March 22, 2021

Background:  Chest pain is one of the most frequent presenting patient complaints in emergency departments (ED) and has an extensive differential diagnosis with very different levels of severity (1). Many of these chest pain presentations require a significant stay in the ED to rule out acute coronary syndromes (ACS). Low-risk chest pain has been defined by consensus guidelines as having a less than 1% risk of a Major Adverse Cardiac Event (MACE) - a composite of death, myocardial infarction (MI) and coronary revascularization (2,3). There is certainly an overuse of troponin ordering in certain low-risk chest pain populations, translating into unnecessary resource utilization and possible downstream patient harm. The HEART Pathway combines a History, ECG, Age, Risk factors (HEAR) score and serial troponins to stratify patients with acute chest pain and attempt to identify those who most likely do not have ACS that are most suitable for early discharge from the ED without further testing (4). The HEART Pathway ideally reduces hospitalisations from the ED and outpatient cardiac testing, but it is not known if there exists a sub-population of very low-risk patients who could be objectively identified for discharge without any troponin testing at all. This study sought to measure the MACE rate among very low-risk chest pain patients, as defined by a HEAR score ≤1, and determine whether the HEART Pathway requires troponin testing among very low-risk patients to achieve an accepted missed MACE event rate of less than 1%.

March 19, 2021

Introduction: Chest pain is a common reason or presentation to the Emergency Department (ED). Emergency physicians are often challenged to identify patients who are at high risk for an acute coronary syndrome (ACS), from those with low risk, who might benefit from early discharge without extensive diagnostic workup. The introduction of high sensitivity cardiac troponins have improved early rule out strategies. Previous studies on high sensitivity troponins (hs-cTnT) have yielded two risk stratification strategies for rule in / rule out of myocardial infarction (MI); using an initial hs-cTnT below the limit of quantification (LOQ) alone and using an algorithm with initial and 1-hour hs-cTNT (0/1-h algorithm), as currently recommended by the European Society of Cardiology. These strategies are often combined with a risk score, of which in the United States (US) the HEART score is the most commonly used. However, due to the relatively late introduction of hs-cTnT in the US, multicenter US data for these risk stratification strategies using hs-cTnT are lacking. The goal of the current study was to prospectively evaluate the diagnostic performance of a hs-cTnT assay (Roche, Basel Switzerland) for the detection of 30-day MACE using two different strategies: an initial hs-cTnT <LOQ alone and a 0/1-h algorithm, both with and without clinical variables (ECG interpretation and HEART score).

March 3, 2021

Background: One of the most common reasons for Emergency Department (ED) visits is chest pain. While most of these presentations are at a low risk for cardiac events, it is generally required to perform a full work-up to rule out an Acute Coronary Syndrome (ACS), including an Acute Myocardial Infarction (AMI), before being discharged responsibly. The biggest challenge for physicians is to not only identify patients who are likely to have ACS but also to identify low risk patients that can be safely discharged without prolonged stays for further investigation. The current standard of practice, including risk assessment protocols, recommend using serial troponin testing and detection of absolute changes in troponin levels to rule out AMI in the ED. Recent studies using high sensitivity troponin (hsTnT) have shown that if the initial troponin is very low, one troponin may be sufficient to safely discharge patients from the ED, especially when combined with the HEART score. In practice however, in countries where hsTnT is not generally available, some clinicians have adopted this strategy using conventional troponin. This particular practice of using single conventional troponin testing has not been studied well.

February 10, 2021

Take Home Points
  • Consider ruptured AAA in patients (especially those > 50 years of age) with unexplained hypotension, back or abdominal pain
  • All ruptured AAAs should be considered unstable regardless of vital signs as rapid deterioration is common
  • A ruptured AAA is 100% fatal without surgical or endovascular intervention. Mobilize your surgical colleagues early
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