Remote management of low to intermediate risk chest pain: A case series.

We report a case series of three low to intermediate risk chest pain patients who presented to the emergency department and were managed as outpatients via the Cellular Outpatient Twelve-Lead Telemetry with Emergency Response (COTTER™). This technology allows for certain chest pain patients to be managed remotely via telemedicine while receiving care comparable to that which would be available in a hospital or chest pain observation unit.

Efficacy of Noncontrast Computed Tomography of the Abdomen and Pelvis for Evaluating Nontraumatic Acute Abdominal Pain in the Emergency Department.

BACKGROUND: Computed tomography (CT) clarity has significantly improved since it became widely available in the early 1980s, making the utility and benefit of contrast material for image quality of the abdomen and pelvis uncertain, and so far, minimally studied. OBJECTIVES: This study sought to assess the efficacy of a noncontrast CT scan of the abdomen and pelvis by evaluating patients presenting to the emergency department (ED) with acute nontraumatic abdominal pain by following them for 7 days and observing for signs and symptoms of clinically significant acute emergent pathology. METHODS: We enrolled, and for 7 days followed, a prospective observational convenience sample of patients who received a noncontrast CT scan of the abdomen and pelvis in the ED for acute nontraumatic abdominal pain. The primary outcome, and defined as a failure, was abdominal surgery or death as the result of an intraabdominal process not found on the original noncontrast CT scan, or a subsequent contrasted CT scan with a finding that could explain the original complaint of abdominal pain that was also not seen on the initial noncontrast CT, during the 7-day observation. RESULTS: Seventy-two patients were enrolled in the study. The incidence of failure was 0% (0/72), 46% of patients (33/72) had a negative CT scan, 54% (39/72) had a positive CT scan, 57% (41/72) were admitted, 43% (31/72) discharged, 11% (8/72) had abdominal surgery, and a repeat contrasted CT scan was done on 4% (3/72). CONCLUSIONS: With certain inclusion and exclusion criteria, noncontrast CT of the abdomen and pelvis is likely a reliable diagnostic modality for the evaluation of acute nontraumatic abdominal pain in the ED.

Comparing two strategies for emergency department chest pain patients: immediate computed tomography coronary angiography versus delayed outpatient treadmill testing.

Chest pain (CP) is a common emergency department (ED) complaint and return visits (recidivism) are common. Recidivism may be related to incomplete evaluation of a patient's complaint. Computed tomography coronary angiography (CTCA) is accurate for diagnosing coronary artery disease (CAD) in patients with CP. We will compare a strategy of immediate CTCA with a strategy of delayed outpatient stress testing and hypothesize that CTCA will reduce recidivism in patients with CP. We conducted a retrospective cohort study comparing strategies for ED patients with CP: immediate CTCA (CT cohort) versus delayed outpatient stress testing (control cohort). Two hundred eighty subjects were included, 140 in each of the strategies. Recidivism within 6 months of the index ED evaluation occurred in 12 subjects from the CT cohort and 18 subjects from the control cohort (9% vs. 13%, P = 0.41). Duration of stay was increased in the CT cohort (456 vs. 417 min, P = 0.031). Immediate CTCA was associated with improved detection of obstructive CAD (8% vs. 1%, P = 0.005). In conclusion, immediate CTCA, when compared with delayed outpatient stress testing, did not reduce ED recidivism for CP. Length of stay was increased in the immediate CTCA cohort. The use of CTCA improved detection of obstructive CAD.

Intravenous nicardipine and labetalol use in hypertensive patients with signs or symptoms suggestive of end-organ damage in the emergency department: a subgroup analysis of the CLUE trial.

OBJECTIVE: To compare the efficacy of Food and Drug Administration recommended dosing of nicardipine versus labetalol for the management of hypertensive patients with signs and/or symptoms (S/S) suggestive of end-organ damage (EOD). DESIGN: Secondary analysis of the multicentre prospective, randomised CLUE trial. SETTING: 13 academic emergency departments in the USA. PARTICIPANTS: Eligible patients had two systolic blood pressure (SBP) measures ≥180 mm Hg at least 10 min apart, no contraindications to nicardipine or labetalol and predefined S/S suggestive of EOD on arrival. INTERVENTIONS: Medications were administered by continuous infusion (nicardipine) or repeat intravenous bolus (labetalol) for a study period of 30 min or until a specified target SBP ±20 mm Hg was achieved. PRIMARY OUTCOME MEASURE: Percentage of participants achieving a predefined target SBP range (TR) defined as an SBP within ±20 mm Hg as established by the treating physician. RESULTS: Of the 141 eligible patients, 49.6% received nicardipine, 51.7% were women and 81.6% were black. Mean age was 52.2±13.9 years. Median initial SBP did not differ in the nicardipine (210.5 (IQR 197-226) mm Hg) and labetalol (210 (200-226) mm Hg) groups (p=0.862). Nicardipine patients were more likely to have a history of diabetes (41.4% vs 25.7%, p=0.05) but there were no other historical, demographic or laboratory differences between groups. Within 30 min, nicardipine patients more often reached the target SBP range than those receiving labetalol (91.4% vs 76.1%, difference=15.3% (95% CI 3.5% to 27.3%); p=0.01). On multivariable modelling with adjustment for gender and clinical site, nicardipine patients were more likely to be in TR by 30 min than patients receiving labetalol (OR 3.65, 95% CI 1.31 to 10.18, C statistic=0.72). CONCLUSIONS: In the setting of hypertension with suspected EOD, patients treated with nicardipine are more likely to reach prespecified SBP targets within 30 min than patients receiving labetalol. CLINICAL TRIAL REGISTRATION: NCT00765648, clinicaltrials.gov.

Cardio-renal syndrome type 2: epidemiology, pathophysiology, and treatment.

Cardiac and kidney disease are becoming increasingly more prevalent in the population, and may exist concurrently. One of the most important comorbidities in heart failure is renal dysfunction. The pathophysiology of cardio-renal syndromes is complicated, and has been divided into five categories. Cardio-Renal syndrome type 2 is described by chronic cardiac abnormalities resulting in impaired renal function. It is important to recognize this entity and to understand the pathophysiology underlying the cardiac and renal disorders to distinguish best treatment practices. The success in improved outcomes lies in optimization of heart failure therapies.

Design and implementation of a stand-alone chest pain evaluation center within an academic emergency department.

Chest pain is a common presenting symptom for emergency department (ED) patients; however, a thorough cardiac evaluation can be difficult to complete within the ED setting. Implementation of a stand-alone unit for the evaluation of chest pain may improve care for patients with chest pain. We designed a protocol for identifying patients without an acute coronary syndrome and with low-to-intermediate likelihood of obstructive coronary artery disease (CAD). These patients were monitored in a stand-alone chest pain evaluation center (CPEC) staffed with a small group of providers and tested for CAD, if necessary. In the first 6 weeks of operation, 181 patients were evaluated in the CPEC. The prevalence of CAD risk factors was low. Of the 181 patients, 159 (88%) were discharged home and 22 (12%) required admission to the hospital for further care. We compared the number of chest pain evaluations and admissions for first 6 weeks of operation to the same 6-week period from the 2 previous years. Whereas ED chest pain evaluations increased 66% over the 2-year time frame, the proportion admitted to the hospital decreased from 53% to 42% (P < 0.0001). In conclusion, evidence-based evaluation of chest pain in patients without acute coronary syndrome and with low-to-intermediate likelihood of obstructive CAD can result in the significant majority of patients being discharged from the ED. Creation of a stand-alone CPEC in an academic hospital was associated with a significant reduction in hospital admissions.

Immediate computed tomography coronary angiography versus delayed outpatient stress testing for detecting coronary artery disease in emergency department patients with chest pain.

Noninvasive testing for coronary artery disease (CAD) is warranted for symptomatic patients with intermediate pretest likelihood of CAD. Accomplishing testing in an emergency department (ED) environment is challenging. We compared two strategies of CAD testing in ED patients: immediate computed tomography coronary angiography (CTCA) versus delayed outpatient stress testing. We conducted a historical control cohort study comparing symptomatic ED patients without an acute coronary syndrome who warranted noninvasive CAD testing. Two cohorts (50 patients each) were defined by CAD testing strategy, immediate CTCA versus delayed stress testing. Outcomes were duration of ED stay, detection of CAD, and 3-month rates of readmission, myocardial infarction, (MI) or death. Median duration of stay was 417.5 minutes (interquartile range [IQR] 359.0-581.0) in the CT cohort and 400.0 minutes (IQR 338.0-471.0) in the control cohort (P = 0.53). CAD was detected in 14 CT cohort patients versus 1 in control (P = 0.0004), due to low follow-up in the control cohort (18 of 50, 36%). Obstructive CAD was diagnosed in 6 CT cohort patients versus 1 in control (P = 0.11). During 3 months of follow-up, four patients in each cohort were reevaluated in the ED for chest pain; no patients suffered MI or death. A strategy of immediate CTCA is superior to a delayed stress testing strategy for detecting CAD in ED patients with chest pain and prompting appropriate referrals for further management. Delayed stress testing was primarily ineffective due to low follow-up. Immediate CTCA can be used safely without altering the ED duration of stay.

Trends in death attributed to heart failure over the past two decades in Europe.

AIMS: Little is known regarding temporal trends in mortality attributed to heart failure (HF) from a population perspective. The aim of this study was to assess the mortality related to HF as an underlying cause during the last 20 years in seven European countries. METHODS AND RESULTS: The number of deaths with HF as the underlying cause was collected in seven European states: Germany, Greece, England and Wales, Spain, France, Finland, and Sweden from 1987 to 2008. Disease coding for HF was based on the International Classification of Diseases (ICD 9th and 10th versions). We computed age-standardized death rates (SDRs) per 100 000 inhabitants. Mean age at death from HF was also calculated for the same period. In the seven studied countries, the HF SDR decreased continuously from 54.2 (1987) to 32.6 (2008). Despite differences in the early 1990s, SDRs related to HF seemed to converge, in these seven European countries, to ∼30 deaths per 100 000 population in the near future, for both men and women. During the study period, the mean age at death increased from 80.0 to 82.7 years. Half of the deaths from HF occurred in hospital, without change over time. CONCLUSION: There has been a 40% reduction of the SDR due to HF in seven European countries during two decades and a concomitant increase in the mean age at death from HF. We hypothesize that these results may be related to a better management of chronic and acute HF patients over the past 20 years.