P5519Effects of crowding in the emergency department on time dependent processes and outcomes using fast diagnostic protocols in patients with suspected acute coronary syndrome

Abstract Background Accelerated diagnostic algorithms using high-sensitivity troponin (hsTn) assays in suspected acute coronary syndrome (ACS) are regarded as particularly beneficial to expedite diagnosis and safe discharge of low risk patients in crowded emergency departments (ED). However, little is known about potential negative effects of crowding on implementation and efficacy of fast diagnostic protocols. We studied the effects of crowding on outcomes and process times in patients admitted with suspected ACS using fast diagnostic protocols. Methods A total of 2,525 consecutive patients were evaluated during 12 months using 2015 ESC guideline recommended fast protocols. Crowding was defined as mismatch between patient visits and monitoring capacities as well as effective physician time per case. Electronic time-stamps were available for length of ED stay, timing of hsTnT measurements, time intervals between measurements, and laboratory turn-around-times (TAT). Patients were followed up for all-cause mortality at 30 days and 1 year. Results Crowding was associated with increasing intervals between blood samples from 98 to 107 minutes (p=0.008), increasing median TAT from 53 to 57 minutes (p<0.001), significantly higher numbers of additional hsTnT measurements after diagnosis (p<0.001 for trend), and a trend for more frequent hospital discharge (58.9 vs. 62.8%, p=0.08) across crowding levels. There were indirect findings for additional negative effects on time dependent care processes. However, there was no significant effect of crowding on 30-day (1.8 vs. 1.9%) or 1-year all-cause mortality (5.4 vs. 5.9%). Conclusion Time-dependent processes are prolonged in a crowded ED diminishing some positive effects of fast diagnostic protocols for evaluation of suspected ACS. Acknowledgement/Funding Roche Diagnostics International Ltd.

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Changing in the profile of a patient with acute coronary syndrome without ST-segment elevation over the years 2015-2020

Medicni perspektivi (Medical perspectives) ◽

10.26641/2307-0404.2021.4.248164 ◽

2021 ◽

Vol 26 (4) ◽

pp. 94-98

Author(s):

O.S. Shchukina

Keyword(s):

Acute Coronary Syndrome ◽

Clinical Laboratory ◽

Clinical Status ◽

High Sensitivity ◽

St Segment Elevation ◽

Coronary Syndrome ◽

St Segment ◽

Number Of Patients ◽

Noteworthy Feature ◽

Risk Patients

The article represents an analysis of the dynamics of the main demographic, clinical, laboratory, and instrumental investigations, final diagnoses of patients who were hospitalized with a diagnosis of acute coronary syndrome without ST segment elevation. A distinctive feature of the work is the recruitment of patients in the same medical institution for different periods of time, which makes possible to trace the dynamics of the clinical profile of patients in the population of Dnipro, a large industrial center of Ukraine. The prevalence of arterial hypertension, chronic heart failure and previous myocardial infarction remained at the same level. In the 2017-2020’s group compared with the 2015’s group, electrocardiographic manifestations of acute coronary syndrome without ST-segment elevation upon admission were more often detected. Laboratory indicators such as hemoglobin, creatinine and total cholesterol levels remained the same. Another interesting finding is a statistically significant decrease in the number of patients with a reduced glomerular filtration rate according to MDRD (less than 60 ml/min/1.73 m2) in the 2017-2020’s group compared to patients in 2015’s group, although the clinical course of the disease remained practically unchanged. There was a trend towards a worsening of the clinical status and prognosis, namely, increase in the prevalence of atrial fibrillation and diabetes mellitus, increase in the risk of GRACE, as well as increase in the quantity of verified diagnoses of unstable angina, which is most likely associated with the increased use of high-sensitivity troponin. Noteworthy feature is that increase in the quantity of high-risk patients led to an increase in the mean GRACE score.

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Efficacy of High-Sensitivity Troponin T in Identifying Very-Low-Risk Patients with Possible Acute Coronary Syndrome

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2018.04.043 ◽

2018 ◽

Vol 54 (6) ◽

pp. 901

Author(s):

Patrick Joynt

Keyword(s):

Acute Coronary Syndrome ◽

Troponin T ◽

High Sensitivity ◽

Low Risk ◽

Coronary Syndrome ◽

High Sensitivity Troponin ◽

Risk Patients ◽

High Sensitivity Troponin T

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High-Sensitivity Troponin T vs I in Acute Coronary Syndrome: Prediction of Significant Coronary Lesions and Long-term Prognosis

Clinical Chemistry ◽

10.1373/clinchem.2016.261107 ◽

2017 ◽

Vol 63 (2) ◽

pp. 552-562 ◽

Cited By ~ 15

Author(s):

Brede Kvisvik ◽

Lars Mørkrid ◽

Helge Røsjø ◽

Milada Cvancarova ◽

Alexander D Rowe ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Coronary Angiography ◽

High Sensitivity ◽

Coronary Syndrome ◽

Prognostic Accuracy ◽

All Cause Mortality ◽

Coronary Lesions ◽

Long Term Prognosis

Abstract BACKGROUND High-sensitivity cardiac troponin (hs-cTn) T and I assays are established as crucial tools for the diagnosis of acute myocardial infarction (AMI), as they have been found superior to old troponin assays. However, eventual differences between the assays in prediction of significant coronary lesions and long-term prognosis in patients with acute coronary syndrome (ACS) have not been fully unraveled. METHODS Serum concentrations of hs-cTnT (Roche), hs-cTnI (Abbott), and amino-terminal pro-B-type natriuretic peptide (NT-proBNP; Roche) in 390 non-ST-elevation (NSTE) ACS patients were evaluated in relation to significant coronary lesions on coronary angiography (defined as a stenosis >50% of the luminal diameter, with need for revascularization) and prognostic accuracy for cardiovascular mortality, all-cause mortality, as well as the composite end point of cardiovascular mortality and hospitalizations for AMI or heart failure. RESULTS The mean (SD) follow-up was 2921 (168) days. Absolute hs-cTnI concentrations were significantly higher than the hs-cTnT concentrations. The relationship between analyzed biomarkers and significant coronary lesions on coronary angiography, as quantified by the area under the ROC curve (AUC), revealed no difference between hs-cTnT [AUC, 0.81; 95% CI, 0.77–0.86] and hs-cTnI (AUC, 0.81; 95% CI, 0.76–0.86; P = NS). NT-proBNP was superior to both hs-cTn assays regarding prognostic accuracy for both cardiovascular and all-cause mortality and for the composite end point during follow-up, also in multivariate analyses. CONCLUSIONS The hs-cTnT and hs-cTnI assays displayed a similar ability to predict significant coronary lesions in NSTE-ACS patients. NT-proBNP was superior to both hs-cTn assays as a marker of long-term prognosis in this patient group.

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Biomarkers-in-Cardiology 8 RE-VISITED—Consistent Safety of Early Discharge with a Dual Marker Strategy Combining a Normal hs-cTnT with a Normal Copeptin in Low-to-Intermediate Risk Patients with Suspected Acute Coronary Syndrome—A Secondary Analysis of the Randomized Biomarkers-in-Cardiology 8 Trial

Cells ◽

10.3390/cells11020211 ◽

2022 ◽

Vol 11 (2) ◽

pp. 211

Author(s):

Evangelos Giannitsis ◽

Tania Garfias-Veitl ◽

Anna Slagman ◽

Julia Searle ◽

Christian Müller ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Cardiac Troponin ◽

Troponin T ◽

High Sensitivity ◽

Early Discharge ◽

Cardiac Troponin T ◽

Cardiac Events ◽

Coronary Syndrome ◽

Adverse Cardiac Events ◽

Risk Patients

Regarding the management of suspected Non-ST-segment-elevation acute coronary syndrome (ACS), the main Biomarker-in-Cardiology (BIC)-8 randomized controlled trial study had reported non-inferiority for the incidence of major adverse cardiac events at 30 days in the Copeptin group (dual marker strategy of copeptin and hs-cTnT at presentation) compared to the standard process (serial hs-cTnT testing). However, in 349 (38.7%) of the 902 patients, high-sensitivity cardiac troponin was not available for the treating physicians. High sensitivity cardiac troponin T was re-measured from thawed blood samples collected at baseline. This cohort qualified for a re-analysis of the 30-day incidence rate of MACE (death, survived cardiac death, acute myocardial infarction, re-hospitalization for acute coronary syndrome, acute unplanned percutaneous coronary intervention, coronary bypass grafting, or documented life-threatening arrhythmias), or components of the primary endpoint including death or death/MI. After re-measurement of troponin and exclusion of 9 patients with insufficient blood sample volume, 893 patients qualified for re-analysis. A total of 57 cases were detected with high sensitivity cardiac troponin T ≥ 14 ng/L who had been classified as “troponin negative” based on a conventional cardiac troponin T or I < 99th percentile upper limit of normal. Major adverse cardiac events rates after exclusion were non-inferior in the Copeptin group compared to the standard group (4.34% (95% confidence intervals 2.60–6.78%) vs. 4.27% (2.55–6.66%)). Rates were 53% lower in the per-protocol analysis (HR 0.47, 95% CI: 0.18–1.15, p = 0.09). No deaths occurred within 30 days in the discharged low risk patients of the Copeptin group. Copeptin combined with high sensitivity cardiac troponin is useful for risk stratification and allows early discharge of low-to-intermediate risk patients with suspected acute coronary syndrome is as safe as a re-testing strategy at 3 h or later.

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Abstract 13173: Unusual Fatigue and Failure to Utilize Emergency Medical Services Are Associated With Prolonged Prehospital Delay for Suspected Acute Coronary Syndrome

Circulation ◽

10.1161/circ.142.suppl_3.13173 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Holli A Devon ◽

Mohamud R Daya ◽

Elizabeth Knight ◽

Mary-Lynn Brecht ◽

Erica Su ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Delay Time ◽

Failure Time ◽

Secondary Analysis ◽

High Sensitivity ◽

Final Diagnosis ◽

Prehospital Delay ◽

Coronary Syndrome ◽

Risk Patients

Introduction: Rapid reperfusion reduces infarct size and mortality for acute coronary syndrome (ACS) but efficacy is time dependent. Time to presentation in the Emergency Department (ED) remains excessive and patient-controlled prehospital delay may be a modifiable variable for intervention. The aim of the study was to determine if transportation factors and clinical presentation predicted prehospital delay for suspected ACS stratified by final diagnosis (ACS vs. no ACS). Hypothesis: Symptoms other than chest pain would contribute to longer prehospital delay that would vary by final diagnosis. Methods: Secondary analysis of data collected from a multi-center prospective study. A heterogeneous sample of ED patients with symptoms suggestive of ACS were enrolled at five sites in the US. Accelerated failure time (AFT) models were used to specify a direct relationship between delay time and variables to predict prehospital delay by final diagnosis. Results: The sample of 975 adults included 609 (62.5%) men and 366 (37.5%) women who were predominantly Caucasian (69.1%), had a mean age of 60.32 (±14.07) years, and had lower income levels (66.4% ≤$50,000 annually). Median delay time was 6.68 (1.91, 24.94) hours and only 26.2% had a prehospital delay of 2 hours or less. Patients with and without ACS presenting with unusual fatigue (TR=1.71, p=0.002; TR=1.54, p=0.003 , respectively) or self-transporting to the ED experienced significantly longer prehospital delay (TR 1.93, p<0.001; TR 1.71, p<0.001 , respectively). Predictors of shorter delay in patients with ACS were shoulder pain and lightheadedness (TR=0.65, p =0.013 and TR=0.67, p =0.022, respectively). Predictors of shorter delay for patients ruled-out for ACS were the presence of chest pain, sweating (TR=0.071, p =0.025 and TR=0.073, p =0.032, respectively). Conclusion: Patients self-transporting to the ED had prolonged prehospital delays. Encouraging the use of EMS is an important modifiable factor for patients with symptoms concerning for ACS. Calling 911 can be positively framed to at risk patients and the community as having advanced care come to them since EMS diagnostic capabilities include 12-lead ECG acquisition and possibly high sensitivity troponin assays.

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Effects of crowding in the emergency department on the diagnosis and management of suspected acute coronary syndrome using rapid algorithms: an observational study

BMJ Open ◽

10.1136/bmjopen-2020-041757 ◽

2020 ◽

Vol 10 (10) ◽

pp. e041757

Author(s):

Kiril M Stoyanov ◽

Moritz Biener ◽

Hauke Hund ◽

Matthias Mueller-Hennessen ◽

Mehrshad Vafaie ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Observational Study ◽

Outcome Measures ◽

Fast Algorithms ◽

High Sensitivity ◽

Diagnostic Algorithms ◽

Positive Effects ◽

Coronary Syndrome ◽

European Society Of Cardiology ◽

Laboratory Time

ObjectivesFast diagnostic algorithms using high-sensitivity troponin (hsTn) in suspected acute coronary syndrome (ACS) are regarded as beneficial to expedite diagnosis and safe discharge of patients in crowded emergency departments (ED). This study investigates the effects of crowding on process times related to the diagnostic protocol itself or other time delays, and outcomes.DesignProspective single-centre observational study.SettingED (Germany).ParticipantsFinal study population of 2525 consecutive patients with suspected ACS within 12 months, after exclusion of patients with ST-elevation myocardial infarction, missing blood samples, referral from other hospitals or repeated visits.InterventionsUse of fast algorithms as per 2015 European Society of Cardiology guidelines.Main outcome measuresCrowding was defined as mismatch between patient numbers and monitoring capacities, or mean physician time per case, categorised as normal, high and very high crowding. Outcome measures were length of ED stay, direct discharge from ED, laboratory turn around times (TAT), utilisation of fast algorithms, absolute and relative non-laboratory time, as well as mortality.ResultsCrowding was associated with increased length of ED stay (3.75–4.89 hours, p<0.001). While median TAT of the first hsTnT increased (53–57 min, p<0.001), total TAT of serial hsTnT did not increase significantly with higher crowding (p=0.170). Lower utilisation of fast algorithms (p=0.009) and increase of additional hsTnT measurements after diagnosis (p=0.001) were observed in higher crowding. Most importantly, crowding was significantly associated with prolonged absolute (p<0.001), and particularly relative non-laboratory time (63.3%–71.3%, p<0.001). However, there was no significant effect of crowding on mortality, even after adjustment for relevant clinical variables.ConclusionsProcess times, and particularly non-laboratory times, are prolonged in a crowded ED diminishing some positive effects of fast diagnostic algorithms in suspected ACS. Higher crowding levels were not significantly associated with higher all-cause mortality rates.Trial registration numberNCT03111862.

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LO005: Association between emergency department chest pain volume and outcomes among patients presenting with chest pain

CJEM ◽

10.1017/cem.2016.42 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S31-S32

Author(s):

N.D. Dattani ◽

M. Koh ◽

A. Chong ◽

A. Czarnecki ◽

D.T. Ko

Keyword(s):

Emergency Department ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

High Risk ◽

High Volume ◽

Mortality Rates ◽

Low Risk ◽

Coronary Syndrome ◽

All Cause Mortality ◽

Risk Patients

Introduction: Chest pain is one of the most common reasons for emergency department (ED) visits in developed countries. Patients discharged after ED assessment remain at risk for adverse cardiac events. Although a volume-outcome relationship has been shown for myocardial infarction, it is uncertain whether a similar relationship exists with ED chest pain volume. Accordingly, we aimed to determine whether ED chest pain volume influences outcomes of patients presenting to the ED with chest pain who were discharged home. Methods: This was a retrospective cohort study using population-based data from Ontario, Canada. Patients who were discharged home from an ED in Ontario with a primary diagnosis of chest pain from April 1, 2004 to March 31, 2010 were included. High-risk patients were defined as the presence of diabetes or pre-existing cardiovascular disease, while low-risk patients were defined as the absence of these conditions. ED volume was categorized as low, medium, or high, based on tertiles of annual chest pain patient volume. The primary outcome of this study was all-cause mortality one year after the index ED visit. Mantel-Haenszel Chi-Square was used to compare crude outcome rates. Results: There were 56,767 high-risk patients. The average age was 66 years and 53% were male. All-cause mortality rates were 6.8%, 6.3%, and 6.0% (p=0.028), and rates of hospitalization for acute coronary syndrome were 5.8%, 4.6%, and 4.0% (p<0.001) among low, medium, and high volume EDs respectively. There were 216,527 low-risk patients. The average age was 64 years and 42% were male. All-cause mortality rates were 2.0%, 1.9%, and 1.6% (p<0.001), and rates of hospitalization for acute coronary syndrome were 1.5%, 1.4%, and 1.0% (p<0.001) among low, medium, and high volume EDs respectively. Conclusion: Higher volume EDs were associated with decreased rates of all-cause mortality and admission for acute coronary syndrome among chest pain patients who were discharged home. Future research should study the reasons for this finding and attempt to improve outcomes in lower volume EDs.

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3302Effects of implementation of the ESC 0/1-hour algorithm on efficiacy and safety of discharge after rule-out in a consecutive cohort of patients with suspected acute coronary syndrome - RAPID-CPU study

European Heart Journal ◽

10.1093/eurheartj/ehz745.0066 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

K M Stoyanov ◽

H Hund ◽

M Biener ◽

J Gandowitz ◽

C Riedle ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Limit Of Detection ◽

Troponin T ◽

High Sensitivity ◽

Coronary Syndrome ◽

Lengths Of Stay ◽

Discharge Rates ◽

All Cause Mortality ◽

Implementation Period ◽

Rule Out

Abstract Aims The feasibility, efficacy and safety of ESC 0/1- and 0/3-hour algorithms using high-sensitivity troponin T (hsTnT) were evaluated in an all-comer cohort with suspected acute coronary syndrome, based on a broad spectrum of symptoms. Methods During 12 months, 2,525 eligible patients were enrolled. In a pre-implementation period of 6 months, prevalence of protocols, disposition, lengths of emergency department (ED) stay and treatments were registered. Implementation of ESC 0/1-hour protocol was monitored for another 6 months. Primary endpoints comprised the change of diagnostic protocols, and all-cause mortality at 30 days following direct discharge from the ED. Secondary endpoints included length of ED stay, hospital discharge, and 1-year mortality. Results Use of the ESC 0/1-hour algorithm increased by 270% at the cost of the standard 0/3-hour protocol. Median follow-up times were 400 (316–459) days, with vital status available for 98.7%. After rule-out (1,588 patients), 1,309 patients (76.1%) were discharged directly from the ED, with an all-cause mortality of 0.08% at 30 days (1 death due to lung cancer). Median lengths of stay were 2.9 (1.9–3.8) and 3.2 (2.7–4.4) hours using a single hsTnT below limit of detection (LoD) (5 ng/L) at presentation and the ESC 0/1-hour algorithm, respectively, as compared to 5.3 (4.7–6.5) hours using the ESC 0/3-hour rule-out protocol. Discharge rates increased from 53.9% to 62.8% (p<0.0001), without excessive use of diagnostic resources within 30 days. Mortality by diagnostic rule Conclusion Implementation of the ESC 0/1-hour algorithm seems feasible and safe. It is associated with shorter ED stays than the ESC 0/3-hour protocol and a further increase of discharge rates. Acknowledgement/Funding Roche Diagnostics International Ltd.

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