Impact of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) on the speed of triage decision making for emergency department patients presenting with chest pain

Objective: Emergency department (ED) triage for acute cardiac ischemia in the primary teaching hospital in Geneva, Switzerland, is very accurate, but at the cost of very long ED stays. Thus, the authors sought: 1) to determine the impact of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI), incorporated into a computerized electrocardiograph, on length of stay and speed of triage decision making for ED patients presenting with symptoms suggesting acute cardiac ischemia, and 2) to study the ACI-TIPI’s impact on physicians of different training levels. Design: A seven-month prospective clinical trial with alternating-month experimental and control periods. Setting: An urban major teaching hospital in Geneva, Switzerland. Participants: Patients over the age of 18 years presenting to the ED with chest pain or other symptoms suggesting acute cardiac ischemia (acute myocardial infarction or unstable angina pectoris). Emergency department physicians, classified as novice (those in their first ED rotations) and experienced (those in their second or later ED rotations). Patients staying overnight in the ED (n=111) were excluded from the analysis. Intervention: During the experimental months, the computerized electrocardiograph printed the ACI-TIPI probability of acute cardiac ischemia at the top of each subject’s electrocardiogram. During control months, the probability was not provided. Measurements and main results: Among the 418 study subjects, for patients with acute ischemia seen by novice clinicians, the use of the ACI-TIPI decreased ED time from presentation to triage decision and ED release by 0.7 hour (19%) (p=0.007). Subgroup analyses for patients with acute myocardial infarction, patients with unstable angina pectoris, and patients given thrombolytic therapy also showed analogous decreases in ED time consistent with this finding. Other key determinants of ED length of stay included: age, whether the coronary care unit was full, whether patients received thrombolytic therapy, and whether admission was during the night shift. The experimental and control groups did not differ in triage disposition appropriateness or mortality. Conclusions: For ED patients with acute cardiac ischemia evaluated by novice clinicians, the ACI-TIPI substantially speeded ED decision making and triage. The suggestion of an impact on different cardiac ischemia subgroups and mortality deserves further larger clinical trials.     

Late complications after prosthetic replacement of the ascending aorta: what did we learn from routine magnetic resonance imaging follow-up?

OBJECTIVE: Advances in surgical technique have improved early survival after surgery of the ascending aorta. However, follow-up data document serious late complications, mainly evolutive peri-prosthetic false aneurysms. Magnetic resonance imaging (MRI) has proved to be highly effective for monitoring these complications. This study evaluates 10 years of experience with routine MRI for follow-up. METHODS: Since January 1988, 114 patients with replacement of the ascending aorta either for type A acute dissection (group I, 45 patients) or aneurysms (group II, 69 patients) were followed up with annual MRI. Prosthetic replacement was either limited to supra-coronary ascending aorta (45%, 51/114) or extended to the aortic root and/or the aortic arch (55%). Biological glue was always utilized. MRI focused on peri-prosthetic haematoma, analyzing signal intensity changes and volume augmentation for early detection of false aneurysms, and on persistent residual dissection with or without evolutive aortic aneurysm distant to the prosthesis. RESULTS: Peri-prosthetic hematomas were almost equally found in both groups (26 (58%) in group I and 42 (61%) in group II) and were detected within the first year. Peri-prosthetic false aneurysms developed in 15 patients (group I, seven; group II, eight) as a complication of pre-existing hematomas and were indicated for elective reoperation. Forty-three (96%) of patients in group I had persistent residual dissection. Five patients in group I and two in group II needed reoperation for evolutive aortic aneurysm. In total, 22 of 114 (19%) patients were reoperated on during follow-up (12 (27%) in group I and ten (15%) in group II). Operative mortality was 13% (3/22). Freedom from reoperation at 1 year/5 years was: group I, 93%/84%; group II, 98%/88%. CONCLUSION: Peri-prosthetic haematoma occurs equally after aneurysm or dissection repairs and is a pre-existing condition for peri-prosthetic false aneurysm; biological glue or extended repair do not prevent late complications. Long-term MRI follow-up allows successful elective reoperation for life-threatened but asymptomatic patients.