A HEART Pathway pitfall in an admitted patient

This paper discusses a possible weakness of the HEART Pathway specific to patients identified as high risk, requiring admission for inpatient risk stratification. Emergency Department (ED) crowding is at an all-time high and the possibility that many of these patients will board in the ED for a period of time before they are transported to an inpatient ward is becoming more likely. Given troponins peak at 6?h after the initial cardiac injury, it is plausible an initial troponin could still remain negative upon arrival. Extending the HEART Pathway to include a 3-hour delta troponin for admitted patients boarded in the emergency department may help alert the patient's inpatient team of those requiring more aggressive evaluations or more timely interventions. The case discussed herein highlights the course of a patient who was admitted to a medicine floor for chest pain along the HEART Pathway. After remaining in the ED for 3?h following admission a second troponin was drawn that resulted in the diagnosis of a non-ST segment myocardial infarction. The patient then received further management in the ED and a change in admission to the Cardiac Care Unit instead of the medicine floor. The patient ultimately received a Coronary Artery Bypass Graft during admission. If the patient had not had the second troponin while in the ED this care would have been delayed.     

The disutility of stress testing in low-risk HEART Pathway patients

BackgroundThe HEART Pathway identifies low-risk chest pain patients for discharge from the Emergency Department without stress testing. However, HEART Pathway recommendations are not always followed. The objective of this study is to determine the frequency and diagnostic yield of stress testing among low-risk patients.MethodsAn academic hospital's chest pain registry was analyzed for low-risk HEART Pathway patients (HEAR score ≤ 3 with non-elevated troponins) from 1/2017 to 7/2018. Stress tests were reviewed for inducible ischemia. Diagnostic yield was defined as the rate of obstructive CAD among patients with positive stress testing. T-test or Fisher's exact test was used to test the univariate association of age, sex, race/ethnicity, and HEAR score with stress testing. Multivariate logistic regression was used to determine the association of age, sex, race/ethnicity, and HEAR score with stress testing.ResultsThere were 4743 HEART Pathway assessments, with 43.7% (2074/4743) being low-risk. Stress testing was performed on 4.1% (84/2074). Of the 84 low-risk patients who underwent testing, 8.3% (7/84) had non-diagnostic studies and 2.6% (2/84) had positive studies. Among the 2 patients with positive studies, angiography revealed that 1 had widely patent coronary arteries and the other had multivessel obstructive coronary artery disease, making the diagnostic yield of stress testing 1.2% (1/84). Each one-point increase in HEAR score (aOR 2.17, 95% CI 1.45–3.24) and being male (aOR 1.59, 95% CI 1.02–2.49) were associated with testing.ConclusionsStress testing among low-risk HEART Pathway patients was uncommon, low yield, and more likely in males and those with a higher HEAR score.     

Utility of HEART Pathway in Identifying Low-Risk Chest Pain in Emergency Department

BackgroundChest pain is a common presenting symptom in the emergency department (ED). The HEART (history, electroencephalogram [ECG], age, risk factors, and troponin I) score, with addition of troponin at 3 h, helps to determine appropriate risk stratification of the patients.ObjectiveThis study evaluated the utility of the HEART pathway as a decision aid designed for risk stratification of patients with acute-onset chest pain for early and safe disposition.MethodsThis was a prospective observational study done in a tertiary care center. Focused history, 12-lead ECG, and baseline troponin I level on arrival and at hour 3 were recorded. Subjects were classified as low risk (HEART score 0–3) or high risk (HEART score ≥ 4). Patients with a HEART score of 0–3 with negative troponin I at 3 h were discharged and were followed up for major adverse cardiac events (MACEs) within 30 days of ED presentation.ResultsA total of 250 patients were screened for the study, of which 151 were included for the final analysis. One hundred and two patients (68%) were male and 54% of patients were younger than 45 years. HEART scores of 0 (n = 16), 1 (n = 43), 2 (n = 44), and 3 (n = 48) were observed. There was only 1 MACE (0.7%) in 30 days after ED discharge in the study population. The mean length of ED stay in the low-risk group was 4.5 h.ConclusionsLow-risk patients, as per the HEART pathway, can be discharged safely from the ED, which reduces ED stay and health care resource use.     

Impact of the HEART Pathway on Admission Rates for Emergency Department Patients with Chest Pain: An External Clinical Validation Study

Background

Chest pain is a common emergency department (ED) chief complaint. Safe discharge mechanisms for low-risk chest pain patients would be useful.

Comparing the Effects of Dual-Task Gait Testing in New and Established Ambulators With Lower Extremity Amputations

Background

Gait is a complex process that involves coordinating motor and sensory systems through higher-order cognitive processes. Walking with a prosthesis after lower extremity amputation challenges these processes. However, the factors that influence the cognitive-motor interaction in gait among lower extremity amputees has not been evaluated. To assess the interaction of cognition and mobility, individuals must be evaluated using the dual-task paradigm.

Cost analysis of the History,ECG, Age,Risk factors,and initial Troponin (HEART) Pathway randomized control trial

Introduction

The HEART Pathway is a diagnostic protocol designed to identify low-risk patients presenting to the emergency department with chest pain that are safe for early discharge. This protocol has been shown to significantly decrease health care resource utilization compared with usual care. However, the impact of the HEART Pathway on the cost of care has yet to be reported.

浅析误诊的主客观因素

文章分析了误诊的主观因素和客观因素。误诊的主观因素有责任因素、心理心素、临床思维因素。医师责任心差、不良的心理状态、思维基点选择错误、辐射－辐集思维不良等均可导致误诊。误诊的客观因素：病人心理因素对医生的误导，病人表达能力低下及所患疾病的复杂多变，环境因素，社会因素等均会影响疾病的诊断。     

Objective response of desmoid fibroma to chemotherapy

Six patients with inoperable desmoid tumors have been treated by preoperative chemotherapy. In all six cases objective response occurred and allowed conservative surgery. Objective responses included tumor softening (6/6), releasing of articular motion previously limited (3/3), and tumor size' decreasing (2/6). Few histologic modifications were seen. Such data advocates for preoperative chemotherapy in desmoid tumor when large and threatening the limb or the life of the patient.