Appropriateness criteria are an imprecise measure for repeat echocardiograms

Background: Previous studies have reported that most transthoracic echocardiograms meet current ACC/ASE appropriateness criteria, but efficacy of appropriateness criteria for repeat echocardiograms has not been investigated. We sought to prospectively determine whether current appropriateness criteria accurately assess the need for repeat echocardiograms in a consecutive series of inpatients in a tertiary care community teaching hospital. Methods and Results: Appropriateness criteria were assessed for consecutive echocardiograms ordered over 30 days. Ordering clinician specialty and level of training were recorded. For repeat echocardiograms, change in clinical status between first and second echocardiogram and any change in echocardiographic findings were documented. Out of 574 echocardiograms analyzed, 143 repeat studies were performed in 104 patients. Level of appropriateness for first time studies was estimated at 84.6% and for repeat studies at 73.4% (x²= 7.71, P = 0.005). Of those patients receiving at least 1 repeat echocardiogram 42 patients (40%) experienced no detectable change in clinical status or other reason that would justify a repeat study. New echocardiographic findings were found in slightly more than half (52%) of patients receiving repeat studies. Conclusions: Inappropriate repeat echocardiograms are ordered more frequently than first time studies. A significant proportion of repeat echocardiograms do not appear to be justified, and often yield no new echocardiographic findings. Our data suggest that current appropriateness criteria might benefit from further revision with particular regard to justification for repeat studies. (Echocardiography 2011;28:131‐135)     

Can Hospital Rounds With Pocket Ultrasound By Cardiologists Reduce Standard Echocardiography?

Background

Frequently, hospitalized patients are referred for transthoracic echocardiograms. The availability of a pocket mobile echocardiography device that can be incorporated on bedside rounds by cardiologists may be a useful and frugal alternative.

Methods

This was a cross-sectional study designed to compare the accuracy of pocket mobile echocardiography images with those acquired by transthoracic echocardiography in a sample of hospitalized patients. Each patient referred for echocardiography underwent pocket mobile echocardiography acquisition and interpretation by a senior cardiology fellow with level II training in echocardiography. Subsequently, transthoracic echocardiography was performed by skilled ultrasonographers and interpreted by experienced echocardiographers. Both groups were blinded to the results of the alternative imaging modality. Visualizability and accuracy for all key echocardiographic parameters (ejection fraction, wall motion abnormalities, left ventricular end-diastolic dimension, inferior vena cava size, aortic and mitral valve pathology, and pericardial effusion) were determined and compared between imaging modalities.

Results

A total of 240 hospitalized patients underwent echocardiography with pocket mobile echocardiography and transthoracic echocardiography. The mean age was 71 ± 17 years. Pocket mobile echocardiography imaging time was 6.3 ± 1.5 minutes. Sensitivity of pocket mobile echocardiography varied by parameter and was highest for aortic stenosis (97%) and lowest for aortic insufficiency (76%). Specificity also varied by parameter and was highest for mitral regurgitation (100%) and lowest for left ventricular ejection fraction (92%). Equivalence testing revealed the pocket mobile echocardiography outcomes to be significantly equivalent to the transthoracic echocardiography outcomes with no discernible differences in image quality between pocket mobile echocardiography and transthoracic echocardiography (P = 7.22 × 10⁻⁷). All outcomes remain significant after correcting for multiple testing using the false discovery rate.

Conclusions

The results from rapid bedside pocket mobile echocardiography examinations performed by experienced cardiology fellows compared favorably with those from formal transthoracic echocardiography studies. For hospitalized patients, this finding could shift the burden of performing and interpreting the echocardiogram to the examining physician and reduce the number and cost associated with formal echocardiography studies.     

Appropriateness vs value: Echocardiography in primary care

Background

Despite efforts targeting the growth of healthcare spending within the United States, the current increase in expenditures remains a widespread systemic issue. The overuse of healthcare testing has previously been identified as a modifiable contributing factor. One such test, echocardiography, has seen a continuous increase in its rate of use. This test is frequently ordered by primary‐care physicians.

Hypothesis

In the setting of a low likelihood of disease, echocardiography does not substantially change cardiac therapy, even if appropriately ordered.

Methods

We randomly identified 500 patients who received an echocardiogram ordered by a primary‐care physician between January 1, 2014, and December 31, 2014. Of these, 239 patient charts were reviewed and the following extracted: primary indication for the test, echocardiogram results, and changes in patient medical management. In addition, appropriateness of the test was assessed using the appropriate use criteria guidelines for echocardiography.

Results

Nearly 97% of the studies within the ambulatory primary‐care setting were appropriately ordered according to the appropriate use criteria. Among the 239 patients studied, only 52 had abnormalities and only 6 (2.5%) experienced a change in management that corresponded with the initial suspected diagnosis and echocardiographic findings.

Conclusions

To ensure the greatest value and optimize use of diagnostic testing, it may be necessary to develop a more comprehensive set of guidelines to assist clinicians to readily identify patient populations at low, moderate, and high risk for the presence of disease and provide educational interventions, including feedback regarding individual ordering behaviors.

     

Resource reduction in pediatric chest pain: Standardized clinical assessment and management plan

Objective

Using a Standardized Clinical Assessment and Management Plan (SCAMP) for pediatric patients presenting to clinic with chest pain, we evaluated the cost impact associated with implementation of the care algorithm. Prior to introduction of the SCAMP, we analyzed charges for 406 patients with chest pain, seen in 2009, and predicted 21% reduction of overall charges had the SCAMP methodology been used. The SCAMP recommended an echocardiogram for history, examination, or ECG findings suggestive of a cardiac etiology for chest pain.

Design

Resource utilization was reviewed for 1517 patients (7‐21 years) enrolled in the SCAMP from July 2010 to April 2014.

Results

Compared to the 2009 historic cohort, patients evaluated by the SCAMP had higher rates of exertional chest pain (45% vs 37%) and positive family history (5% vs 1%). The SCAMP cohort had fewer abnormal physical examination findings (1% vs 6%) and abnormal electrocardiograms (3% vs 5%). Echocardiogram use increased in the SCAMP cohort compared to the 2009 historic cohort (45% vs 41%), whereas all other ancillary testing was reduced: exercise stress testing (4% SCAMP vs 28% historic), Holter (4% vs 7%), event monitors (3% vs 10%), and MRI (1% vs 2%). Total charges were reduced by 22% ($822 625) by use of the Chest Pain SCAMP, despite a higher percentage of patients for whom echocardiogram was recommended compared to the historic cohort.

Conclusions

The Chest Pain SCAMP effectively streamlines cardiac testing and reduces resource utilization. Further reductions can be made by algorithm refinement regarding echocardiograms for exertional symptoms.     

Increased left atrial size is associated with higher atrial fibrillation recurrence in patients treated with antiarrhythmic medications

Background

Atrial fibrillation (AF) is highly prevalent, and antiarrhythmic therapy is often used to help with rhythm control. Some common echocardiographic parameters may be useful in predicting AF recurrence among these patients. The purpose of this study was to evaluate the association between 3 common echocardiographic parameters (left atrial [LA] size, left ventricular ejection fraction [LVEF], and mitral regurgitation [MR]) and AF recurrence among patients treated with antiarrhythmic medications.

Hypothesis

We hypothesized that LA size, LVEF, and severity of MR are predictors of AF recurrence in this population.

Methods

A real‐world cohort of AF patients who had transthoracic echocardiograms was analyzed. Data on LA size, LVEF, and MR were collected retrospectively from echocardiography reports. Patients were followed from the time of the echocardiogram until first recurrence of AF.

Results

A total of 2522 patients had echocardiography reports available for review. LA size showed the strongest prognostic relationship with AF recurrence; neither LVEF nor MR was significantly associated with AF recurrence. These results persisted after adjusting for age, sex, race, tobacco use, alcohol use, drug use, body mass index, and Charlson Comorbidity Index in a multivariable model.

Conclusions

In a cohort of patients treated with antiarrhythmic medications that had transthoracic echocardiogram data, LA size was a significant predictor of AF recurrence. The clinical utility of this finding would be strengthened by replication in a multicenter setting.     

Appropriate use criteria for transthoracic echocardiography: Are they relevant to European centers?

Background

There is a growing interest in appropriate use criteria (AUC) for cardiovascular imaging referrals in Europe. These criteria, developed by American subspecialty societies, have been in use since 2007 and show a temporal reduction in inappropriate transthoracic echocardiogram (TTE) requests. When applied to European centers, inappropriate referral rates as high as 15% have been observed.

Methods

A retrospective analysis of TTE referrals for appropriateness and major abnormality detection was conducted over a two‐month period at Cork University Hospital (CUH).

Results

Overall, 1277 requests were assessed, of which 97.7% were classifiable. Of the 1235 classifiable studies, 1049 (84.9%) were appropriate, 135 (10.9%) were inappropriate, and 51 (4.1%) were uncertain. Main indications were the evaluation of cardiac structure and function (496, 40.2%), hypertension, heart failure or cardiomyopathy (349, 28.3%), and valvular function (228, 18.5%). Inappropriate referral rates were significantly higher for outpatients compared to inpatients (13.8% vs 7.1%, P < .05) and cardiologist referrals compared to noncardiologists (13.1 vs 8.0%, P < .05), while one in three requests for the evaluation of valvular function (32.5%) were inappropriate. Compared to inappropriate studies, appropriate and uncertain scans had a greater prevalence of ≥1 major abnormalities (33.6% vs 19.3%, P < .001) and greater detection rates of new abnormalities (27.6% vs 13.3%, P < .001).

Conclusion

Application of the 2011 AUC yields similar results to those reported from the US. The application of said criteria to our center could avoid one of every ten scans currently ordered.     

The effect of type 2 diabetes mellitus on multiple obstructive coronary artery disease

Background

Although type 2 diabetes mellitus (T2DM) individuals easily develop three-vessel disease (3VD) coronary artery disease (CAD), there is very little information available about their left ventricle (LV) functions. The purpose of this study is to evaluate the LV function using two-dimensional speckle tracking echocardiography (2-D STE) in T2DM patients with 3VD.

Methods

One hundred and three consecutive patients with confirmed 3VD CAD were enrolled and divided into two groups, while 53 patients with DM and 50 patients without. The control group was composed of 30 age- and sex-matched healthy individuals. All patients underwent 2-D STE and standard echocardiograms. The durations of DM and the level of HbA1c were also recorded.

Result

Between the 3VD-DM and 3VD-non-DM groups, normal echocardiography did not reveal any appreciable differences. However, patients with 3VD-DM had significantly lower global longitudinal strain (GLS) than those with 3VD-non-DM (15.87 ± 2.51 vs.17.56 ± 2.72, p < .05) by 2-D STE strain measurement. Besides, patients whose duration of DM excess 5 years showed significant lower GLS than those with less than 5 years duration (14.25 ± 2.31 vs. 16.65 ± 1.96, p = .007). However, there was no difference in GLS between the 3VD-DM patients with HbA1c ≥ 7% and HbA1c < 7%.

Conclusions

Compared to patients with 3VD alone, those with 3VD-DM have a lower cardiac function. In 3VD-DM patients, the duration of DM is a significant factor that contributes to cardiac function deterioration, whereas, the glucose control state has limited influence.     

Do we overestimate left ventricular ejection fraction by two‐dimensional echocardiography in patients with left bundle branch block?

Aims

Left bundle branch block (LBBB) causes a dyssynchronized contraction of left ventricle. This is a kind of regional wall‐motion abnormality and measuring left ventricular ejection fraction (LVEF) by two‐dimensional (2D) echocardiography could be less reliable in this particular condition. Our aim was to evaluate the role of dyssynchrony index (SDI), measured by three‐dimensional (3D) echocardiography, in assessment of LVEF and left ventricular volumes accurately in patients with LBBB.

Methods and Results

In this case–control study, we included 52 of 64 enrolled participants (twelve participants with poor image quality were excluded) with LBBB and normal LVEF or nonischemic cardiomyopathy. Left ventricular ejection fraction (LVEF) and left ventricular volumes were assessed by 2D (modified Simpson's rule) and 3D (four beats full volume analysis) echocardiography and the impact of SDI on results were evaluated. In patients with SDI ≥6%, LVEF measurements were significantly different (46.00% [29.50–52.50] vs 37.60% [24.70–45.15], P < .001) between 2D and 3D echocardiography, respectively. In patients with SDI < 6%, there were no significant differences between two modalities in terms of LVEF measurements (54.50% [49.00–59.00] vs 54.25% [40.00–58.25], P = .193). LV diastolic volumes were not significantly different while systolic volumes were underestimated by 2D echocardiography, and this finding was more pronounced when SDI ≥ 6%.

Conclusion

In patients with LBBB and high SDI (≥6%), LVEF values were overestimated and systolic volumes were underestimated by 2D echocardiography compared to 3D echocardiography.     

The Utility of Handheld Cardiac and Lung Ultrasound in Predicting Outcomes of Hospitalised Patients With COVID-19

BackgroundStrict isolation precautions limit formal echocardiography use in the setting of COVID-19 infection. Information on the importance of handheld focused ultrasound for cardiac evaluation in these patients is scarce. This study investigated the utility of a handheld echocardiography device in hospitalised patients with COVID-19 in diagnosing cardiac pathologies and predicting the composite end point of in-hospital death, mechanical ventilation, shock, and acute decompensated heart failure.MethodsFrom April 28 through July 27, 2020, consecutive patients diagnosed with COVID-19 underwent evaluation with the use of handheld ultrasound (Vscan Extend with Dual Probe; GE Healthcare) within 48 hours of admission. The patients were divided into 2 groups: “normal” and “abnormal” echocardiogram, as defined by biventricular systolic dysfunction/enlargement or moderate/severe valvular regurgitation/stenosis.ResultsAmong 102 patients, 26 (25.5%) had abnormal echocardiograms. They were older with more comorbidities and more severe presenting symptoms compared with the group with normal echocardiograms. The prevalences of the composite outcome among low- and high-risk patients (oxygen saturation < 94%) were 3.1% and 27.1%, respectively. Multivariate logistic regression analysis revealed that an abnormal echocardiogram at presentation was independently associated with the composite end point (odds ratio 6.19, 95% confidence interval 1.50-25.57; P = 0.012).ConclusionsAn abnormal echocardiogram in COVID-19 infection settings is associated with a higher burden of medical comorbidities and independently predicts major adverse end points. Handheld focused echocardiography can be used as an important “rule-out” tool among high-risk patients with COVID-19 and should be integrated into their routine admission evaluation. However, its routine use among low-risk patients is not recommended.     

Repeated hemoglobin A1C ordering in the VA Health System

Background

Hemoglobin A1c (HbA1c) is used to assess glycemic control in patients with diabetes. While underuse of HbA1c testing has been well studied, potential overuse is poorly characterized.

Methods

Our objective was to examine the frequency of HbA1c testing in an integrated delivery system. We conducted a retrospective study of administrative data of 130,538 patients with newly diagnosed diabetes receiving care in the Veterans Administration Healthcare System during 2006 and 2007 (mean age 64.1 years, 97.3% male). Our main outcome measures were the proportion of patients receiving repeat HbA1c testing within 30 and 90 days and the proportion of patients receiving more than 4 repeat tests within 12 months of their initial HbA1c.

Results

Overall 8.4% of patients (N = 11,003) received at least one repeat HbA1c within 30 days of their initial test and 30.8% (N = 40,162) within 90 days. A significantly higher proportion of patients with poor diabetes control received a repeat test within 30 days (14.7%) than patients with intermediate control (9.1%) or good control (6.8%) (P < 0.01). Overall, 4.2% of patients (N = 5,468) received more than 4 repeat HbA1c tests and 0.4% received more than 6 (N = 479). In logistic regression models, receipt of more than 4 repeat HbA1c tests was more common among patients age 50-70 years (compared to younger and older patients), whites (compared to blacks and Hispanics), and patients manifesting complications of diabetes (P < 0.01 for all).

Conclusion

Repeat HbA1c testing appears to occur somewhat more frequently than is warranted.     

Echocardiography and monitoring patients receiving dopamine agonist therapy for hyperprolactinaemia: A joint position statement of the British Society of Echocardiography,the British Heart Valve Society and the Society for Endocrinology

This is a joint position statement of the British Society of Echocardiography, the British Heart Valve Society and the Society for Endocrinology on the role of echocardiography in monitoring patients receiving dopamine agonist (DA) therapy for hyperprolactinaemia.

1. Evidence that DA pharmacotherapy causes abnormal valve morphology and dysfunction at doses used in the management of hyperprolactinaemia is extremely limited. Evidence of clinically significant valve pathology is absent, except for isolated case reports around which questions remain.
2. Attributing change in degree of valvar regurgitation, especially in mild and moderate tricuspid regurgitation, to adverse effects of DA in hyperprolactinaemia should be avoided if there are no associated pathological changes in leaflet thickness, restriction or retraction. Note must be taken that even where morphological change in leaflet structure and function may be suspected, grading is semi‐quantitative on echocardiography and may vary between different machines, ultrasound settings and operators.
3. Decisions regarding discontinuation of medication should only be made after review of serial imaging by an echocardiographer experienced in analysing drug‐induced valvulopathy or carcinoid heart disease.
4. A standard transthoracic echocardiogram should be performed before a patient starts DA therapy for hyperprolactinaemia. Repeat transthoracic echocardiography should then be performed at 5 years after starting cabergoline in patients taking a total weekly dose less than or equal to 2 mg. If there has been no change on the 5‐year scan, repeat echocardiography could continue at 5‐yearly intervals. If a patient is taking more than a total weekly dose of 2 mg, then annual echocardiography is recommended.

     

Pacemaker-Detected Atrial Fibrillation in Patients With Pacemakers: Prevalence,Predictors, and Current Use of Oral Anticoagulation

Background

Dual-chamber pacemakers frequently document atrial fibrillation (AF) in patients without symptoms. Pacemaker-detected AF is associated with a 2.5-fold increased risk of stroke, although it is not established whether oral anticoagulation reduces this risk. This study sought to determine the prevalence and predictors of pacemaker-detected AF and to document current oral anticoagulant use.

Methods

A retrospective analysis included all patients from a single academic hospital who had pacemakers capable of documenting AF. Blinded evaluation of all echocardiograms conducted within 6 months of implantation was performed.

Results

Of 445 patients, pacemaker-detected AF was present in 246 (55.3%), who were older (74.3 ± 13.7 years vs 71.7 ± 14.4, P = 0.046), more likely to have a history of clinical AF (29.7% vs 19.1%, P = 0.01), and had a larger left atrial volume index (34.4 ± 11.8 mL/m² vs 30.0 ± 9.9 mL/m², P = 0.019) than the patients without pacemaker-detected AF. Among patients without a clinical history of AF, left atrial volume index was higher among those with pacemaker-detected AF (33.7 ± 11.3 mL/m² vs 29.0 ± 10.1 mL/m², P = 0.034). Anticoagulants were used in 35.3% of patients with pacemaker-detected AF, compared with 21.6% of patients without (P < 0.05). In patients with pacemaker-detected AF, anticoagulants were used more frequently among patients who also had clinical AF (58.9%) compared with those without (23.7%, P < 0.001).

Conclusions

Pacemaker-detected AF occurs in 50% of pacemaker patients and is treated with anticoagulants in less than 25% of patients who do not have a history of clinical AF. Clinical trials are needed to determine the role of anticoagulation in this population.     

Coronary Angiography and Revascularization Following Coronary Artery Bypass Grafting in British Columbia: Incidence,Predictors and Longer-term Outcomes

Background

Coronary artery bypass grafting (CABG) is established treatment for subsets of coronary artery disease (CAD). Observational data have characterised significant progression of native coronary as well as graft vessel disease during longer-term follow-up, potentially reducing the benefit of CABG. We sought to assess longer-term outcomes following CABG by determining rates of repeat coronary angiography, revascularization procedures, and survival.

Left ventricular end‐diastolic volume predicts exercise capacity in patients with a normal ejection fraction

Background

Exercise capacity is a powerful predictor of all‐cause mortality. The duration of exercise with treadmill stress testing is an important prognostic marker in both healthy subjects and patients with cardiovascular disease. Left ventricular (LV) structure is known to adapt to sustained changes in level of physical activity.

Hypothesis

Poor exercise capacity in patients with a preserved LV ejection fraction (LVEF) should be reflected in smaller LV dimensions, and a normal exercise capacity should be associated with larger LV dimensions, irrespective of comorbidities.

Methods

This hypothesis was first tested in a cross‐sectional analysis of 201 patients with normal chamber dimensions and preserved LVEF who underwent a clinically indicated treadmill stress echocardiogram using the Bruce protocol (derivation cohort). The best LV dimensional predictor of exercise capacity was then tested in 1285 patients who had a Bruce‐protocol treadmill exercise stress test and a separate transthoracic echocardiogram (validation cohort).

Results

In the derivation cohort, there was a strong positive relationship between exercise duration and LV end‐diastolic volume deciles (r ² = 0.85; P < 0.001). Regression analyses of several LV dimensional parameters revealed that the body surface area–based LV end‐diastolic volume index was best suited to predict exercise capacity (P < 0.0001). In a large validation cohort, LV end‐diastolic volume was confirmed to predict exercise capacity (P < 0.0001).

Conclusions

Among patients referred for outpatient stress echocardiography who have a preserved LVEF and no evidence of myocardial ischemia, we found a strong positive association between LV volume and exercise capacity.     

Evaluation of Patients with an Apparent False Positive Stool DNA Test: The Role of Repeat Stool DNA Testing

Background

There is uncertainty as to the appropriate follow-up of patients who test positive on multimarker stool DNA (sDNA) testing and have a colonoscopy without neoplasia.

Aims

To determine the prevalence of missed colonic or occult upper gastrointestinal neoplasia in patients with an apparent false positive sDNA.

Methods

We prospectively identified 30 patients who tested positive with a commercially available sDNA followed by colonoscopy without neoplastic lesions. Patients were invited to undergo repeat sDNA at 11–29 months after the initial test followed by repeat colonoscopy and upper endoscopy. We determined the presence of neoplastic lesions on repeat evaluation stratified by results of repeat sDNA.

Results

Twelve patients were restudied. Seven patients had a negative second sDNA test and a normal second colonoscopy and upper endoscopy. In contrast, 5 of 12 subjects had a persistently positive second sDNA test, and 3 had positive findings, including a 3-cm sessile transverse colon adenoma with high-grade dysplasia, a 2-cm right colon sessile serrated adenoma with dysplasia, and a nonadvanced colon adenoma (p?=?0.045). These corresponded to a positive predictive value of 0.60 (95% CI 0.17–1.00) and a negative predictive value of 1.00 (95% CI 1.00–1.00) for the second sDNA test. In addition, the medical records of all 30 subjects with apparent false positive testing were reviewed and no documented cases of malignant tumors were recorded.

Conclusions

Repeat positive sDNA testing may identify a subset of patients with missed or occult colorectal neoplasia after negative colonoscopy for an initially positive sDNA. High-quality colonoscopy with careful attention to the right colon in patients with positive sDNA is critically important and may avoid false negative colonoscopy.

     

Utility of Repeated Abdominal CT Scans After Prior Negative CT Scans in Patients Presenting to ER with Nontraumatic Abdominal Pain

Purpose

The purpose of this study was to analyze diagnostic yield of repeat computed tomography (CT) after negative initial CT versus yield of initial CT in patients presenting repeatedly to emergency room (ER) for nontraumatic abdominal pain. Medical costs and radiation exposure from repeat CT could be reduced if repeat CT after negative initial CT has a low diagnostic yield.

Methods

Patients included consecutive adults presenting to William Beaumont Hospital, from 2007 to 2010, undergoing abdominal CT for nontraumatic abdominal pain retrospectively identified by medical diagnostic and CT procedural codes. Exclusion criteria were prior abdominal trauma, recent abdominal surgery, and known chronic gastrointestinal disease. The CT was labeled “positive” if findings explained patient’s abdominal pain or was clinically significant. Positivity rate was compared for repeat versus initial CT.

Results

Among 200 consecutive patients undergoing (659) multiple CTs (mean age = 45.7 years, 74 % female), positivity rate for initial CT (22.5 %) was significantly higher than positivity rates for CT#2 (8.4 %, p = 0.002), for CT#3 (4.9 %, p = 0.005), and for CT ≥ #4 (5.9 %, p = 0.006). Generally, CT positivity rate declined with increasing number of prior negative CTs. CT positivity rate was significantly higher in 100 patients undergoing single CT versus 155 patients undergoing repeat CTs (46.5 vs. 6.5 %, p = 0.0001). Positive repeat CT findings included intestinal mural thickening/mass (7), colitis (5), appendicitis (4), and other (14). Among 15 analyzed clinical parameters, two significantly predicted repeat CT positivity, namely, leukocytosis (p = 0.03) and APACHE-II-score >5 (p = 0.01). Repeat CTs constituted 47 % of all CTs.

Conclusions

Repeat abdominal CT after initially negative CT(s) performed for nontraumatic abdominal pain has a low diagnostic yield. Leukocytosis and APACHE-II score might help predict CT scan positivity. Data suggest restricted abdominal CT utilization in ER patients with multiple prior negative CTs. Findings warrant confirmation in prospective studies.     

Appropriateness of Cardiac Troponin Testing: Insights from the Use of TROPonin In Acute coronary syndromes (UTROPIA) Study

ObjectiveOur objective was to examine the appropriateness of cardiac troponin (cTn) testing among patients with cTn increases.MethodsThis is a planned secondary analysis of the Use of TROPonin In Acute coronary syndromes (UTROPIA, NCT02060760) observational cohort study. Appropriateness of cTn testing was adjudicated for emergency department patients with cTn increases > 99^th percentile and analyzed using both contemporary and high-sensitivity (hs) cTnI assays according to sub-specialty, diagnoses, and symptoms.ResultsAppropriateness was determined from 1272 and 1078 adjudication forms completed for 497 and 422 patients with contemporary and hs-cTnI increases, respectively. Appropriateness of cTnI testing across adjudication forms was 71.5% and 72.0% for cTnI and hs-cTnI, respectively. Compared with emergency physicians, cardiologists were less likely to classify cTnI orders as appropriate (cTnI: 79% vs 56%, P < .0001; hs-cTnI: 82% vs 51%, P < .0001). For contemporary cTnI, appropriateness of 95%, 70%, and 39% was observed among adjudication forms completed by cardiologists for type 1 myocardial infarction, type 2 myocardial infarction, and myocardial injury, respectively; compared with 90%, 86%, and 71%, respectively, among emergency physicians. Similar findings were observed using hs-cTnI. Discordance in appropriateness adjudication forms occurred most frequently in cases of myocardial injury (62% both assays) or type 2 myocardial infarction (cTnI 31%; hs-cTnI 23%).ConclusionsMarked differences exist in the perception of what constitutes appropriate clinical use of cTn testing between cardiologists and emergency physicians, with emergency physicians more likely to see testing as appropriate across a range of clinical scenarios. Discordance derives most often from cases classified as myocardial injury or type 2 myocardial infarction.