High-Sensitivity Troponin Test Could Identify Low Risk Chest Pain Patients In The ED Reply

Approximately 15-20 million people in Europe and the United States go to the emergency department every year with chest pain. Many can be discharged early if they are not having an acute coronary syndrome. A large new single-center observational study, presented at the American College of Cardiology meeting in Washington, DC and published simultaneously in the Journal of the American College of Cardiology, provides fresh evidence that high-sensitivity cardiac troponin T (hs-cTnT) may be useful in helping identify chest pain patients in the emergency department who do not need to be admitted to the hospital.

Click here to read the full post on Forbes.


Little Difference In Chest Pain Between Men And Women 1

In recent years the medical community has grown increasingly concerned that women with heart attacks may be less likely to receive prompt and effective treatment. The difference between the sexes in the presentation of symptoms is thought to be a major barrier to better treatment for women. But now a new study published in JAMA Internal Medicine finds that a key aspect of these differences– the description of chest pain in the emergency department– may not play as big a role as previously suspected.

Click here to read the full post on Forbes.


JAMA Int Med

Too Much Emphasis on Door-to-Balloon Time? Reply

One of the great medical advances in recent years has been the improved treatment of acute myocardial infarction. As the enormous benefits of earlier reperfusion became evident, medical systems in many parts of the world aimed to treat increasing numbers of patients in a shorter time frame. The door-to-balloon (D2B) time as a performance measure has emerged as a key part of this initiative. Now a study published in the New England Journal of Medicine finds that in-hospital mortality for acute MI patients receiving PCI has not fallen despite improvements in the D2B time. But some experts fear this finding may be misinterpreted, as it more accurately reflects a growing and changing population receiving PCI than any shortcomings in the D2B initiative.

Using the CathPCI Registry of the National Cardiovascular Data Registry, Daniel Menees and colleagues analyzed data from almost 100,000 hospital admissions for primary PCI between July 2005 and June 2009.

Click here to read the full story on Forbes.


Observation Units For Heart Failure Could Reduce Unnecessary Hospitalizations 1

Two new papers published in the Journal of the American College of Cardiology propose that most heart failure (HF) patients who present to the emergency department (ED) don’t need to be hospitalized and can be safely managed in an observation unit. Currently, the vast majority of HF patients  who show up in the ED are hospitalized….

Click here to read my complete story on Forbes.

Journal of the American College of Cardiology



Troponin Test May Allow Rapid MI Rule-Out in the Emergency Department Reply

More than three-quarters of people with chest pain can be triaged within an hour of arrival at the emergency department with a novel strategy utilizing high-sensitivity cardiac troponin (hs-cTnT), according to a study from Switzerland published in the Archives of Internal Medicine. The strategy is promising, according to anaccompanying editorial, but much work remains before it can be implemented in clinical practice.

Tobias Reichlin and colleagues first studied 436 patients and developed a treatment algorithm utilizing hs-cTnT baseline changes and absolute changes over the initial hour. The algorithm was then tested in a second validation cohort of 436 patients, with the following results:

  • 60% were classified as “rule-out”
  • 17% were classified as “rule-in”
  • 23% required further observation
  • Overall sensitivity and negative predictive value: 100% for rule-out
  • Specificity for rule-in: 97%
  • Positive predictive value for rule-in: 84%
  • Prevalence of MI in the observational group:  8%
  • 30-day survival: 99.8% in the rule-out group, 98.6% in the observational group, and 95.3% in the rule-in group

The authors claim that their strategy “may obviate the need for prolonged monitoring and serial blood sampling in 3 of 4 patients.”

In an accompanying comment, L. Kristin Newby writes that the Swiss study “is a major advance in understanding the application of hsTn testing that with continued development could substantially improve evaluation of ED patients with suspected MI.” However, she notes that the excellent results obtained in this initial study will probably not be equalled in the real world. In addition, she writes, “although touted as ‘simple’ by the authors, the need for multicomponent algorithms that are different for rule-in and rule-out and that vary by age group or other parameters will challenge application by busy clinicians unlikely to remember or accurately process the proposed algorithm. As such, it will be imperative that hsTn algorithms, if validated, are built into clinical decision support layered onto electronic health records so that testing results are provided electronically to physicians along with the algorithmic interpretation to allow systematic application in triage and treatment.”
Click here to read the press release from Archives…

ROMICAT-II Provokes Opposing Views On CT Angiography In The Emergency Department 1

For patients with suspected acute coronary syndromes (ACS) CT angiography (CTA) compared to standard treatment can reduce the time in the emergency department (ED), according to results of the ROMICAT-II (Rule Out Myocardial Infarction/Ischemia Using Computer-Assisted Tomography) trial published in the New England Journal of Medicine. However, CTA resulted in more tests being performed and increased radiation exposure.

1000 patients with possible ACS but without ECG signs of ischemia or a positive troponin test were randomized to either CTA or standard treatment. The primary endpoint of the study, the mean length of hospital stay, was reduced from 30.8 hours in the standard evaluation group to 23.2 hours in the CTA group, a highly significant reduction of 7.6 hours (p<<0.001). In addition, many more patients in the CTA group were discharged directly from the ED (47% vs 12%, P<0.001). There were no cases of undetected ACS in either group and very few major adverse cardiovascular events (2 vs 6, p=0.18). Half of the patients in the CTA group were discharged within 8.6 hours, compared with only 10% of the controls.

ED and hospital costs were similar in both groups. Radiation exposure was increased in the CTA group (13.9 mSv vs 4.7 mSv) and more diagnostic tests were performed  in the CTA group.

The authors concluded that their “data should allow providers and patients to make informed decisions about the use of this technology as an option for evaluation when symptoms are suggestive of an acute coronary syndrome.”

Schrödinger’s ROMICAT

In contrast to the neutral presentation of the authors in the NEJM paper, strikingly different positions about the utility of CT angiography were taken in an accompanying editorial by Rita Redberg and a press release issued by the National Heart Lung and Blood Institute, which sponsored the study.

In her editorial, Redberg writes:

 Although shorter lengths of stay in the hospital are highly desirable, especially from the patient’s point of view, the ROMICAT-II study reveals a deeper flaw in the approach to chest pain in the emergency department. The underlying assumption… is that some diagnostic test must be performed before discharging these low-to-intermediate-risk patients from the emergency department. This assumption is unproven and probably unwarranted. The rationale for any test, as compared with no testing, should be that it will lead to an improved outcome, and here there is no evidence that the tests performed led to improved outcomes.

Redberg points out that the very low (under 1%) rate of patients who actually had an MI in the study means “that it is impossible to know whether the CCTA groups received any benefit whatsoever.” Further, factoring in radiation doses  both from CTA and nuclear stress tests and adverse reactions to contrast dye, “clinicians may legitimately ask whether the tests did more harm than good.”

For patients like those in ROMICAT II, with normal ECG findings and negative troponin tests, “multiple studies show no evidence that any additional testing further reduces that risk.”Although CTA can reduce length of stay in the hospital compared to standard care, “it is even faster to discharge these patients without any additional diagnostic test after determining that their ECG findings and troponin levels are normal.” She concludes:

In short, the question is not which test leads to faster discharge of patients from the emergency department, but whether a test is needed at all.”

By contrast, the NHLBI press release focuses exclusively on the benefits of CTA and lacks any significant discussion of its potential limitations, as presented in the NEJM paper and as discussed in detail by Redberg. The press release quotes Susan Shurin, the acting director of the NHLBI:

Identifying the underlying cause of chest pain more quickly with CT scans could allow medical care providers to better allocate limited resources to the patients who are most in need of treatment.

The principal investigator of the study, Udo Hoffmann, says that ROMICAT II can “help health care providers and patients make better informed decisions by knowing the risks and potential benefits of using CT scans to more quickly diagnose acute coronary syndrome,” but he glosses over the risks and then focuses on the benefits:

“It can be a relief to patients with chest pain to quickly know they are not having a heart attack and that they can spend the night at home, instead of in a hospital bed.”

Finally, the press release gives short shrift to the radiation issue:

Participants in the CT group were exposed to more radiation than those in the standard screening group, though the study authors suggested that future CT scans could be done using less radiation, which could help lower exposure without sacrificing accuracy.

Click here to read the NHLBI press release…