scholarly journals 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 ◽  
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.

Performance of the European Society of Cardiology 0/1-hour algorithm in the diagnosis of myocardial infarction with high-sensitivity cardiac troponin: Systematic review and meta-analysis

2020 ◽  
pp. 204887262093539 ◽  
Author(s):  
Lucrecia M Burgos ◽  
Marcelo Trivi ◽  
Juan P Costabel
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Diagnostic Accuracy ◽  
Likelihood Ratio ◽  
European Society ◽  
Cardiac Troponin ◽  
High Sensitivity ◽  
Coronary Syndrome ◽  
European Society Of Cardiology ◽  
Rule Out

Introduction: A rapid rule-out or rule-in protocol based on the 0-hour/1-hour algorithm using high-sensitivity cardiac troponin (hs-cTn) is recommended by the European Society of Cardiology (ESC); recently multiple studies have validated it in their settings. We aimed to assess the diagnostic accuracy of the 2015 ESC guidelines for management of acute coronary syndrome in patients without ST-segment elevation 0-hour/1-hour algorithm using hs-cTn for the early rule-out and rule-in of acute myocardial infarction (AMI) on presentation. Methods: Systematic searches were conducted using PubMed, the Cochrane Library and the International Clinical Trials Registry Platform to identify prospective studies from 2015 to October 2019 involving adults presenting to the emergency department with possible acute coronary syndrome in which hs-cTn measurements were obtained according to the ESC algorithm and AMI outcomes were adjudicated during the initial hospitalization. Results: Eleven studies, involving 19,213 patients, were identified. Pooled prevalence of AMI during the index hospitalization was 11.3% (95% confidence interval (CI) 3.9–18.8%). Summary sensitivity and specificity in diagnosing AMI were 99% (95% CI 98–99%; I2 63%) and 91% (95% CI 91–92%; I2 96%) respectively. The summary positive likelihood ratio was 11.6 (95% CI 8.5–15.8; I2 97%) and the pooled likelihood ratio negative 0.02 (0.01–0.03; I2 52%). Cumulative all-cause mortality at 30 days in the rule-out group was 0.11%, and 2.8% in the rule-in group, and 30 days AMI in the rule-out group was 0.08%. Conclusion: The ESC 0-hour/1-hour algorithm using high-sensitivity cardiac troponin has high diagnostic accuracy; it allows safe rule-out as well as accurate rule-in of AMI, with low cumulative 30-day mortality and AMI in patients assigned the rule-out zone.

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

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
E Giannitsis ◽  
M Biener ◽  
H Hund ◽  
M Mueller-Hennessen ◽  
M Vafaie ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
High Sensitivity ◽  
Time Dependent ◽  
Negative Effects ◽  
Positive Effects ◽  
Coronary Syndrome ◽  
All Cause Mortality ◽  
Time Stamps ◽  
Risk Patients ◽  
Dependent Processes

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.

scholarly journals Smoking determines the 10-year (2004–2014) prognosis in patients with Acute Coronary Syndrome: the GREECS observational study

2015 ◽  
Vol 13 (1) ◽  
Author(s):  
Venetia Notara ◽  
◽  
Demosthenes B. Panagiotakos ◽  
Semina Kouroupi ◽  
Ifigenia Stergiouli ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Observational Study ◽  
Coronary Syndrome

scholarly journals Subanalysis of the AUGUSTUS trial

2020 ◽  
Vol 25 ◽  
pp. 4104
Author(s):  
T. V. Pavlova ◽  
P. D. Duplyakova ◽  
O. V. Shkaeva ◽  
S. P. Krivova
Keyword(s):  
Acute Coronary Syndrome ◽  
Large Scale ◽  
Coronary Intervention ◽  
The Novel ◽  
Actual Clinical Practice ◽  
Coronary Syndrome ◽  
Hospitalization Rates ◽  
Percutaneous Coronary ◽  
Artery Disease ◽  
European Society Of Cardiology

Comorbidity is a common feature of a modern patient. The combination of atrial fibrillation (AF) and various types of coronary artery disease is widespread in actual clinical practice. In such cases, additional pathophysiological mechanisms appear that worsen the clinical course and patient’s prognosis. The management of AF patients who have undergone acute coronary syndrome and/or percutaneous coronary intervention is a challenging problem, which can be solved by large-scale clinical trials. The AUGUSTUS randomized trial with a two-by-two factorial design proved that full-dose apixaban is superior in safety to the vitamin K antagonist warfarin, while not inferior in effectiveness. This pattern has been preserved in several important subanalysis on stent thrombosis, hospitalization rates, and conservative management of acute coronary syndrome. The obtained results are included in the novel European Society of Cardiology guidelines on AF.

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