scholarly journals Patients’ and health professionals’ perceptions of the LoDED (limit of detection and ECG discharge) strategy for low-risk chest pain management: a qualitative study

2020 ◽  
pp. emermed-2020-209539
Author(s):  
Lucy Beasant ◽  
Edward Carlton ◽  
Gareth Williams ◽  
Jonathan Benger ◽  
Jenny Ingram
Keyword(s):  
Chest Pain ◽  
Qualitative Study ◽  
Focus Groups ◽  
Health Professionals ◽  
Limit Of Detection ◽  
High Sensitivity ◽  
Patient Discharge ◽  
Information Provision ◽  
Structured Interview ◽  
Low Risk

BackgroundRapid discharge strategies for patients with low-risk chest pain using high-sensitivity troponin assays have been extensively evaluated. The adherence to, and acceptability of such strategies, has largely been explored using quantitative data. The aims of this integrated qualitative study were to explore the acceptability of the limit of detection and ECG discharge strategy (LoDED) to patients and health professionals, and to refine a discharge information leaflet for patients with low-risk chest pain.MethodsPatients with low-risk chest pain who consented to a semi-structured interview were purposively sampled for maximum variation from four of the participating National Health Service sites between October 2018 and May 2019. Two focus groups with ED health professionals at two of the participating sites were completed in April and June 2019.ResultsA discharge strategy based on a single undetectable hs-cTn test (LoDED) was acceptable to patients. They trusted the health professionals who were treating them and felt reassured by other tests, (ECG) alongside blood test(s), even when the clinical assessment did not provide a firm diagnosis. In contrast, health professionals had reservations about the LoDED strategy, including concern about identifying low-risk patients and a shortened patient observation period. Findings from 11 patient interviews and 2 staff focus groups (with 20 clinicians) centred around three overarching themes: acceptability of the LoDED strategy, perceptions of symptom severity and uncertainty, and patient discharge information.ConclusionRapid discharge for low-risk chest pain is acceptable to patients, but clinicians reported some reticence in implementing the LoDED strategy. Further work is required to optimise discharge discussions and information provision for patients.

scholarly journals LO10: Low high-sensitivity troponin concentrations identify low-risk chest pain patients unlikely to benefit from further risk stratification

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S10-S10
Author(s):  
J. Andruchow ◽  
T. Boyne ◽  
G. Innes ◽  
S. Vatanpour ◽  
I. Seiden-Long ◽  
...  
Keyword(s):  
Chest Pain ◽  
Risk Stratification ◽  
Symptom Onset ◽  
Limit Of Detection ◽  
Troponin T ◽  
High Sensitivity ◽  
Low Risk ◽  
High Sensitivity Troponin ◽  
Pain Patients ◽  
Rule Out

Introduction: Very low high-sensitivity troponin-T (hs-cTnT) concentrations on presentation can rule out acute myocardial infarction (AMI), but the ability to identify patients at low risk of 30-day major adverse cardiac events (MACE) is less clear. This study examines the sensitivity of low concentrations of hs-cTnT on presentation to rule out 30-day MACE. Methods: This prospective cohort study enrolled emergency department chest pain patients with non-ischemic ECGs who underwent AMI rule-out with an hs-cTnT assay. The primary outcome was 30-day MACE; secondary outcomes were individual MACE components. Because guidelines recommend using a single hs-cTnT strategy only for patients with more than 3-hours since symptom onset, a subgroup analysis was performed for this population. Outcomes were adjudicated based on review of medical records and telephone follow-up. Results: Of 1,167 patients enrolled, 125 (10.7%) experienced 30-day MACE and 97 (8.3%) suffered AMI on the index visit. More than one-third (35.6%) had presenting hs-cTnT concentrations below the limit of detection (5ng/L), which was 94.4% (95%CI 88.8-97.7%) sensitive for 30-day MACE and 99.0% (95%CI 94.5-100%) sensitive for index AMI. Of 292 (25.0%) patients with hs-cTnT < 5ng/L and at least 3-hours since symptom onset, only 3 experienced 30-day MACE (sensitivity 97.6%, 95%CI 93.2-100%) and none suffered AMI within 30-days (sensitivity 100%, 95%CI 96.3-100%). Conclusion: Among patients with non-ischemic ECGs and >3-hours since symptom onset, low hs-cTnT concentrations on presentation confer a very low risk of 30-day MACE. In the absence of a high risk clinical presentation, further risk stratification is likely to be low yield.

scholarly journals Perceptions and Barriers to Physical Activity in Childhood and Adulthood Among Latinas

2021 ◽  
Vol 8 (4) ◽  
Author(s):  
Rosenda Murillo ◽  
Mariana Vazquez ◽  
Isabel Leal ◽  
Daphne Hernandez ◽  
Qian Lu ◽  
...  
Keyword(s):  
Physical Activity ◽  
Qualitative Study ◽  
Focus Groups ◽  
Thematic Analysis ◽  
Structured Interview ◽  
Individual Interview ◽  
Latina Women ◽  
The Us ◽  
Promotion Of Physical Activity ◽  
Barriers To Physical Activity

Objective: The purpose of this qualitative study was to identify perceptions and barriers to physical activity in childhood and adulthood among Latina adults. Methods: We conducted 3 focus groups, 2 dyadic interviews, and an individual interview using semi-structured interview guides with 23 Latina women aged 21-35. A thematic analysis approach employing inductive and deductive coding was utilized to code, categorize, and summarize data into themes. Results: The themes that emerged focused on: (1) physical activity is enjoyable; (2) family influenced physical activity; (3) different lifestyle in the US influenced physical activity; (4) physical activity is important for health; and (5) responsibilities (eg, work, caregiving) as barriers to physical activity in adulthood. Conclusions: Perceptions and barriers to physical activity experienced in both childhood and adulthood should be considered in the promotion of physical activity among Latinas.

scholarly journals Randomised controlled trial of the Limit of Detection of Troponin and ECG Discharge (LoDED) strategy versus usual care in adult patients with chest pain attending the emergency department: study protocol

BMJ Open ◽  
2018 ◽  
Vol 8 (10) ◽  
pp. e025339 ◽  
Author(s):  
Edward Carlton ◽  
Sarah Campbell ◽  
Jenny Ingram ◽  
Rebecca Kandiyali ◽  
Hazel Taylor ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Randomised Controlled Trial ◽  
Limit Of Detection ◽  
Controlled Trial ◽  
High Sensitivity ◽  
Early Discharge ◽  
High Sensitivity Troponin ◽  
Randomised Controlled ◽  
Rule Out

IntroductionObservational data suggest a single high-sensitivity troponin blood test taken at emergency department (ED) presentation could be used to rule out major adverse cardiac events (MACE) in 10%–60% of ED patients with chest pain. This is done using an ‘undetectable’ cut-off (the Limit of Detection: LoD). We combined the LoD cut-off with ECG findings to create the LoDED strategy. We aim to establish whether the LoDED strategy works under real-life conditions, when compared with existing strategies, in a way that is cost-effective and acceptable to patients.Methods and analysisThis is a parallel-group pragmatic randomised controlled trial across UK EDs. Adults presenting to ED with suspected cardiac chest pain will be randomised 1:1. Existing rule-out strategies in current use across study centres, using serial high-sensitivity troponin testing, will be compared with the LoDED strategy. The primary outcome is successful early discharge (discharge from hospital within 4 hours of arrival) without MACE occurring within 30 days. Secondary outcomes include initial length of hospital stay; comparative costs; patient satisfaction and acceptability to patients. To detect a 9% difference between the early discharge rates (assuming an 8% rate in the standard care group) with 90% power, 594 patients need to be recruited, assuming a 95% follow-up rate.Ethics and disseminationThe study has been approved by the Frenchay Research Ethics Committee (reference 18/SW/0038). Results will be published in an international peer-reviewed journal. Lay summaries will be made available to patients.Trial registration numberISRCTN86184521; Pre-results.

Identifying low-risk chest pain in the emergency department without troponin testing: a validation study of the HE-MACS and HEAR risk scores

2021 ◽  
pp. emermed-2021-211669
Author(s):  
Fraser Todd ◽  
James Duff ◽  
Edward Carlton
Keyword(s):  
Risk Factors ◽  
Chest Pain ◽  
Limit Of Detection ◽  
Controlled Trial ◽  
Statistical Significance ◽  
Low Risk ◽  
Risk Scores ◽  
Cardiac Events ◽  
Presenting Symptoms ◽  
Randomised Controlled

IntroductionPatients presenting to EDs with chest pain of possible cardiac origin represent a substantial and challenging cohort to risk stratify. Scores such as HE-MACS (History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid) and HEAR (History, ECG, Age, Risk factors) have been developed to stratify risk without the need for troponin testing. Validation of these scores remains limited.MethodsWe performed a post hoc analysis of the Limit of Detection and ECG discharge strategy randomised-controlled trial dataset (n=629; June 2018 to March 2019; 8 UK hospitals) to calculate HEAR and HE-MACS scores. A <4% risk of major adverse cardiac events (MACE) at 30 days using HE-MACS and a score of <2 calculated using HEAR defined ‘very low risk’ patients suitable for discharge. The primary outcome of MACE at 30 days was used to assess diagnostic accuracy.ResultsMACE within 30 days occurred in 42/629 (7%) of the cohort. HE-MACS and HEAR scores identified 85/629 and 181/629 patients as ‘very low risk’, with MACE occurring in 0/85 and 1/181 patients, respectively. The sensitivities of each score for ruling out MACE were 100% (95% CI: 91.6% to 100%) for HE-MACS and 97.6% (95% CI: 87.7% to 99.9%) for HEAR. Presenting symptoms within these scores were poorly predictive, with only diaphoresis reaching statistical significance (OR: 4.99 (2.33 to 10.67)). Conventional cardiovascular risk factors and clinician suspicion were related to the presence of MACE at 30 days.ConclusionHEAR and HE-MACS show potential as rule out tools for acute myocardial infarction without the need for troponin testing. However, prospective studies are required to further validate these scores.

Risk stratifying chest pain patients in the emergency department using HEART, GRACE and TIMI scores, with a single contemporary troponin result, to predict major adverse cardiac events

2018 ◽  
Vol 35 (7) ◽  
pp. 420-427 ◽  
Author(s):  
Peter D W Reaney ◽  
Hamish I Elliott ◽  
Awsan Noman ◽  
Jamie G Cooper
Keyword(s):  
Chest Pain ◽  
High Sensitivity ◽  
Tertiary Hospital ◽  
Low Risk ◽  
Cardiac Events ◽  
Heart Score ◽  
Coronary Syndrome ◽  
C Statistic ◽  
Diagnostic Characteristics ◽  
Coronary Events

BackgroundThe majority of patients presenting to the ED with cardiac sounding chest pain have a non-diagnostic ECG and the problem of differentiating those suffering an acute coronary syndrome from those without is familiar to all ED clinical staff. To stratify risk in these patients, specific scores have been developed. Recent work has focused on incorporating newer high-sensitivity cardiac troponin (hs-cTn) assays; however, issues regarding performance and availability of these assays remain.AimProspectively compare HEART, Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) scores, using a single contemporary cTn at admission, to predict a major adverse cardiac event (MACE) at 30 days.MethodProspective observational cohort study performed in a UK tertiary hospital in patients with suspected cardiac chest pain and no significant ST elevation on initial ECG. Data collection took place 2 December 2014 to 8 February 2016. The treating clinician recorded risk score data real time and a single contemporary cTn taken at presentation was used in score calculation. The primary endpoint was 30-day MACE. C-statistic was determined for each score and diagnostic characteristics of high-risk and low-risk cut-offs were calculated.Results189/1000 patients in the study developed a 30-day MACE. The c-statistic of HEART for 30-day MACE (0.87 (95% CI 0.84 to 0.90)) was higher than TIMI (0.78 (95% CI 0.74 to 0.81)) and GRACE (0.74 (95% CI 0.70 to 0.78)).HEART score ≤3 identified low-risk patients with sensitivity 99.5% (95% CI 97.1% to 99.9%) and negative predictive value (NPV) 99.6% (95% CI 97.3% to 99.9%) exceeding TIMI 0 (sensitivity 97.4% (95% CI 93.9% to 99.1%) and NPV 97.8% (95% CI 94.8% to 99.1%)) and GRACE score 0–55 (sensitivity 95.2% (95% CI 91.1% to 97.8%) and NPV 95.8% (95% CI 92.2% to 97.7%)).ConclusionHEART outperformed both TIMI and GRACE in overall discriminative capacity for 30-day MACE. Using a single contemporary cTn at presentation, a HEART score of ≤3 demonstrated sensitivity and NPV of ≥99.5% for 30-day MACE. These results reach the threshold for a safe discharge strategy but should be interpreted thoughtfully in light of other work.

scholarly journals LO97: Validation of the HEART score in Canadian emergency department chest pain patients using a high-sensitivity troponin T assay

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S61-S62 ◽  
Author(s):  
J. Andruchow ◽  
A. McRae ◽  
T. Abedin ◽  
D. Wang ◽  
G. Innes ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Troponin T ◽  
High Sensitivity ◽  
Low Risk ◽  
Moderate Risk ◽  
Heart Score ◽  
High Sensitivity Troponin ◽  
High Sensitivity Troponin T ◽  
Pain Patients

Introduction: The HEART score is a validated tool created to risk stratify emergency department (ED) chest pain patients using 5 simple criteria (History, ECG findings, Age, Risk factors, and Troponin). Several studies have demonstrated the superiority of HEART over other well known risk stratification tools in identifying low risk chest pain patients suitable for early discharge. All but one of these studies used conventional troponin assays, and most were conducted in European populations. This study aims to validate the HEART score using a high-sensitivity troponin T assay in a Canadian population. Methods: This prospective cohort study was conducted at a single urban tertiary centre and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were age 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. Clinical data were recorded by the emergency physician at the time of enrolment and outcomes were obtained from administrative data. High-sensitivity troponin-T (Roche Elecsys hs-cTnT) results were obtained in all patients at presentation. The primary outcome was AMI within 30-days of ED visit, the secondary outcome was 30-day major adverse cardiac events (MACE). Results: A total of 984 ED patients with complete HEART scores were enrolled from August 2014 to September 2016. The 30-day incidence of AMI and MACE in the overall population was 3.3% and 20.6%, respectively. HEART scores were predictive of 30-day AMI incidence: low risk (0-3): 0.77% (95%CI 0.0-1.5%), moderate risk (4-6): 4.3% (95%CI 2.3-6.2%) and high risk (7-10): 12.2% (95%CI 5.5-19.0%). HEART scores also predicted 30-day MACE: low risk (0-3): 5.0% (95%CI 3.1-6.9%), moderate risk (4-6): 31.8% (95%CI 27.2-36.4%) and high-risk (7-10): 61.4% (95%CI 51.2-71.5%). More than half of patients, 522 (53.0%) could be identified as low risk based on the HEART score using a single troponin result. Conclusion: Using a single high-sensitivity troponin result collected at ED presentation, the HEART score can rapidly and effectively identify more than half of ED chest pain patients as low risk for 30-day AMI, but is less sensitive for 30-day MACE.

Risk reduction as an accepted framework for safer-sex promotion among women who have sex with women

Sexual Health ◽  
2009 ◽  
Vol 6 (1) ◽  
pp. 15 ◽  
Author(s):  
Peta Cox ◽  
Ruth McNair
Keyword(s):  
Health Promotion ◽  
Mixed Methods ◽  
Focus Groups ◽  
Risk Reduction ◽  
Present Article ◽  
Health Professionals ◽  
Safer Sex ◽  
Low Risk ◽  
Sexually Transmissible Infections ◽  
Safer Sex Practices

Background: Safer-sex information for women who have sex with women (WSW) is often very difficult to locate. Girl2girl.info is one of the only websites focussed on safer sex for WSW. The present article describes the predevelopment consultation and evaluation of girl2girl.info. A risk-reduction framework was used to develop the website. Methods: Girl2girl.info was developed in 2004 using questionnaires and focus groups with 36 consumers who were WSW, largely based in Canberra, Australia. In 2006–2007 the site was evaluated using mixed methods of questionnaires with 74 WSW and interviews with 17 health professionals around Australia. Results: This research has identified some key attitudes toward safer sex of WSW participants, in particular a misperception that the majority of WSW are at low risk for sexually transmissible infections and a consistent aversion to using latex for safer sex. Conclusions: The article concludes that the promotion of a risk-reduction approach – including non-latex-based safer-sex practices – for WSW is both a theoretically appropriate and engaging form of health promotion for WSW.

scholarly journals Adapting ‘Tame Your Gut’ for patients with inflammatory bowel disease and co-morbid anxiety and/or depression

2020 ◽  
pp. 135910532094500
Author(s):  
Inna Hanlon ◽  
Catherine Hewitt ◽  
Subhadra Evans ◽  
Jo Taylor ◽  
Christian Selinger ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Qualitative Study ◽  
Focus Groups ◽  
Thematic Analysis ◽  
Bowel Disease ◽  
Health Professionals ◽  
Positive Attitude ◽  
Comorbid Anxiety ◽  
Online Psychotherapy ◽  
Inflammatory Bowel

This qualitative study collected stakeholders’ views on adapting an existing online psychotherapy programme, ‘Tame Your Gut’, to the needs of patients with inflammatory bowel disease (IBD) and comorbid anxiety and/or depression. Adult patients ( n = 13) and health professionals ( n = 12) participated in semi-structured focus groups or interviews, analysed with a thematic analysis. Patients had a generally positive attitude towards ‘Tame Your Gut’, while health professionals saw it as useful for selected patients only. Both groups indicated their preference for clinician-assisted online psychotherapy. ‘Tame Your Gut’ is acceptable to patients and health professionals but only when supported by clinicians.

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