Telecardiology improves quality of diagnosis and reduces delay to treatment in elderly patients with acute myocardial infarction and atypical presentation.

AIM: To assess whether telemedicine technology applied to public emergency healthcare system improves overall quality of home diagnosis in case of acute myocardial infarction among elderly patients, often characterized by higher rates of atypical presentation. METHODS: About 27 841 patients from Apulia (Italy) who called public emergency healthcare number '118' underwent home ECG evaluation. Data were transmitted with a mobile telephone support to a telecardiology 'hub' active continuously (24/7). Data from elderly patients (>70 years) were compared with younger ones. RESULTS: Thirty-nine percent of patients complained of chest (or epigastric) pain; ST elevation acute myocardial infarction (STEMI) was diagnosed in 1.9% of patients enrolled; 50.2% of patients with STEMI were above 70 years of age. Among STEMI patients older than 70 years, atypical presentation was detected in 32% [95% confidence interval (CI): 26.8-38.1] of patients (vs. 11% 95% CI: 7.8-15.5, P<0.001). Rate of atypical STEMI presentation, immediately diagnosed, thanks to telecardiology, rose up from 9.2% (95% CI: 5-17%) in the class of age 60-69 years to 25.6% (95% CI: 20-35%) in the class of age 70-79 years, to 35.2% (95% CI: 26-45%) in the class 80-89, and to 46.1% (95% CI: 26-67%) in the class greater than 89 years of age (P<0.01 in all cases). Number needed to treat (to avoid a single missed STEMI diagnosis) was 9.4 (95% CI: 6.4-12.9) for patients younger than 70 years versus 3.1 (95% CI: 2.6-3.7) among those older than 70 years (P<0.001). CONCLUSION: Telecardiology home ECG diagnosis could significantly help in avoiding errors and delay in STEMI diagnosis in elderly patients.

Cardiac biomarkers in acute coronary syndromes: a review.

Early recognition is indispensable for the optimal management of Acute Coronary Syndrome (ACS); moreover, early prognostic stratification of patients with established ACS is useful to improve strategies for these patients. The paper focuses attention on troponins (I and T), the most validated biomarker for early diagnosis of ACS and on B-type natriuretic peptide (BNP) and N-terminal proB-type natriuretic peptide (NT-proBNP), the most powerful cardiac marker after troponin to be used as prognostic indicator in patients with ACS. We pay particular attention to the troponin story in ACS, including discussions about high sensitivity methods and on the most recent techniques (e.g. Point Of Care) available to shorten times from the blood sampling to the validated report [Turn around time (TAT) arm-to-report]. We report the differences between BNP and NT-proBNP, both from an analytical and a clinical point of view and discuss the use of cardiac natriuretic peptides for early recognition of cardiac insufficiency and early management of patients presenting to Emergency Departments with dyspnoea. Finally, we briefly discuss the most promising new cardiac markers actually used only in preclinical studies.

Telecardiology applied to a region-wide public emergency health-care service.

AIM: To assess feasibility and reliability of telecardiology technologies applied to a region-wide public emergency health-care service. METHODS: About 27,841 patients from all over Apulia (19.362 km(2), 4 million inhabitants) were referred from October 2004 until April 2006 to public emergency health-care number "118" and underwent ECG evaluation according to a previously fixed inclusion protocol. Data recorded were transmitted with mobile telephone support to a telecardiology "hub" active 24-h a day. Hospitalization or further examinations were arranged by emergency physicians on the basis of ECG diagnosis and consultation. RESULTS: Thirty-nine percent of patients complained of chest pain (CP) or epigastric pain, 26% loss of consciousness, 10% breathlessness, and 7% palpitations. Atrial fibrillation (AF) was diagnosed in 11.68% of patients and ST-elevation acute myocardial infarction (STEMI) in 1.91%. Among patients with CP, ECG showed STEMI in only 3.84% of cases, theoretically eligible for fibrinolysis or primary PCI; patients with STEMI complained of CP in 78.94% of cases. Of the patients, 65.28% with STEMI were from small towns without coronary care units, thus benefiting from an immediate pre-hospital diagnosis. Among patients with palpitations, only 10.27% of subjects showed ECG signs of supra-ventricular tachycardia and 25.18% of AF; other subjects avoided further improper hospitalization or emergency department monitoring. CONCLUSIONS: This first region-wide leading experience shows the feasibility and reliability of telecardiology applied to a public emergency health-care service. Telemedicine protocols would probably be useful in lowering the number of improper hospitalizations and shortening delay in the diagnosis process of some heart diseases.

Clinical impact of the troponin 99th percentile cut-off and clinical utility of myoglobin measurement in the early management of chest pain patients admitted to the Emergency Cardiology Department.

OBJECTIVE: To verify the clinical impact of different low cut-offs for troponin I/cardiac troponin I (99th percentile to 10% CV) and for myoglobin, in early risk stratification of patients with suspected acute coronary syndrome. METHODS: A total of 516 consecutive non-ST-elevation patients admitted to hospital were followed. The first measurement of cardiac markers was performed at the point-of-care in the Emergency Cardiology Department, using Stratus CS. The lowest cardiac troponin I concentration with a CV0.07 microg/l in the Emergency Cardiology Department (P>0.05). Using lowering cut-off values, the difference between the fraction of patients that was positive compared with the diagnosis according to European Society of Cardiology and American College of Cardiology criteria and had remained statistically significant (P<0.05) up to 0.03 microg/l (99th percentile upper reference limit) was considered (85 patients, 16.5%, n.s.). Relative operating characteristic analysis confirmed that the best clinical cut-off was related to the cardiac troponin I concentration that meets the 99th percentile upper reference limit. The diagnostic accuracy of myoglobin in detecting the minimum cardiac damage was significantly lower, independently from the cut-offs considered. CONCLUSION: The diagnostic accuracy in detecting myocardial damage early in the Emergency Cardiology Department improves when the 99th percentile is used as a decisional value of cardiac troponin I; the use of this cut-off makes the measurement of myoglobin unnecessary.

Proteomic approach to the diagnosis of acute coronary syndrome: preliminary results.

BACKGROUND: Cardiac multimarker strategy is recommended by the IFCC, ESC and the ACC for an early risk stratification in non-ST-segment elevation (NSTE) ECG patients with chest pain. A new approach, based on protein biochip array technology, performs simultaneously: cTnI, CK-MB, myoglobin, CAIII, GFBB and FABP using a single chip. METHODS: We evaluated the analytical performance of the Randox-Evidence Investigator -biochip cardiac panel according to IFCC recommendations and NCCLS guidelines; a preliminary clinical evaluation was carried out on chest pain NSTE ECG patients, to evaluate the accuracy of the multimarker approach in an early diagnosis of AMI, related to the final diagnosis (ACC/ESC criteria). RESULTS: Troponin, CK-MB and FABP methods provide reproducible within-run and between-day results (total % CVs from 5.9% to 9.7%), and myoglobin and CAIII methods showed the total % CVs from 16.4% to 25.8%. Our preliminary clinical data suggests that FABP had a better diagnostic performance (sensibility = 100%) than myoglobin (sensibility = 75%) to detect AMI in the first hours after the onset of the chest pain and myoglobin/CAIII ratio (specificity = 92.9%) improved the myoglobin specificity. CONCLUSIONS: Cardiac markers have different diagnostic roles and, in this contest, biochip technology could be an interesting approach supporting clinical expectations.

Integration between point-of-care cardiac markers in an emergency/cardiology department and the central laboratory: methodological and preliminary clinical evaluation.

To achieve rapid assessment of chest pain in emergency/cardiology departments, a short turnaround time for cardiac marker testing is necessary. Nevertheless, Total Quality Management principles must be incorporated into the management of point-of-care testing (POCT); in this setting we implemented the Stratus CS assay as POCT for cardiac markers in our emergency/cardiology department. The analytical performance of the troponin I method was evaluated; information connectivity between the Stratus CS data management system and the laboratory information system was implemented and practical training of testing personnel was carried out at the POCT site. A total of 41 non-ST-segment elevation patients admitted to the hospital were followed to evaluate the appropriateness of hospital admission, formulated on the basis of the cardiac troponin-I level measured at the POCT site by clinical staff. Our preliminary clinical data suggest that the high sensitivity of the Stratus CS troponin method could play an important role in the early identification of patients with acute myocardial infarction in a low to intermediate-risk population for acute coronary syndrome. Our POCT model suggests that the central laboratory could ensure that the POCT program remains in compliance with quality requirements. Nevertheless, our comparison studies suggest that the implementation of POCT requires a high level of integration between cardiologists and pathologists to guarantee appropriate interpretation of the monitoring results for suspected ACS patients.