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Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine:
doi: 10.1097/HPC.0000000000000024
Abstracts

Abstracts of the Seventeenth Congress of the Cardiovascular Patient Care Center

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Hypertensive Acute Decompensated Heart Failure Presentations: On the Decline?

Chad E. Darling, MD, Jiayuan E. Sun, Jordan Goldberg, Bridget Straub, and David D. McManus, UMass-Memorial Health Care, Worcester, MA

Background: Background: Historically, approximately one-half of patients with Acute Decompensated Heart Failure (ADHF) are hypertensive on presentation to the hospital. Since the management of HF and HTN has improved, we hypothesized that ADHF presentations accompanied by significant HTN may have declined over time. Objectives: To compare contemporary data regarding the proportion of patients presenting to the Emergency Department (ED) with ADHF and HTN (defined as SBP>160 mm Hg) with historical cohorts of ADHF patients.

Methods: Methods: This observational study compared data from an ongoing, prospective study of ADHF patients (2012–2013) with data from two Worcester HF Study (WHFS) cohorts (1995, 2004). All patients were admitted to the same tertiary care hospital. Data were obtained via chart review in the WHFS and from chart review and direct observation in the ongoing study. Modified Framingham Heart Study Criteria were used for the diagnosis of ADHF.

Results: Over time, patients presenting to our University ED with ADHF have become increasingly male and have had an increased history of HTN and more outpatient ace-Inhibitor and beta-blocker therapy. However, we found a steady decrease in the proportion of patients presenting with ADHF and a triage SBP>160 mm Hg over time (p<0.0005 by X2). Table. Demographic and clinical characteristics Year 1995 2004 2012-13 n 486 494 247 Age, yrs (mean) 78 75 75 Female (%) 60 53 40 HTN history (%) 62 69 90 ACE-I (%) 45 41 56 Beta blocker(%) 18 62 75 Triage SBP≥160 mmHG 33 24 20.

Conclusion: Conclusions: ED treatment decisions and prognosis are both informed by initial BP values of patients with ADHF. Our results demonstrate that presentations of hypertensive ADHF may be on the decline. The reasons for these trends are unclear but analyses of data from additional cohorts are ongoing.

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Diagnostic Yield of Noninvasive Cardiovascular Testing in a Low Risk Chest Pain Unit Population

David Winchester, MD, MS, FACP, FACC, Carla Schmidt, CVT, Brandon Allen, MD, and Thomas Payton, MD, University of Florida, Gainesville, FL

Background: Chest pain complaints are common among patients seeking acute medical care. Numerous approaches have been studied for how to risk stratify patients for further cardiovascular testing. Less is known about the diagnostic yield of noninvasive testing after patients have been screened for risk based on their clinical presentation.

Methods: The Chest Pain Evaluation Center (CPEC) at the University of Florida is an observation unit for extended evaluation of patients with low/intermediate risk of acute coronary syndrome (ACS) and coronary artery disease (CAD). Patients with known CAD or evidence of ischemia are excluded from observation in the CPEC. All noninvasive testing modalities are available for use, however exercise treadmill testing (ETT) and computed tomographic coronary angiography (CTCA) are encouraged as first choice of test in the appropriately screened patient. All patients in the CPEC are asked to participate in a prospective registry documenting the care they receive.

Results: We evaluated data from 194 subjects evaluated in the CPEC who consented to participate in the registry. Prevalence of CAD risk factors was low (diabetes mellitus 11.3%, hypertension 37.1%, hyperlipidemia 18.0%, current tobacco use 23.7%) with mean age of 45.6 ± 9.5 years and mean body mass index of 30.9 ± 7.6. Based on our clinical risk assessment tool, 60.5% of the population was low risk, 34.2% intermediate risk, and 5.3% high risk. To evaluate this population, a total of 112 ETTs, 62 CTCAs, 19 nuclear stress tests and 1 dobutamine stress echocardiogram were performed; 7 subjects underwent no testing. 4 ETT were positive for ischemia and 5 CTCA showed obstructive CAD. Invasive coronary angiography was performed on 8 patients, 2 with normal coronary arteries, 4 with nonobstructive CAD, and 2 with obstructive CAD. Both patients with obstructive CAD were pre-determined to be at intermediate risk.

Conclusion: In a population of 194 subjects at low to intermediate risk of CAD and ACS based on clinical presentation, only 2 were found to have obstructive CAD. No subjects categorized as low risk had obstructive CAD. Robust clinical risk assessment strategies may be adequate to identify patients with exceedingly low risk of ACS/CAD for which further noninvasive cardiovascular testing is not warranted.

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Quality of Life in Symptomatic Patients with Atrial Fibrillation: Preliminary Data from the InRhythm Study

Donna Suter, BSN, RN, Jane Saczynski, PhD, Kevin Floyd, MD, Clifford Browning, MD, Lawrence Rosenthal, MD PhD, and David McManus, MD, ScM, University of Massachusetts Medical School, Worcester, MA

Background: Atrial fibrillation (AF) is the most common persistent heart rhythm disorder worldwide and its prevalence is increasing. Patients with AF often experience symptoms that can adversely affect their quality of life and influence therapeutic decision-making. In a cohort of symptomatic patients eligible for AF ablation, we examine the association between demographic and clinical factors and AF-related quality of life (QOL) and compare predictors of QOL in patients undergoing two common AF treatments (catheter-based AF ablation vs. medical rhythm control).

Methods: 219 patients with symptomatic AF had clinical and demographic data abstracted from their health records and reported health-related quality of life using the Atrial Fibrillation Effect on Quality of Life tool (AFEQT, range 0–100, higher score represents higher QOL)) as part of an ongoing observational study of AF treatment. In the catheter-ablated group, the QOL questionnaire was administered prior to AF ablation. We used logistic regression models to examine the association between clinical factors and high quality of life separately for catheter-ablated and medically treated AF patients. The top quartile of the treatment group specific AFEQT distribution represented high QOL (AFEQT Score >80 in ablation group, >95 in medically treated group).

Results: Participants (n=130) who opted to undergo catheter ablation were slightly younger (60 ± 10 vs. 65 ± 11, p <0.001), had failed a greater number of antiarrhythmic drugs, were affected by fewer comorbid cardiovascular diseases, and reported a lower quality of life (52 ± 21 vs. 70 ± 22, p <0.001) than participants who opted for medical treatment of their AF (n=89). In multivariable models adjusting for age, sex, AF type (paroxysmal, persistent, longstanding persistent), current smoker, coronary heart disease, history of heart failure, hypertension, diabetes mellitus, obstructive sleep apnea, and alcohol consumption, as well as number of failed antiarrhythmic drugs and ablation type (cryoablation vs. radiofrequency ablation), male sex was associated with lower odds (OR = 0.26, 95% CI = 0.08, 0.90), and persistent AF higher odds of high AF-specific quality of life in the catheter ablation group (OR = 3.07, 95% CI 1.18,7.99). No demographic or clinical factors were associated with quality of life in patients opting to undergo medical rhythm control.

Conclusion: Participants who opt for catheter-ablation for rhythm control of symptomatic AF report lower QOL at baseline than participants eligible for AF ablation but opting for medical rhythm control. In multivariable models adjusting for factors associated with AF or diminished QOL, male sex was associated with lower QOL, suggesting that AF-specific QOL may differ between men and women. In contrast, patients with persistent AF had higher quality of life, perhaps reflecting a greater degree of adaptation to, or acceptance of, their AF diagnosis. There are few clinical predictors of disease-specific QOL in symptomatic AF patients opting for catheter ablation and no clinical or demographic predictors among symptomatic AF patients opting for medical treatment. Studies are needed to establish what other factors, such as psychosocial characteristics or cognitive function, influence AF-related QOL.

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Door to Balloon Times from Freestanding Emergency Departments Meet ST-Segment Elevation Myocardial Infarction Reperfusion Guidelines

Erin Leslie Simon, DO, and Tom Lloyd, MD, Akron General Medical Center, Akron, OH

Background: Freestanding emergency departments (FEDs) introduce a challenge to physicians who care for patients with a ST-segment elevation myocardial infarction (STEMI) since treatment is highly time dependent. FEDs have no percutaneous coronary intervention (PCI) capabilities, which necessitate transfer to a PCI-capable facility or fibrinolysis. We sought to determine the proportion of STEMI patients who arrived to an FED and were subsequently transferred for PCI who met door-to-balloon reperfusion guidelines of 90 minutes.

Methods: This was a dual-center retrospective cohort review of all patients 18 years and older who were diagnosed with a STEMI and presented to the main hospital affiliated FED’s. Electronic medical records and emergency medical services (EMS) documentation were reviewed for all cases since the opening of the FED’s in July 2007 and August 2009 respectively. Key time points were abstracted and statistical evaluation was performed using Fisher’s Exact test.

Results: A total of 47 patients met the inclusion criteria. The median door-to-transport time was 34 minutes (IQR 15). The median transport time from the FEDs to the main hospital catheterization lab was 21 minutes (IQR 5). The median arrival at the catheterization lab to balloon time was 25 minutes (IQR 13). The median total door-to-balloon time was 83 minutes (IQR 10.5) with 78.7% meeting the AHA recommended guidelines of 90 minutes or less.

Conclusion: STEMI patients initially seen at two FEDs achieved door-to-balloon time goals of less than 90 minutes. This work has been previously published: J Emerg Med. 2013 Dec 17. [Epub ahead of print] Door-to-Balloon Times from Freestanding Emergency Departments Meet ST-Segment Elevation Myocardial Infarction Reperfusion Guidelines. Simon EL, Griffin P, Medepalli K, Griffin G, Williams CJ, Hewit M4, Lloyd TS. PMID: 24360123.

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Chest Pain Protocol in Diabetic Patients: Atypical Presentations are more Frequent?

Marcelo Bueno da Silva Rivas, Evandro Tinoco, Andre Volschan, Marcelo Iorio, Marcus Vinicius Martins, Adriano Velloso, and Mirna Fontoura, Procardíaco Hospital, Rio de Janeiro, Brazil

Background: Chest pain (CP) is the most frequent symptom associated with acute coronary syndromes (ACS). Atypical forms of CP are described in diabetic patients and may difficult diagnostic stratification, however, its association with ACS remains controversial. Objective: to compare the clinical presentation and the occurrence of ACS between diabetic (DM) and nondiabetic (nonDM) patients admitted to the chest pain unit (CPU).

Methods: Prospective study of 1206 patients consecutively admitted to CPU with clinical suspicion of ACS. The diagnosis of diabetes mellitus was based on a history of chronic use of oral and/or parenteral antidiabetic drugs, regardless of glucose level obtained at admission. Clinical presentation was classified as A (definitely angina), B (probably angina), C (probably not angina) and D (definitely not angina). Patients underwent serial assessment of electrocardiogram and troponin I on admission and after 6h. The diagnosis of ACS was made by detection of ischemia on provocative tests or presence of significant coronary stenoses on coronary angiography. Statistical analysis was performed using chi square and Student t test.

Results: The mean age was significantly higher on DM compared to non DM (68.5 +11.4 vs 61+15.7 years; p<0.001) and 26.2% of total admissions were in the DM group. The overall occurrence of ACS was higher in DM (51.9% vs 17.5%; p<0.0001). Typical presentations (A and B) were more frequent in DM (62.4 % vs 39 %; p<0.0001). There was no difference in the occurrence of ACS between DM and non- DM with typical CP (50.9 % vs 41.2 %; p=0.24). In the subgroup with atypical CP a higher incidence of ACS was found in DM (11.8% vs 3.1%, p<0.001).

Conclusion: Atypical presentations are not more frequent in DM admitted to the CPU, in spite of its higher association with ACS. Future studies may identify whether there are advantages in CP specific protocols for DM.

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STOP STEMI© - A Novel Medical Application to Improve the Coordination of STEMI Care: A Brief Report on Door-to-Balloon Times After Initiating the Application

Robert L Dickson, MD, Adrian Nedelcut, MD, Rawle Seupaul, MD, and Mohammed Hamzeh, MD, Good Shepherd Health, Longview, TX

Background: The objective of our study was to evaluate the effect of the STOP STEMI© medical application on door- to -balloon time (D2B) in patients arriving to our emergency department with acute ST Elevation Myocardial Infarction (STEMI). STOP STEMI© is a novel medical application developed by physicians to improve the coordination and communication tasks essential to rapid assessment and care of patients suffering from a STEMI.

Methods: We conducted a retrospective review of the Good Shepherd Health System STEMI quality assurance/improvement dashboard between November 2012 and September 2013 (4 months prior to 6 months after STOP STEMI© application institution). The data was collected using a standard data collection form and entered on the dashboard by a STEMI coordinator blinded to study objectives. We calculated the average D2B times before and after initiation of the STOP STEMI© application as well as improvement in the benchmarks of D2B <90 min and D2B<60 minutes. A sub group analysis of Center for Medicare and Medicaid services (CMS) reportable cases was conducted to evaluate these benchmarks in the subset of patients meeting criteria for CMS reporting at our facility.

Results: During the study period we received 155 STEMI patients, an average of 0.5 patients per day. One hundred and twelve underwent percutaneous coronary intervention (PCI), 37 pre-STOP STEMI© and 75 post-STOP STEMI©. Of the 112 PCI cases, 7 were excluded leaving 105 cases for analysis 36 pre-application and 69 post-application. We found a 22% decrease in average door-to-balloon time after implementing the STOP STEMI© application (91-71 minutes) respectively (P=0.05). In the analysis of CMS reportable cases (n=64 cases) we observed a 22% reduction in average D2B (68-53 min) (P= 0.03). Further, we saw improvement in “D2B time < 90 minutes” from 78% to 95% and “D2B time <60 min” from 56%-80%. We also observed a 30% relative reduction in PCI resource utilization after deploying the application.

Conclusion: In this cohort of patients, the STOP STEMI© application decreased average door- to -balloon times by 22% in patients with acute STEMI arriving at our emergency department. This effect was maintained when looking at the subset of all STEMI cases reportable to CMS. We also observed modest improvements in meeting the <60 -minute, <90-minute benchmarks and in decreasing resource utilization. We recognize that there are some limitations to the findings reported in this investigation. We utilized a retrospective design which has inherent biases. The data, however, are compelling given the low cost and safety of this intervention. We conclude that STOP STEMI© improved D2B times and decreased resource utilization in STEMI care when initiated at our hospital. We believe this effect may have even greater magnitude in other centers without well-developed STEMI care processes already in place. Multicenter prospective trials are needed to fully characterize the effect of this application in a heterogeneous population of hospitals.

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Paramedics Appropriately Identify STEMIs at Rates Comparable to Residents

Tom Lloyd, MD, and Erin Simon, DO, Akron General Medical Center, Akron, OH

Background: Introduction: Early identification of ST segment elevation myocardial infarction (STEMI) is necessary in order to meet the guidelines for recommended reperfusion time. Whether an EKG is identified as a STEMI may be dependent on a first-responder’s ability to recognize it. Data regarding the accuracy with which paramedics and other first responders can correctly identify STEMIs has yet to be evaluated. We developed an educational training and self-assessment program utilizing Audience Response Clickers (ARC’s) in order to evaluate the accuracy with which paramedics are able to correctly identify STEMIs compared to emergency medicine residents and attending physicians.

Methods: A total of 60 participants including paramedics, resident physicians from emergency medicine, family medicine, and internal medicine; attending physicians; nurses; and medical students attended two interactive sessions in November 2010. During each session, participants viewed 30 ECGs that were projected on a large screen using PowerPoint. Participants were instructed to assume that each EKG displayed was associated with a patient having (a) no prior medical history and (b) a presentation consistent with cardiac ischemia. Participants were then asked to use their ARC to choose from (A) “STEMI,” (B) “Not a STEMI,” or (C) “ECG not a STEMI but suggesting Urgent Treatment.” The anonymous response of audience participants along with the correct answer was provided following each ECG presentation on the large screen. The answers selected by each participant on their ARC were recorded and downloaded.

Results: There were nine professional groups who participated and 60 individual participants. All together, 65% of the ECGs were correctly identified. Amongst the groups, attending physicians (n=3) scored the highest, with 74% correct. Emergency medicine residents (n=12) correctly answered 68% of ECGs, while paramedics (n=9) correctly answered 69%. Participants evaluated the event as a positive experience reporting that the program helped them to identify STEMIs and, more specifically, posterior myocardial infarctions.

Conclusion: Paramedics tested in this program identify STEMIs at a rate comparable to that of emergency medicine resident physicians.

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A Double-blind Randomized Controlled Trial Comparing the Effectiveness of External Loop Monitor and Automatic Trigger Atrial Fibrillation Memory Loop Recorder in Detecting Atrial Fibrillation Among Patients with TIA: A Pilot Study

Wadea Tarhuni, MD, and Maher El-Masri, MD, Windsor Cardiac Centre, Windsor, ON

Background: Atrial fibrillation (AF), including paroxysmal AF, is known to be a major risk factor in the development of TIA and ischemic stroke.1–5 Early detection of AF is therefore key to timely management and prevention of long term complications. Purpose: The primary purpose of this study was to compare the diagnostic yield of AF among TIA patients between Transtelephonic external loop and automatic real time Tele-ECG cardiac Monitor.

Methods: A single blind randomized clinical pilot trial was conducted on a convenience sample of 160 patients with confirmed TIA who have no documented AF and require cardiac monitoring

Results: Adjusted cox-regressions showed results that the group using the automatic real time Tele-ECG cardiac monitor. was 8 times more likely to be diagnosed with AF (HR = 8.44; 95% CI = 2.51 - 28.36) compared to those who used the external loop monitors. Interestingly, Alcohol consumption was an independent predictor of AF in our study whereby those who had one or more alcoholic drinks per day were two times more likely to have AF than those who either never or occasionally drank alcohol (HR = 2.20; 95% CI = 1.02 – 4.76).

Conclusion: Our findings suggest that the use of Transtelephonic external loop monitors may not be as effective in the diagnosis of AF among TIA patients as the Automatic real time Tele-ECG cardiac Monitor.

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Brain-to-Brain Time Compared for Cardiac Troponin I at Point-of-Care vs Central Lab

Robert H. Christenson, PhD, DABCC, FACB, and Show-Hong Duh, PhD, University of Maryland School of Medicine, Baltimore, MD

Background: We compared turnaround times for cardiac troponin I (cTnI) measurement from order to analytical system (pre-analytical), system to result (analytical/post-analytical) and Brain-to-Brain (Order to Result) for the Pathfast point-of-care system (Misubushi) and for the Vitros 5600 central lab analyzer and track system (Ortho Clinical Diagnostics [OCD]). Point-of-Care availability has been shown to improve the disposition time for patients with suspected myocardial ischemia in the Emergency Department (ED).

Methods: We compared the turnaround times in a busy ED associated with a 750-bed tertiary care medical center. Orders for both the Pathfast point-of-care and the OCD central lab systems are placed by clinicians in the hospital information system and barcode labels print; this is ‘Order’ time. When the specimen is presented to the point-of-care system the label is scanned; after the sample is tubed to the lab, the specimen is placed on the OCD track system and scanned; the time scanned is ‘Instrument’ time. Both the point-of-care and lab systems are interfaced and auto-verify results if no issues impacting analytic testing quality are detected; this is ‘Report’ time. The total turnaround time is termed ‘Brain to Brain’. Results for 73 patients were audited to determine if there were differences in diagnostic results between the Pathfast point-of-care and central lab OCD systems.

Results: Data are displayed in the table. There was no diagnostic difference between the Pathfast and OCD systems (p>0.05).

Conclusion: Use of the Pathfast point-of-care device decreased Brain-to-Brain turnaround time by 30 min or more (25 to 60% faster) compared to the automated OCD system with no difference in diagnostic categorization.

Copyright © 2014 by Lippincott Williams & Wilkins

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