, thinning of the fibrous cap, and inflammation leading to plaque instability, there are no strategies in clinical use that uniquely target the unstable plaque.

Objective

A critical review of recent publications on potential therapies that could be used to stabilize unstable plaque.

Methods

We searched PubMed, other literature databases, drug development sites, and clinical trial registries to retrieve clinical studies on anti-inflammatory and lipid-modulating therapies that could be used to stabilize unstable atherosclerotic plaque.

Results

Multiple experimental targets involving lipid and inflammatory pathways have the potential to stabilize the plaque and expand the armamentarium against coronary artery disease. Randomized clinical trials of darapladib, methotrexate, canakinumab, and colchicine are well advanced to establish if plaque stabilization is feasible and effective in patients with acute coronary syndromes.

Conclusions

Although there are still no agents in clinical use for plaque stabilization, there are important advances in understanding plaque instability and several encouraging approaches are being evaluated in Phase III clinical trials.     

Incomplete Data Reporting in Studies of Emergency Department Patients with Potential Acute Coronary Syndromes Using Troponins

OBJECTIVES: A multidisciplinary panel of experts is developing standardized reporting criteria for risk stratification studies of emergency department (ED) patients with potential acute coronary syndromes (ACS). The authors assessed the need for such criteria by reviewing published studies to determine whether these core criteria currently are being reported. METHODS: Studies published during 2000-2001 in eight journals representing emergency medicine, cardiology, and general medicine that evaluated the cardiac troponins for risk stratification of ED patients with chest pain were identified by a systematic MEDLINE review. Two raters independently analyzed each study with a structured tool. The presence or absence of 47 core criteria in eight major reporting categories, which were determined by expert consensus, was abstracted from the articles. When the two raters disagreed, discrepancies were resolved by consensus. Data are presented as percent frequency of occurrence with 95% confidence intervals. RESULTS: Twenty-two articles met inclusion criteria. The two reviewers had a median of 7.5 initial discrepancies per article (interquartile range = 6 to 10) but achieved consensus on all. The median of the percent of articles reporting the core criteria within each major reporting category is shown [table: see text].CONCLUSIONS: Many of the 47 items considered core criteria by the expert committee writing standardized reporting guidelines for risk stratification studies of potential ACS patients were not reported often in major cardiology and emergency medicine journals. There seems to be a need for standardized reporting guidelines because important information is not currently being reported.     

辛伐他汀对急性冠状动脉综合征患者血清MMP-1、MMP-9水平的影响

目的探讨急性冠状动脉综合征(ACS)辛伐他汀与动脉粥样斑块稳定的可能机制。方法选择ACS患者60例,随机分成辛伐他汀治疗组(30例)及常规治疗组(30例),比较各组患者血清MMP-1、MMP-9水平变化。30例健康人作为对照。结果ACS、健康对照组之间MMP-1、MMP-9水平比较差异有统计学意义,辛伐他汀治疗组与常规治疗组治疗后血清MMP-1、MMP-9水平相比差异有统计学意义。结论辛伐他汀可降低ACS患者血清MMP-1、MMP-9水平从而起到稳定动脉粥样硬化斑块的作用。     

The Role of Colchicine in Acute Coronary Syndromes

Purpose

Because inflammation is a key process implicated in the pathogenesis of atherosclerosis at all stages, including plaque formation, progression, instability, and rupture, and because colchicine has unique anti-inflammatory properties, this review article summarizes the pathophysiologic mechanisms underpinning inflammation in atherosclerosis and acute coronary syndrome (ACS), outlines anti-inflammatory therapeutic approaches that have been tested thus far, and evaluates the evidence supporting the potential role of colchicine in improving outcomes and reducing cardiovascular morbidity and mortality in patients after ACS.

Computed Tomography Coronary Angiography for Rapid Disposition of Low-risk Emergency Department Patients with Chest Pain Syndromes

Background Patients with recent normal cardiac catheterization are at low risk for complications of ischemic chest pain. Computed tomography (CT) coronary angiography has high correlation with cardiac catheterization for detection of coronary stenosis. Therefore, the investigators' emergency department (ED) incorporated CT coronary angiography into the evaluation of low-risk patients with chest pain. Objectives To report on the 30-day cardiovascular event rates of the first 54 patients evaluated by this strategy. Methods Low-risk chest pain patients (Thrombolysis In Myocardial Infarction [TIMI] score of 2 or less) without acute ischemia on an electrocardiogram had CT coronary angiography performed in the ED. If the CT coronary angiography was negative, the patient was discharged home. The main outcomes were death and myocardial infarction within 30 days of ED discharge, as determined by telephone follow up and record review. Data are presented as percentage frequency of occurrence with 95% confidence intervals (CIs). Results Of the 54 patients evaluated, after CT coronary angiography, 46 patients (85%) were immediately released from the ED, and none had cardiovascular complications within 30 days. Eight patients were admitted after CT coronary angiography: one had >70% stenosis, five patients had 50%–69% stenosis, and two had 0–49% stenosis. Three patients had further noninvasive testing; one had reversible ischemia, and catheterization confirmed the results of CT coronary angiography. All patients were followed for 30 days, and none (0; 95% CI = 0 to 6.6%) had an adverse event during index hospitalization or at 30-day follow up. Conclusions When used in the clinical setting for the evaluation of ED patients with low-risk chest pain, CT coronary angiography may safely allow rapid discharge of patients with negative studies. Further study to conclusively determine the safety and cost effectiveness of this approach is warranted.     

Effectiveness of an Organized Follow-up System for Elder Patients Released from the Emergency Department

Objectives : To determine whether an effective telephone callback system can be successfully implemented in a busy ED and to quantify the benefits that can be obtained related to the follow-up care of elder patients.
Methods : This was a prospective, cohort study conducted at a community teaching hospital during a 6-month period. Consecutive patients ≥60 years old and released from the ED were selected for telephone follow-up. Calls were made by a research nurse within 72 hours after the patient's ED visit. Follow-up information included current medical status, problems encountered during the ED visit, compliance, and impact of the illness on self-care capabilities.
Results : Seventy-nine percent (831/1,048) of the patients selected for telephone follow-up were successfully contacted. The calls lasted an average of 4 ± 2.5 minutes. Although 94% (778/831) of these patients had a regular physician, 14% failed to make their recommended follow-up arrangements. Compliance was significantly improved when a follow-up physician was contacted during the patient's ED visit. Approximately 96% of the patients were either satisfied or very satisfied with their ED care. However, 13% (109/831) had moderate deterioration in their ability to care for themselves. Of the patients contacted, 333 (40%) required further clarification of their home care instructions, 31 were advised to return to the ED for reevaluation, and 26 were referred to a medical social worker for psychosocial concerns.
Conclusion : A telephone callback system is a feasible and effective method to improve follow-up care of elder patients released from the ED.     

Emergency Department Presentation of Patients with Spontaneous Coronary Artery Dissection

Background

Spontaneous coronary artery dissection (SCAD) is an infrequently recognized but potentially fatal cause of acute coronary syndrome (ACS) that disproportionately affects women. Little is currently known about how patients with SCAD initially present.

Bench to Bedside: Pathophysiology of Acute Coronary Syndromes and Implications for Therapy

Our understanding of the pathophysiology of unstable angina (UA) and non-ST-segment elevation (NSTE) myocardial infarction (MI) [commonly referred to as NSTE acute coronary syndrome(s) (ACS)] has evolved considerably over the years, with atherothrombosis playing a pivotal role. This review discusses the molecular interactions in coronary thrombosis that may serve as therapeutic targets for more effective management of these syndromes. The purposes of this review are: 1) to discuss current understanding of the pathophysiology of NSTE ACS; 2) to describe recent studies with novel antithrombotic agents [e.g., low-molecular-weight heparin, thienopyridines, glycoprotein (GP) IIb-IIIa inhibitors] in patients with NSTE ACS; and 3) to highlight recommendations for management of patients with NSTE ACS in the recently updated American College of Cardiology (ACC)/ American Heart Association (AHA) guidelines, including the appropriate use of antithrombotic therapies.     

Utilization of Emergency Medical Services by Patients with Acute Coronary Syndromes in the Arab Gulf States

Background

Emergency Medical Services (EMS) play a central role in caring for patients with acute coronary syndromes (ACS). To date, no data exist on utilization of EMS systems in the Arab Gulf States.

Objective

To examine EMS use by patients with ACS in the Gulf Registry of Acute Coronary Events (Gulf RACE). Methods: Gulf RACE was a prospective, multinational study conducted in 2007 of all patients hospitalized with ACS in 65 centers in six Arab countries. Data were analyzed based on mode of presentation (EMS vs. other).

Results

Of 7859 patients hospitalized with ACS through the emergency department (ED), only 1336 (17%) used EMS, with wide variation among countries (2% in Yemen to 37% in Oman). Younger age (odds ratio [OR] 1.09; 95% confidence interval [CI] 1.03–1.15 per 10-year decrement), presence of chest pain (OR 1.73; 95% CI 1.48–2.03), prior myocardial infarction (OR 1.58; 95% CI 1.34–1.86), prior percutaneous coronary intervention (OR 1.27; 95% CI 1.02–1.59), family history of premature coronary disease (OR 1.25; 95% CI 1.09–1.51), and current smoking (OR 1.30; 95% CI 1.13–1.50) were independently associated with not utilizing EMS. Patients with ST-segment elevation myocardial infarction/left bundle branch block myocardial infarction who were transported by EMS were significantly less likely to exhibit major delay in presentation, and were significantly more likely to receive favorable processes of care, including shorter door-to-electrocardiogram time, more frequent coronary reperfusion therapy, and thrombolytic therapy within 30 min of arrival at the ED.

Conclusion

Despite current recommendations, fewer than 1 in 5 patients with ACS use EMS in the Arab Gulf States, highlighting a significant opportunity for improvement. Factors causing this underutilization deserve further investigation.     

Alcohol and Tobacco Use in the Elder Emergency Department Patient: Assessment of Rates and Medical Care Utilization

OBJECTIVES: To determine rates of alcohol and tobacco use among independent elder emergency department (ED) patients and assess the extent of health care use of this population. METHODS: A convenience sample of independent elders (age > or =65 years) in an urban academic ED was enrolled. Patients were excluded if they were medically unstable or had a change in mental status. The Fagerstrom Test for Nicotine Dependence, and the Alcohol Use Disorders Identification Test (AUDIT) scales were used to measure tobacco and alcohol use. Subjects completed questionnaires about their health and use of the health care system. Data were analyzed by using t-tests to compare independent variables. RESULTS: A total of 565 subjects completed the study. Of these, 296 (52.4%) were male and 269 (47.6%) were female; mean age was 77.1 years. Fifty-four (9.5%) were smokers, and 22 (3.9%) were nicotine-dependent by the Fagerstrom test (Fagerstrom+). Alcohol use was reported at least once monthly by 176 (31.2%) and twice monthly by 76 (13.5%) patients; 12 (2.1%) were alcohol-dependent by the AUDIT scale (AUDIT+). Two (0.35%) were both Fagerstrom+ and AUDIT+. Fagerstrom+ subjects visited a physician less often than Fagerstrom- subjects (3.9 vs. 4.6 annual visits, p < 0.0009). AUDIT+ subjects visited a primary care physician less (3.3 vs. 4.2 annual visits, p < 0.007) or "any" physician less (3.9 vs. 4.6 annual visits, p < 0.01) than AUDIT- subjects. AUDIT+ and Fagerstrom+ subjects did not differ from AUDIT- and Fagerstrom- subjects in number of annual ED visits, self-reported general health, physical symptoms (except nervousness, p < 0.004), comorbid illnesses, hospital admissions, and injuries requiring treatment. CONCLUSIONS: Elder ED patients have low rates of nicotine and alcohol dependence. Nicotine- or alcohol-dependent elders use outpatient providers less often than nondependent elders but use EDs at the same rate and report similar health patterns.     

Prognostic Value of Symptoms during a Normal or Nonspecific Electrocardiogram in Emergency Department Patients with Potential Acute Coronary Syndrome

Objectives Emergency department (ED) patients with symptoms concerning for acute coronary syndrome (ACS) and a normal electrocardiogram (ECG) are at risk for adverse cardiovascular events. The authors hypothesized that patients with a normal or nonspecific ECG during symptoms have a lower risk for ACS than do those who are asymptomatic.
Methods This was a prospective cohort study of ED patients with potential ACS. Outcomes were acute myocardial infarction (AMI), ACS, and 30-day cardiovascular events (death, AMI, revascularization). Fisher's exact test, t-tests, and logistic regression were used for data analysis.
Results Of 2,593 patient visits, 2,007 patients had normal or nonspecific ECG findings. There were 1,196 who had symptoms during ECG, whereas 811 did not. Patients with symptoms at ECG acquisition were younger (49.9 vs. 55.2 years; p < 0.001) and were more likely to be black (70% vs. 64%; p = 0.002), female (63% vs. 58%; p = 0.03), and to have used cocaine (5% vs. 2%; p = 0.004). They were less likely to have hypertension (49% vs. 58%; p < 0.001), and diabetes (22% vs. 17%; p = 0.002). Patients with and without symptoms were equally likely to have AMI (both 2.8%; p > 0.99), ACS (10.1% vs. 11.5%; p = 0.34), and 30-day adverse outcomes (both 5.3%; p > 0.99). After adjustment for baseline cardiovascular-risk factors, odds ratios for patients with symptoms at the time of ECG acquisition were not significantly different for any of the outcomes: AMI (1.1; 95% confidence interval [CI] = 0.6 to 1.9); ACS (1.1; 95% CI = 0.8 to 1.4); or 30-day events (1.2; 95% CI = 0.8 to 1.9).
Conclusions Patients who are symptomatic during acquisition of a normal or nonspecific ECG have rates of adverse cardiovascular events similar to those of patients without symptoms. Clinicians should not rely on the absence of ECG abnormalities during symptoms to help exclude ACS.     

New Antiplatelet Agents and the Role of Platelet Function Testing in Acute Coronary Syndromes

Background

Dual antiplatelet therapy is a guideline mandated for patients with acute coronary syndromes (ACS). Despite its use, thrombotic events continue to occur both early and late. Platelet function testing has been used to define the in vitro effects of new antiplatelet agents, and it has been suggested that it be used to choose therapy. The role of platelet function testing, particularly with newer antiplatelet agents, remains unclear.

Objective

We review the rationale for platelet function testing and its application in monitoring patients on antiplatelet therapy. We also review recent clinical trials of newer antiplatelet agents. On the basis of this review, we reach conclusions on the current role of antiplatelet function testing in monitoring modern antiplatelet therapy and the role of the new antiplatelet agents in the treatment of ACS.

Methods

We reviewed recent publications on platelet function testing and clinical trials of newer antiplatelet therapies compared with clopidogrel.

Results

Platelet function testing is complex, but there is now a bedside test, VerifyNow. High platelet reactivity has been associated with worse cardiovascular outcomes in patients undergoing percutaneous coronary intervention. Recent clinical trials have not found any advantage in outcomes in patients who have their therapy adjusted by monitoring their platelet function. Newer agents, prasugrel, ticagrelor, and cangrelor, produce more rapid, complete, less variable effects on platelet function than clopidogrel. Prasugrel was found to improve outcomes compared with clopidogrel in patients with ACS undergoing percutaneous intervention. Ticagrelor is beneficial in all patients with ACS and reduces cardiovascular mortality compared with clopidogrel. Cangrelor improves outcomes in patients undergoing stenting. Recent studies to assess the role of platelet function monitoring of the effects of clopidogrel and modifying treatments have not been successful.

Conclusion

Recent clinical trials have indicated that newer antiplatelet agents have advantages over clopidogrel in the treatment of ACS. Platelet function testing gives us a guide to the timing, efficacy, and variability of therapy and can correlate with poor patient outcomes; however, the use of antiplatelet function testing to tailor therapy does not seem appropriate.     

缺血修饰白蛋白早期诊断非ST抬高型急性冠脉综合征的价值探讨

目的 探讨缺血修饰白蛋白(IMA)对非ST抬高型急性冠脉综合征(NSTEACS)的早期诊断价值.方法 177例疑似NSTACS患者于胸痛发作6h内采血,测定心肌肌钙蛋白I(cTnI);用间接白蛋白钴结合试验(ACB法)测定血清IMA值.且均经标准诊疗以及GRACE评分,并根据最终诊断分为NSTEMI组(n=34)、不稳定型心绞痛(UA)组(n=56)和非缺血性胸痛( NICP)组(n=87).另随机选取本院同期行健康体检者58例作为健康对照组.通过绘制IMA诊断NSTEACS的受试者工作特征(ROC)曲线,取得判定IMA的最佳临界值.将IMA、心电图和cTnI单独或联合诊断与最终诊断进行综合分析.结果 NSTEMI组与UA组IMA水平无显著性差异;NSTEMI组、UA组与NICP组比较,其IMA水平均有显著性差异.ROC曲线下面积0.950,Cut-off值取67.49 U/mL时,诊断NSTEACS的敏感性和特异度分别为91.1％和86.2％.IMA水平与GRACE评分呈显著负相关.结论IMA是早期诊断NSTEACS的敏感指标,并有助于判断患者的预后.     

Satisfaction and Emergency Department Revisits in Patients With Possible Acute Coronary Syndrome

Background

Patients with possible acute coronary syndrome (ACS) are typically instructed to return to the emergency department (ED) if their condition worsens. Little is known about the relationship between patient satisfaction in the ED and subsequent return visits.

Objective

Our aim was to determine the association between satisfaction with ED care and subsequent ED return visits.

Methods

One thousand and five consecutive ED patients with symptoms of possible ACS who participated in a prospective guideline implementation trial at two university hospitals completed a telephone survey at 30-day follow-up. Satisfaction with care at the initial ED visit was measured using items from the Press Ganey satisfaction questionnaire. Logistic regression was used to determine the association between individual satisfaction items and the occurrence of any ED revisits, and the association between satisfaction items and return visits to the same ED.

Results

Patients who reported superior ratings of person-centered care (“staff cared about you as a person”) were significantly less likely to return to any ED during 30-day follow-up: 59 vs. 71%, adjusted odds ratio = 0.57 (95% confidence interval 0.37−0.87). Among those with ED revisits, superior ratings of personal care and perceived waiting time for emergency physician evaluation were significantly associated with return to the same ED.

Conclusions

Although diagnostic workup and risk stratification are the primary focus in evaluating patients with possible ACS, greater attention to the patient's experience of care may have the positive impact of reducing ED return visits and increasing the likelihood that patients will return to the same ED for re-evaluation.