Exploratory study of relationship between hospitalized heart failure and chronic renal replacement therapy.

Nephrol Dial Transplant. 2009 Jan 28;

Authors: Liang KV, Greene EL, Williams AW, Herzog CA, Hodge DO, Owan TE, Redfield MM

BACKGROUND: Chronic kidney disease (CKD) is common in heart failure (HF) and is associated with poor outcomes. Renal replacement therapy (RRT) may be deferred over concerns regarding tolerability and outcomes in HF. Our objectives were to ascertain the incidence of RRT, changes in RRT incidence over time and the association between RRT and survival in hospitalized HF patients. METHODS: A retrospective cohort study of consecutive hospitalized HF patients was performed at a single centre from 1987 to 2002 with RRT data from the United States Renal Data System. RESULTS: Of 6276 HF patients without RRT on admission, 304 commenced chronic (>/=3 months) RRT (280 dialysis only; 24 transplant) at a median of 475 days after dismissal. Overall incidence was 1.6% per year. Risk-adjusted incidence increased over time and was similar in those with preserved or reduced (<50%) ejection fraction. RRT patients were younger but had worse renal function and anaemia, and more diabetes, hypertension and coronary disease. Unadjusted survival was worse in the RRT group. However, risk-adjusted survival was similar in RRT and non-RRT groups (HR = 1.11, 95% CI 0.94-1.29, P > 0.05). CONCLUSIONS: Our data show that although RRT is increasingly used in HF patients, the impact on risk-adjusted mortality remains to be established. Further studies should focus on defining the appropriate clinical settings in which RRT should be used in HF, the timing and type of RRT and whether RRT can improve specific outcomes.

PMID: 19176683 [PubMed - as supplied by publisher]

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Albumin dialysis improves hepatic encephalopathy and decreases circulating phenolic aromatic amino acids in patients with alcoholic hepatitis and severe liver failure.

Crit Care. 2009 Jan 28;13(1):R8

Authors: Pares A, Deulofeu R, Cisneros L, Escorsell A, Salmeron JM, Caballeria J, Mas A

ABSTRACT: INTRODUCTION: The aim of the study was to assess the effects of albumin dialysis on hepatic encephalopathy and circulating levels of amino acids in severe alcoholic hepatitis. METHODS: The study was carried out on nine patients with severe alcoholic hepatitis and four with primary biliary cirrhosis treated with the molecular adsorbent recirculating system. Besides standard liver function tests, circulating levels of ammonia, total, branched chain and aromatic amino acids and the presence and severity of hepatic encephalopathy and number connection test were measured before and after each treatment. RESULTS: There were 8 episodes of encephalopathy in patients with alcoholic hepatitis. Albumin dialysis was associated with significant improvement in encephalopathy (p=0.02), and a decrease in total amino acid levels (2490 +/- 152 to 2229 +/- 114 uM, p<0.001). Moreover, the Fischer's ratio, which was significantly lower in patients with alcoholic hepatitis (1.32 +/- 0.08) than in controls (3.20 +/- 0.16), increased by 17% after albumin dialysis (p<0.02) due to a significant decrease in phenolic aromatic amino acids (193 +/- 17 to 165 +/- 9 uM, p=0.04). No differences were observed in circulating ammonia. Changes in phenolic aromatic amino acids and the Fischer's ratio were more prominent in patients with encephalopathy and higher bilirubin removal. Albumin dialysis did not significantly affect the amino acid profile in controls. CONCLUSIONS: Albumin dialysis results in a significant decrease in circulating phenolic aromatic amino acids and improvement of hepatic encephalopathy in patients with severe liver failure.

PMID: 19175915 [PubMed - as supplied by publisher]

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Clinical predictors of cardiac syncope at initial evaluation in patients referred urgently to a general hospital: the EGSYS score.

Heart. 2008 Dec;94(12):1620-6

Authors: Del Rosso A, Ungar A, Maggi R, Giada F, Petix NR, De Santo T, Menozzi C, Brignole M

OBJECTIVE: To develop, in patients referred for syncope to an emergency department (ED), a diagnostic score to identify those patients likely to have a cardiac cause. DESIGN: Prospective cohort study. SETTING: ED of 14 general hospitals. PATIENTS: 516 consecutive patients with unexplained syncope. INTERVENTIONS: Subjects underwent a diagnostic evaluation on adherence to Guidelines of the European Society of Cardiology. The clinical features of syncope were analysed using a standard 52-item form. In a validation cohort of 260 patients the predictive value of symptoms/signs was evaluated, a point score was developed and then validated in a cohort of 256 other patients. Main outcome measurements: Diagnosis of cardiac syncope, mortality. RESULTS: Abnormal ECG and/or heart disease, palpitations before syncope, syncope during effort or in supine position, absence of autonomic prodromes and absence of predisposing and/or precipitating factors were found to be predictors of cardiac syncope. To each variable a score from +4 to -1 was assigned to the magnitude of regression coefficient. A score >or=3 identified cardiac syncope with a sensitivity of 95%/92% and a specificity of 61%/69% in the derivation and validation cohorts, respectively. During follow-up (mean (SD) 614 (73) days) patients with score >or=3 had a higher total mortality than patients with a score <3 both in the derivation (17% vs 3%; p<0.001) and in the validation cohort (21% vs 2%; p<0.001). CONCLUSIONS: A simple score derived from clinical history can be usefully employed for the triage and management of patients with syncope in an ED.

PMID: 18519550 [PubMed - indexed for MEDLINE]

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Is it more difficult to cannulate the right internal jugular vein in morbidly obese patients than in nonobese patients?

Obes Surg. 2008 Sep;18(9):1157-9

Authors: Fujiki M, Guta CG, Lemmens HJ, Brock-Utne JG

BACKGROUND: The placement of an internal jugular vein (IJV) catheter is considered to be more difficult in morbidly obese patients. The objective of this study was to compare the success of simulated IJV puncture between morbidly obese patients and a nonobese control group. METHODS: Thirty-four morbidly obese patients with body mass index (BMI, kg/m(2)) >/=40 were compared with 36 patients with BMI < 30. Right IJV puncture was simulated using an ultrasound probe directed towards the sternal notch at the midpoint between the sternal notch and the mastoid process. The investigator placing the probe was blinded as to the image being created on the ultrasound machine. Success rate was assessed at three different head rotation angles from midline; 0 degrees , 30 degrees , and 60 degrees . RESULTS: There was no statistically significant difference in successful simulated IJV puncture between two groups for any of the head positions. However, there was a higher incidence of the carotid artery (CA) puncture in the morbidly obese patient group when the head rotation was advanced from neutral position to 60 degrees (p < 0.05). In addition, the ultrasound showed significantly more overlapping of the IJV over the CA in morbidly obese patients at 0 degrees (p < 0.05) and 30 degrees (p < 0.05). Our results show no statistically significant difference in success rate of IJV puncture between morbidly obese patients and nonobese patients. Keeping the head in a neutral position in morbidly obese patients minimizes the overlapping of the IJV over the CA and the risk of CA puncture. CONCLUSION: However, due to the fact that even in the neutral position there is a significant increase in overlap between IJV and CA, we recommend the use of ultrasound guidance for IJV cannulation in obese patients.

PMID: 18574645 [PubMed - indexed for MEDLINE]

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The effect of routine rounding by nursing staff on patient satisfaction on a cardiac telemetry unit.

Health Care Manag (Frederick). 2008 Oct-Dec;27(4):332-7

Authors: Sobaski T, Abraham M, Fillmore R, McFall DE, Davidhizar R

Patients’ perception of their care is affected by the attention they receive while hospitalized. It has become a popular metric for improving the quality of care delivered. Rounding is believed to be the key to patients’ perception of the care they receive. In this study, nursing administration wanted to increase patient’s perception of how well their needs were being met. Regular scheduled rounding provided an opportunity for nursing to interact with patients on a regular schedule. All nursing care categories measured exceeded the goal of 90% in the first month after implementation, with the largest increase of averaged percentages being “attention to special or personal needs.

PMID: 19011416 [PubMed - indexed for MEDLINE]

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Centers for Medicare and Medicaid Services’ “never events”: an analysis and recommendations to hospitals.

Health Care Manag (Frederick). 2008 Oct-Dec;27(4):338-49

Authors: Mattie AS, Webster BL

In August 2007, the Centers for Medicare and Medicaid Services (CMS) released the inpatient prospective payment system for fiscal year 2008 prohibiting reimbursement for 8 hospital-acquired conditions. The changes were mandated by section 5001(c) of the Deficit Reduction Act of 2005. Beginning on October 1, 2008, hospitals will no longer receive higher payments for patients with these conditions, termed never events. For fiscal year 2009, a total of 9 additional events are proposed. This initiative signals a new reimbursement strategy of aligning payment to patient outcomes and represents a response to government and private entities’ call for hospital accountability for health care quality. This article identifies key events leading to CMS’ ruling regarding nonpayment for hospital-acquired conditions, outlines the main points of interest in CMS’ new rules, identifies limitations and concerns with this policy, and suggests measures that each hospital should voluntarily take to comply with 2008 and 2009 deadlines.

PMID: 19011417 [PubMed - indexed for MEDLINE]

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Efficacy of pneumococcal vaccination in adults: a meta-analysis.

CMAJ. 2009 Jan 6;180(1):48-58

Authors: Huss A, Scott P, Stuck AE, Trotter C, Egger M

BACKGROUND: Clinical trials and meta-analyses have produced conflicting results of the efficacy of unconjugated pneumococcal polysaccharide vaccine in adults. We sought to evaluate the vaccine's efficacy on clinical outcomes as well as the methodologic quality of the trials. METHODS: We searched several databases and all bibliographies of reviews and meta-analyses for clinical trials that compared pneumococcal polysaccharide vaccine with a control. We examined rates of pneumonia and death, taking the methodologic quality of the trials into consideration. RESULTS: We included 22 trials involving 101 507 participants: 11 trials reported on presumptive pneumococcal pneumonia, 19 on all-cause pneumonia and 12 on all-cause mortality. The current 23-valent vaccine was used in 8 trials. The relative risk (RR) was 0.64 (95% confidence interval [CI] 0.43-0.96) for presumptive pneumococcal pneumonia and 0.73 (95% CI 0.56-0.94) for all-cause pneumonia. There was significant heterogeneity between the trials reporting on presumptive pneumonia (I(2) = 74%, p < 0.001) and between those reporting on all-cause pneumonia (I(2) = 90%, p < 0.001). The RR for all-cause mortality was 0.97 (95% CI 0.87-1.09), with moderate heterogeneity between trials (I(2) = 44%, p = 0.053). Trial quality, especially regarding double blinding, explained a substantial proportion of the heterogeneity in the trials reporting on presumptive pneumonia and all-cause pneumonia. There was little evidence of vaccine protection in trials of higher methodologic quality (RR 1.20, 95% CI 0.75-1.92, for presumptive pneumonia; and 1.19, 95% CI 0.95-1.49, for all-cause pneumonia in double-blind trials; p for heterogeneity > 0.05). The results for all-cause mortality in double-blind trials were similar to those in all trials combined. There was little evidence of vaccine protection among elderly patients or adults with chronic illness in analyses of all trials (RR 1.04, 95% CI 0.78-1.38, for presumptive pneumococcal pneumonia; 0.89, 95% CI 0.69-1.14, for all-cause pneumonia; and 1.00, 95% CI 0.87-1.14, for all-cause mortality). INTERPRETATION: Pneumococcal vaccination does not appear to be effective in preventing pneumonia, even in populations for whom the vaccine is currently recommended.

PMID: 19124790 [PubMed - indexed for MEDLINE]

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The treatment of giant cell arteritis.

Rev Neurol Dis. 2008;5(3):140-52

Authors: Fraser JA, Weyand CM, Newman NJ, Biousse V

Although giant cell arteritis (GCA) is a well-known vasculitis sensitive to corticosteroid-mediated immunosuppression, numerous issues of long-term therapeutic management remain unresolved. Because GCA encompasses a broad spectrum of clinical subtypes, ranging from devastating visual loss and neurological deficits to isolated systemic symptoms, the treatment of GCA must be adjusted to each case, and recommendations vary widely in the literature. This article systematically reviews the treatment options for patients with neuro-ophthalmic and neurological complications of GCA, as well as the evidence for possible adjuvant therapies for patients with GCA. Although there is no randomized controlled clinical trial specifically evaluating GCA patients with ocular and neurological complications, we recommend that GCA patients with acute visual loss or brain ischemia be admitted to the hospital for high-dose intravenous methyl-prednisolone, close monitoring, and prevention of steroid-induced complications. Aspirin may also be helpful in these cases. The evidence supporting the use of steroid-sparing immunomodulatory agents such as methotrexate for long-term management remains debated.

PMID: 18838954 [PubMed - indexed for MEDLINE]

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Resident physician burnout: is there hope?

Fam Med. 2008 Oct;40(9):626-32

Authors: McCray LW, Cronholm PF, Bogner HR, Gallo JJ, Neill RA

BACKGROUND: Prevalent among resident physicians, burnout has been associated with absenteeism, low job satisfaction, and medical errors. Little is known about the number and quality of interventions used to combat burnout. METHODS: We performed a systematic review of the literature using MEDLINE and PubMed databases. We included English-language articles published between 1966 and 2007 identified using combinations of the following medical subject heading terms: burnout, intervention studies, program evaluation, internship and residency, graduate medical education, medical student, health personnel, physician, resident physician, resident work hours, and work hour limitations. Additional articles were also identified from the reference lists of manuscripts. The quality of research was graded with the Strength of Evidence Taxonomy (SORT) from highest (level A) to lowest (level C). RESULTS: Out of 190 identified articles, 129 were reviewed. Nine studies met inclusion criteria, only two of which were randomized, controlled trials. Interventions included workshops, a resident assistance program, a self-care intervention, support groups, didactic sessions, or stress-management/coping training either alone or in various combinations. None of the studied interventions achieved an A-level SORT rating. CONCLUSIONS: Despite the potentially serious personal and professional consequences of burnout, few interventions exist to combat this problem. Prospective, controlled studies are needed to examine the effect of interventions to manage burnout among resident physicians.

PMID: 18830837 [PubMed - indexed for MEDLINE]

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Incidence and clinical implications of venous thromboembolism in advanced colorectal cancer patients: the ‘GISCAD-alternating schedule’ study findings.

Eur J Cancer. 2009 Jan;45(1):65-73

Authors: Mandalà M, Barni S, Floriani I, Isa L, Fornarini G, Marangolo M, Mosconi S, Corsi D, Rulli E, Frontini L, Cortesi E, Zaniboni A, Aglietta M, Labianca R

AIM OF THE STUDY: To investigate the incidence and clinical implications of venous thromboembolism (VTE) in advanced colorectal cancer (ACC) patients treated and followed-up through a prospective randomised trial, comparing FOLFIRI chemotherapy given as an intermittent or as a continuous schedule. PATIENTS, MATERIALS AND METHODS: A total of 266 patients were randomised by 15 experimental centres: 168 (63.2%) were males, median age: 64.6 years, age range: 37-76 years. Almost all (95.5%) patients had metastatic disease, while the remainder were classified with locally advanced irresectable disease. For 138 (51.9%) of the patients, the chemotherapy treatment was intermittent FOLFIRI and the remaining patients received continuous treatment. All toxicities, including VTE, were prospectively collected. RESULTS: During the study protocol, the central data management gathered two cases of VTE. Our analysis retrieved 27 (10.2%) patients who developed a VTE, almost all (89%) during the course of chemotherapy treatment: 20 out of 27 during FOLFIRI, the remaining 7 during following lines or follow-up. VTE was the most frequent grade 3/4 toxicity. The incidence of VTE was significantly increased in the patients receiving continuous rather than intermittent treatment (HR 2.67, 95% CI 1.17-6.10; p<0.02). CONCLUSION: VTE is a common complication among advanced colorectal cancer patients and yet this type of toxicity is widely underestimated. In this randomised trial, VTE was the most frequent grade 3/4 toxicity. Use of an intermittent schedule is associated with a reduced risk of developing VTE.

PMID: 19068274 [PubMed - indexed for MEDLINE]

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Investigation of a nosocomial outbreak by alginate-producing pan-antibiotic-resistant Pseudomonas aeruginosa.

Am J Infect Control. 2008 Dec;36(10):e13-8

Authors: Yakupogullari Y, Otlu B, Dogukan M, Gursoy C, Korkmaz E, Kizirgil A, Ozden M, Durmaz R

BACKGROUND: The nosocomial spread of pan-antibiotic-resistant nonfermentative bacteria is an increasing concern. This study investigated the microbiologic and epidemiologic characteristics of a hospital outbreak due to alginate-producing, pan-antibiotic-resistant Pseudomonas aeruginosa (PAR-Pa). METHODS: All patients with infection with a P. aeruginosa strain that was resistant to all Clinic Laboratory Standards Institute-suggested antimicrobial agents between November 2004 and May 2005 were included in the study. Alginate production detection and pulsed-field gel electrophoresis (PFGE) typing were done for the patient and environmental surveillance isolates. A matched case-control study was performed to identify risk factors and evaluate outcomes. RESULTS: PFGE analysis of a total of 35 PAR-Pa isolates (28 patient and 7 environmental surveillance isolates) identified a single epidemic clone as responsible for the outbreak. All epidemic isolates were alginate-producing and susceptible only to colistin. The Student t-test demonstrated that a longer stay in the intensive care unit (ICU) (6.64 days vs 1.83 days; P < .05) significantly increased the risk of PAR-Pa infection. Systemic PAR-Pa infection resulted in higher mortality (85.7% vs 27.8%; P < .05). Multivariate analysis determined that therapeutic failure (odds ratio = 24.7; 95% confidence interval = 4.144 to 147.221; P < .05) was the independent risk factor related to this high mortality. Localized PAR-Pa infections were associated with longer hospital stays (46.2% vs 14.4%; P < .05) and higher rates of surgery (85.7% vs 15.4%; P < .05) and amputation (42.8% vs 0%; P < .05). The recovery of the pathogen from staff hands and frequently handled surfaces suggests possible handborne transmission. Improved hygienic standards and application of strict contact precautions, including isolation, reduced the spread of the pathogen. CONCLUSION: This study illustrates the ability of pan-antibiotic-resistant P. aeruginosa to cause an outbreak with significant mortality and stresses the need for precautions to prevent the spread of such highly resistant strains.

PMID: 19084158 [PubMed - indexed for MEDLINE]

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Postoperative exacerbation of chronic obstructive pulmonary disease. Does it exist?

Eur J Cardiothorac Surg. 2008 Mar;33(3):424-9

Authors: Leo F, Venissac N, Pop D, Solli P, Filosso P, Minniti A, Radice D, Mouroux J, Spaggiari L, Pastorino U, Jougon J, Velly JF, Oliaro A

BACKGROUND: One of the characteristics of chronic obstructive pulmonary disease (COPD) is the tendency to develop acute exacerbation, defined by the presence of different clinical findings as worsening dyspnea, increase in sputum purulence and volume. This study was designed to verify if definition of acute COPD exacerbation is applicable to patients who underwent pulmonary surgery, and if it has any impact on postoperative morbidity and mortality. METHODS: This study was designed to prospectively enrol 1000 patients undergoing pulmonary resection for lung cancer from five different centres. Postoperative exacerbation of COPD was defined by the concomitant presence of three of the following five signs: deteriorating dyspnea, purulent sputum, bronchial secretion volume >10 ml/24 h, fever without apparent cause, and wheezing. The presence of concomitant pulmonary complications excluded the diagnosis of exacerbation, as they may present one or more of these signs. RESULTS: In the absence of respiratory complications, postoperative stay in exacerbated patients was significantly longer as compared to patients without exacerbation (6.3+/-1.3 vs 8.3+/-1.1, p=0.001). A postoperative exacerbation of COPD was recorded in 276 patients and 152 of them (55%) subsequently developed respiratory complications. Multivariate analysis established that risk factors for postoperative exacerbation are sex (female OR 0.54, CI 0.2-0.8), COPD class (OR 1.5, CI 1.1-8.1), and the postoperative prolonged use of antibiotics (OR 0.6, CI 0.2-0.9). CONCLUSIONS: Postoperative exacerbation of COPD is an existing, frequent clinical entity after lung resection and, when present, it increases the risk of pulmonary complications. The existing guidelines for the treatment of acute exacerbation should be adapted for the management of patients after lung resection in order to test the hypothesis that they could reduce respiratory morbidity.

PMID: 18226541 [PubMed - indexed for MEDLINE]

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Current use of beta blockers in patients with reactive airway disease who are hospitalized with acute coronary syndromes.

Am J Cardiol. 2009 Feb 1;103(3):295-300

Authors: Olenchock BA, Fonarow GG, Pan W, Hernandez A, Cannon CP,

Beta blockers have a proven benefit in the management of patients with acute coronary syndromes (ACS) and for secondary prevention of coronary events. Current guidelines list such reactive airway diseases (RADs) such as asthma and chronic obstructive pulmonary disease as relative contraindications to beta-blocker use. However, the co-morbid burden of RAD and coronary heart disease is substantial, and data suggest that the treatment benefit of beta blockers is shared by patients with RAD. The Get with the Guidelines (GWTG) database was used to evaluate use of beta blockers within 24 hours of admission and at discharge in patients with ACS with (n = 12,967) and without (n = 81,140) a history of RAD. Data were collected in 435 hospitals between January 2000 and September 2006. A multivariable logistic regression model was used to determine predictors of beta-blocker treatment. In patients with no RAD history, beta-blocker prescription rates were 78.3% at admission and 88.7% at discharge; in patients with a RAD history, rates were 65.6% at admission and 77.2% at discharge. Compared with patients with no history of RAD, patients with a history of RAD were 42% less likely (odds ratio 0.58, confidence interval 0.54 to 0.62, p <0.0001) to receive a beta blocker upon admission and 55% less likely (odds ratio 0.45, confidence interval 0.41 to 0.48, p <0.0001) to receive a beta blocker at discharge in multivariable analysis. Among all other clinical factors, RAD history was the most significant predictor of likelihood of not receiving a beta blocker at admission or discharge. Receipt of beta blockers within 24 hours after admission was associated with a lower in-hospital mortality rate for patients with RAD (odds ratio = 0.52, p <0.001) and for patients without RAD (odds ratio = 0.38, p <0.001). Careful assessment of beta-blocker safety and RAD severity by physicians is needed to improve beta-blocker prescription rates in this large group of patients with ACS.

PMID: 19166678 [PubMed - in process]

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Differentiating ST elevation myocardial infarction and nonischemic causes of ST elevation by analyzing the presenting electrocardiogram.

Am J Cardiol. 2009 Feb 1;103(3):301-6

Authors: Jayroe JB, Spodick DH, Nikus K, Madias J, Fiol M, De Luna AB, Goldwasser D, Clemmensen P, Fu Y, Gorgels AP, Sclarovsky S, Kligfield PD, Wagner GS, Maynard C, Birnbaum Y

Guidelines recommend that patients with suggestive symptoms of myocardial ischemia and ST-segment elevation (STE) in > or =2 adjacent electrocardiographic leads should receive immediate reperfusion therapy. Novel strategies aimed to reduce door-to-balloon time, such as prehospital wireless electrocardiographic transmission, may be dependent on the interpretation accuracy of the electrocardiogram (ECG) readers. We assessed the ability of experienced electrocardiographers to differentiate among STE, acute STE myocardial infarction (STEMI), and nonischemic STE (NISTE). A total of 116 consecutive ECGs showing STE were studied. Fifteen experienced cardiologists were asked to decide, based on the ECG and assuming that the patient had compatible symptoms, whether they would send each patient for primary percutaneous coronary intervention (PPCI). If NISTE was chosen, the reader selected 1 or more 12 possible options to explain the choice. Of 116 patients, only 8 had STEMI. The percentage of ECGs for which PPCI was recommended for the patient by the individual readers varied widely (7.8% to 33%). There was no significant difference between the North American and Other Countries readers (p = 0.13). The sensitivity and specificity of the individual readers ranged from 50% to 100% (average 75%) and 73% to 97% (average 85%), respectively. There were broad inconsistencies among the readers in the chosen reasons used to classify NISTE. In conclusion, we found wide variations among experienced electrocardiographers in reading ECGs with STE and differentiating STEMI with need for PPCI from NISTE. There is a need to revise our current electrocardiographic criteria for differentiating STEMI from NISTE.

PMID: 19166679 [PubMed - in process]

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Frequency of electrocardiographic recordings in patients presenting with angina pectoris (from the Investigation of National Coronary Disease Identification).

Am J Cardiol. 2009 Feb 1;103(3):312-5

Authors: Li J, Reaven NL, Funk SE, Lovett JE, DeMaria AN

The appropriate progression of diagnostic testing for acute angina has been the topic of several recommendations by the American College of Cardiology and American Heart Association (ACC/AHA). We measured how frequently electrocardiography (ECG) is provided as the initial cardiac diagnostic test, as recommended for patients with new angina. Using an insurance database representing 2% of the U.S. adult population, we identified patients undergoing a new cardiac diagnostic process for angina. Rates of initial ECG were stratified by age, gender, co-morbid disease, and care setting. Of 4.4 million patients, 18,139 met the entry criteria by presenting with anginal symptoms for testing. A substantial portion (35%, 95% confidence interval [CI] 34% to 35%) did not receive the initial ECG recommended by expert guidelines. Patients treated in emergency departments received an initial ECG more frequently (91%, CI 90% to 92%) than patients tested in outpatient settings (61%, CI 60% to 62%; risk ratio [RR] 0.67, CI for RR 0.65 to 0.68) or in inpatient hospital settings (34%, CI 32% to 37%; RR 0.38, CI for RR 0.36 to 0.40). Slightly lower rates of initial ECG were observed in men (RR 0.93 vs women, CI for RR 0.91 to 0.95) and patients over 64 years (RR 0.93 vs younger patients, CI for RR 0.91 to 0.95). Total diagnostic costs averaged $954 when testing began with the recommended ECG versus $1,233 when testing did not. In conclusion, ECG is not universally obtained as the initial test for patients presenting with anginal symptoms despite evidence-based recommendations for such use. Clinicians should be aware that suboptimal use of ECG in certain settings may hinder investigations of heart disease.

PMID: 19166681 [PubMed - in process]

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