Management of coronary risk factors by registered nurses versus usual care in patients with unstable angina pectoris (a chest pain evaluation in the emergency room [CHEER] substudy).

This study examined whether nurses could manage coronary risk factors in patients with unstable angina more effectively than physicians practicing usual care. Three hundred twenty-six patients were randomized in the emergency room to a 6-month program of risk factor management by a registered nurse versus participation in usual care. The nurse intervention consisted of a 30-minute counseling visit at 6 to 10 days after the chest pain episode and a second 30-minute session 1 month later. Multiple risk factors were assessed and addressed: smoking, blood lipids, blood pressure, blood glucose, physical inactivity, weight, psychological stress, and social isolation. Compared with usual care, nurse intervention patients significantly reduced both triglycerides (-29 +/- 8 vs 5 +/- 6 mg/dl; p <0.0004) and weight (-0.9 +/- 3.3 vs +0.1 +/- 2.1 kg; p = 0.0071), and had corresponding improvements in self-reported diet compliance and exercise (+34 +/- 106 vs +9 +/- 98 minutes, p = 0.0491). No significant differences between groups were observed in terms of 6-month changes in total, high-density lipoprotein, or low-density lipoprotein cholesterol, blood pressure, fasting blood glucose, percent body fat or waist-hip ratio, or psychological distress scores. The 6-month rate of recurrent events (cardiac death, out-of-hospital cardiac arrest, myocardial infarction) and/or revascularizations (coronary artery bypass surgery or coronary angioplasty) was lower in the nurse intervention group (1% vs 9%; p = 0.002). We conclude that a nurse-delivered risk factor intervention program for patients with chest pain is feasible and more effective than usual care in terms of fostering lifestyle changes that may lower coronary risk.

A clinical trial of a chest-pain observation unit for patients with unstable angina. Chest Pain Evaluation in the Emergency Room (CHEER) Investigators.

BACKGROUND: Nearly half of patients hospitalized with unstable angina eventually receive a non-cardiac-related diagnosis, yet 5 percent of patients with myocardial infarction are inappropriately discharged from the emergency department. We evaluated the safety, efficacy, and cost of admission to a chest-pain observation unit (CPU) located in the emergency department for such patients. METHODS: We performed a community-based, prospective, randomized trial of the safety, efficacy, and cost of admission to a CPU as compared with those of regular hospital admission for patients with unstable angina who were considered to be at intermediate risk for cardiovascular events in the short term. A total of 424 eligible patients were randomly assigned to routine hospital admission (a monitored bed under the care of the cardiology service) or admission to the CPU (where patients were cared for according to a strict protocol including aspirin, heparin, continuous ST-segment monitoring, determination of creatine kinase isoenzyme levels, six hours of observation, and a study of cardiac function). The CPU was managed by the emergency department staff. Patients whose test results were negative were discharged, and the others were hospitalized. Primary outcomes (nonfatal myocardial infarction, death, acute congestive heart failure, stroke, or out-of-hospital cardiac arrest) and use of resources were compared between the two groups. RESULTS: The 212 patients in the hospital-admission group had 15 primary events (13 myocardial infarctions and 2 cases of congestive heart failure), and the 212 patients in the CPU group had 7 events (5 myocardial infarctions, 1 death from cardiovascular causes, and 1 case of congestive heart failure). There was no significant difference in the rate of cardiac events between the two groups (odds ratio for the CPU group as compared with the hospital-admission group, 0.50; 95 percent confidence interval, 0.20 to 1.24). No primary events occurred among the 97 patients who were assigned to the CPU and discharged. Resource use during the first six months was greater among patients assigned to hospital admission than among those assigned to the CPU (P<0.01 by the rank-sum test). CONCLUSIONS: A CPU located in the emergency department can be a safe, effective, and cost-saving means of ensuring that patients with unstable angina who are considered to be at intermediate risk of cardiovascular events receive appropriate care.

Incremental value of the leukocyte differential and the rapid creatine kinase-MB isoenzyme for the early diagnosis of myocardial infarction.

OBJECTIVE: To test whether automated measurements of cortisol-induced changes in the leukocyte differential can provide an early marker of myocardial infarction, especially when combined with the rapid creatine kinase-MB isoenzyme. DESIGN: A prospective, blinded study of these measurements at the time of initial assessment in the emergency department. SETTING: Large multispecialty clinic hospital. PATIENTS: 511 consecutive patients presenting to the emergency department with chest pain. One hundred twenty-seven patients with infection, trauma, or metastatic cancer or receiving myelosuppressive or glucocorticoid therapy were excluded. MEASUREMENTS: Automated leukocyte differentials, rapid creatine kinase-MB levels, cortisol levels, and routine clinical measurements. RESULTS: Of 69 patients with myocardial infarction, only 39% had diagnostic electrocardiographic ST-segment elevation. ST-segment elevation had a specificity of 99% and a positive predictive value of 93%. A relative lymphocytopenia (lymphocyte decrease < 20.3%) or elevated rapid creatine kinase-MB level (> 4.7 ng/mL) was more sensitive than ST-segment elevation (sensitivities of 58% and 56%, respectively) but less specific (specificities of 91% and 93%, respectively). The presence of both a relative lymphocytopenia and an elevated rapid creatine kinase-MB level had a sensitivity of 44%, a specificity of 99.7%, and a positive predictive value of 97% (95% Cl, 80% to 99%). Both a relative lymphocytopenia and an elevated rapid creatine kinase-MB level were independent (P < 0.001) predictors of infarction in patients without ST-segment elevation. If myocardial infarction was suspected by the presence of both abnormal markers or ST-segment elevation, the sensitivity for early diagnosis increased from 39% (ST elevation alone) to 65% (Cl, 52% to 76%); the specificity was 99%; and the positive predictive value was 94% (Cl, 82% to 98%). CONCLUSIONS: The presence of both a relative lymphocytopenia and an elevated rapid creatine kinase-MB level was an accurate early marker of myocardial infarction that appeared to improve the sensitivity of early diagnosis compared with that of ST-segment elevation alone.