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Association of Time at First Myocardial Infarction and High-Density Cholesterol Levels
Research Forum Abstracts resources for telemetry monitoring, it is challenging to decide who is at the most risk for VT/V fib. Study Objective: To study the characteristics of adult patients in the emergency department (ED) who develop VT/V fib during hospital stay. Methods: We conducted a retrospective chart review at an urban academic center with annual ED census of 130,000 patients from November 1, 2007 to November 30, 2009. Adult (21 yrs) patients presenting to the emergency department who developed VT/V fib during any point of their hospitalization were included in the study. Patients with initial presentation of VT/V fib were excluded from the study. Our primary outcome was mortality during hospitalization. We also examined the following secondary outcomes: such as rapid response- and cardiac arrest-team activations, implanting of pacemakers or defibrillators, and positive stress test or low ejection fraction noted during hospitalization. Data collection was performed by trained research associates from ED and inpatient records. Descriptive analysis followed by univariate comparison of variables of interest with the outcome of inpatient mortality was performed using chi-square and statistical significance was set at an alpha of 0.05 Results: Total 268 unique patients were noted to have VT/V fib during hospital stay with median age of 77 (IQR 66-84), 165 (61.6%) males, 143 (53.6%) white, 47 (17.5%) African Americans, 32 (11.9%) Asian, 32 (11.9%) Hispanic, 14 (5.3%) others. Total 261 (97.4%) patients had an EKG performed in the ED and 199 (74.2%) had HTN, 105 (39.2%) CAD, 70 (26.1%) atrial fibrillation, 86 (32.1%) DM and 96 (35.8%) were smokers. Seventy (26.1%) patients were on Coumadin, 142 (52.9%) on aspirin, 38 (14.1%) cardiac cath in the past, 43 (16.6%) had AICD, 28 (10.4%) had pacemaker, 1 (0.4%) had cardiac ablation. Of these patients, 78 (29.1%) were admitted to floor, 150 (55.9%) to telemetry, 33 (12.3%) to ICU, 7 (2.6%) to cath lab with median length of stay 6 days (IQR 3-10.5). Total 35 (13.1%) had myocardial infarction and 133 (49.63%) had new onset a-fib during hospital stay with median VT/V fib episode of 1, highest being 16 episodes. During hospital stay, 76 (29.7%) had LVEF40%, 50 (18.6%) had new occlusive findings on PTCA, 23 (8.6%) had AICD placed, 42 (15.7%) had positive gated stress test and 5 (1.87%) had ischemia on cardiac MRI. Total 33 (12.3%) patients died during inpatient stay with (21/97.8%) CAT activation and 11 (4.1%) RRT activation. On univariate analysis, inpatient mortality was significant for only patients on aspirin (p¼0.026) and history of PTCA (p¼0.011) and no other variables were significant for mortality. Conclusions: Atrial fibrillation was most commonly identified new abnormal rhythm in these patients prior to development of VT/V Fib. Mortality is associated with history of PTCA and aspirin use in the past
314
Evaluation of Adverse Outcomes in Syncope: A Comparison of the Boston, San Francisco, and Osservatorio Epidemiologico Sulla Sincope nel Lazio Clinical Prediction Rules
Nunez A, Yeung J, Kim J, Al-Awwad O, Masood A, Villamil J, Bustros T/Lutheran Medical Center, Brooklyn, NY
Study Objective: Clinicians vary in their ability to classify patients into high and low risk categories for syncope. Several clinical prediction rules (CPRs) have been developed to assist clinicians in the decision to admit or safely discharge patients who present to the emergency department (ED) with syncope. This study’s goal was to compare three clinical prediction rules (Boston syncope criteria, San Francisco syncope criteria (SFSR) and Osservatorio Epidemiologico Sulla Sincope nel Lazio (OESIL) score with clinical judgment in predicting short-term adverse outcomes from syncope. Methods: Between January 2012 and July 2012 we reviewed all adult patients that presented to the ED with a chief complaint of syncope, fall, passing out, loss of consciousness, or dizziness. An episode of syncope was defined by the presence of transient loss of consciousness with spontaneous return to baseline. Enrolled patients were interviewed in the ED and followed up via a phone call 10 days after the ED visit for the presence of any adverse outcome or critical intervention. All three clinical prediction rules were applied to each one of the subjects. Physicians’ judgment was scored based on either admission or discharge to the hospital. Any admitted patient was considered high risk for an adverse outcome and any discharge patient was considered as low risk. Results: Of the total 455 patients that were screened, 80 met inclusion criteria and 3 were lost to follow-up. The remaining 77 subjects were enrolled in the study. The Boston syncope rule had a sensitivity of 82.4%, specificity of 66.7%, PPV of 41% and NPV 93%. The SFSR had a sensitivity of 88.9%, specificity of 57.1%, PPV 21% and NPV 97.5%. OESIL had a sensitivity of 77.8%, specificity of 61.4%, PPV 20.5%, and NPV 95.5%. Clinical judgment had a sensitivity of 88.2%, specificity of 41.7%,
Volume 62, no. 4s : October 2013
PPV 30% and NPV 92.6%. Clinical judgment would have admitted the most patients (50) vs. OESIL (34), SFSR (38), and Boston rule (34). According to all the clinical prediction rules, none of the discharged patients would have died. Conclusions: Compared with clinical judgment, all CPRs would have decreased the number of admissions with no difference in missed adverse outcomes. These findings suggest that the use of any of these clinical prediction rules could decrease the costs associated with the management of syncope while still assure appropriate care for patients with high risk for negative outcomes. Further studies on a larger population should be conducted in order to confirm our findings.
315
Association of Time at First Myocardial Infarction and High-Density Cholesterol Levels
Koo TS, Honeycutt E, Shah B, Roe M/St. Luke’s-Roosevelt Hospital, New York, NY; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Duke University Medical Center, Durham, NC; Duke University Medical Center, Durham, NY
Study Objective: Younger age is thought to be protective for the acute manifestations of coronary artery disease, but certain risk factors such as diabetes mellitus and smoking have been shown to be more prevalent among young patients presenting with an acute myocardial infarction (MI). Though low high-density lipoprotein cholesterol (HDL-C) levels are a known risk factor for the development of CAD and are a key component of the diagnostic criteria for the metabolic syndrome, the influence of HDL-C on the temporal onset of acute MI have not been widely investigated. We sought to characterize the association between HDL-C levels and age at presentation of first MI, as well as severity of CAD and the risk of long-term clinical outcomes. Methods: This was a retrospective review utlitizing the Duke Databank for Cardiovascular Disease. Study subjects were those undergoing cardiac cathetertization at Duke University Medical Center between January 1, 1995, and July 1, 2008, with a first-time primary diagnosis of acute MI. The primary analysis examined the association between HDL-C levels measured during the index hospitalization and age at presentation of first acute MI, defined as both ST-elevation and non-STEMI MI. Secondary analyses examined the associations between HDL-C levels and the extent of CAD, defined as 1-, 2-, or 3-vessel disease on angiography, and long-term clinical outcomes, defined as 5- and 10-year incidences of subsequent acute MI or death. Results: In this retrospective cohort study of 5,655 patients presenting with a first MI and found to have significant CAD during angiography, lower HDL-C levels was modestly associated with a younger age at the time of a first acute MI, with an adjusted Pearson correlation coefficient of 0.13 (p< 0.0001). There was no association between lower HDL-C levels, and the severity of CAD and long-term morbidity and mortality. Conclusions: Lower HDL-C levels is associated with an earlier age at presentation with a first MI, but do not appear to be associated with more severe coronary disease or a higher risk of long-term clinical outcomes. Within this context, the utility of treatments designed to raise HDL-C levels for the primary and secondary prevention of CAD remains uncertain.
316
Can GRACE Score Reduce Cardiac Testing in Low-Risk Chest Pain Patients?
Domanski K, Coppola M, Burton M, Akin A, Overstreet S, Delaney K, Wang H/JPS, Fort Worth, TX
Study Objectives: Clinical decision rules, such as the Thrombosis in Myocardial Infarction (TIMI) risk score or Global Registry of Acute Coronary Events (GRACE) score are widely used. Studies have shown the superiority of GRACE scores to predict short term outcomes of both in-hospital and 6-month follow-up periods. However, using GRACE scores to risk stratify low risk chest pain patients that are unlikely to benefit from objective cardiac testing is unknown. The goal of this study was to determine if GRACE scores are predictive of the occurrence of myocardial infarction (MI) and/or mortality, and to evaluate its potential for safely reducing cardiac testing in emergency department (ED) chest pain patients at low risk for acute coronary syndrome (ACS). Methods: From August 2011 till February 2012, a prospective pilot study was conducted with 6 months of short-term follow-up. Patients who presented to the ED with chest pain and who were considered low-risk by the emergency physician and placed in a chest pain observation unit were enrolled in the study. Clinical data including demographics, past medical history, laboratory test results, imaging, EKG, and objective cardiac testing were collected. Patients' GRACE scores were calculated upon their admission. Enrollees received a 6-month follow-up telephone survey. MI and/or mortality
Annals of Emergency Medicine S113
314
Evaluation of Adverse Outcomes in Syncope: A Comparison of the Boston, San Francisco, and Osservatorio Epidemiologico Sulla Sincope nel Lazio Clinical Prediction Rules
Nunez A, Yeung J, Kim J, Al-Awwad O, Masood A, Villamil J, Bustros T/Lutheran Medical Center, Brooklyn, NY
Study Objective: Clinicians vary in their ability to classify patients into high and low risk categories for syncope. Several clinical prediction rules (CPRs) have been developed to assist clinicians in the decision to admit or safely discharge patients who present to the emergency department (ED) with syncope. This study’s goal was to compare three clinical prediction rules (Boston syncope criteria, San Francisco syncope criteria (SFSR) and Osservatorio Epidemiologico Sulla Sincope nel Lazio (OESIL) score with clinical judgment in predicting short-term adverse outcomes from syncope. Methods: Between January 2012 and July 2012 we reviewed all adult patients that presented to the ED with a chief complaint of syncope, fall, passing out, loss of consciousness, or dizziness. An episode of syncope was defined by the presence of transient loss of consciousness with spontaneous return to baseline. Enrolled patients were interviewed in the ED and followed up via a phone call 10 days after the ED visit for the presence of any adverse outcome or critical intervention. All three clinical prediction rules were applied to each one of the subjects. Physicians’ judgment was scored based on either admission or discharge to the hospital. Any admitted patient was considered high risk for an adverse outcome and any discharge patient was considered as low risk. Results: Of the total 455 patients that were screened, 80 met inclusion criteria and 3 were lost to follow-up. The remaining 77 subjects were enrolled in the study. The Boston syncope rule had a sensitivity of 82.4%, specificity of 66.7%, PPV of 41% and NPV 93%. The SFSR had a sensitivity of 88.9%, specificity of 57.1%, PPV 21% and NPV 97.5%. OESIL had a sensitivity of 77.8%, specificity of 61.4%, PPV 20.5%, and NPV 95.5%. Clinical judgment had a sensitivity of 88.2%, specificity of 41.7%,
Volume 62, no. 4s : October 2013
PPV 30% and NPV 92.6%. Clinical judgment would have admitted the most patients (50) vs. OESIL (34), SFSR (38), and Boston rule (34). According to all the clinical prediction rules, none of the discharged patients would have died. Conclusions: Compared with clinical judgment, all CPRs would have decreased the number of admissions with no difference in missed adverse outcomes. These findings suggest that the use of any of these clinical prediction rules could decrease the costs associated with the management of syncope while still assure appropriate care for patients with high risk for negative outcomes. Further studies on a larger population should be conducted in order to confirm our findings.
315
Association of Time at First Myocardial Infarction and High-Density Cholesterol Levels
Koo TS, Honeycutt E, Shah B, Roe M/St. Luke’s-Roosevelt Hospital, New York, NY; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Duke University Medical Center, Durham, NC; Duke University Medical Center, Durham, NY
Study Objective: Younger age is thought to be protective for the acute manifestations of coronary artery disease, but certain risk factors such as diabetes mellitus and smoking have been shown to be more prevalent among young patients presenting with an acute myocardial infarction (MI). Though low high-density lipoprotein cholesterol (HDL-C) levels are a known risk factor for the development of CAD and are a key component of the diagnostic criteria for the metabolic syndrome, the influence of HDL-C on the temporal onset of acute MI have not been widely investigated. We sought to characterize the association between HDL-C levels and age at presentation of first MI, as well as severity of CAD and the risk of long-term clinical outcomes. Methods: This was a retrospective review utlitizing the Duke Databank for Cardiovascular Disease. Study subjects were those undergoing cardiac cathetertization at Duke University Medical Center between January 1, 1995, and July 1, 2008, with a first-time primary diagnosis of acute MI. The primary analysis examined the association between HDL-C levels measured during the index hospitalization and age at presentation of first acute MI, defined as both ST-elevation and non-STEMI MI. Secondary analyses examined the associations between HDL-C levels and the extent of CAD, defined as 1-, 2-, or 3-vessel disease on angiography, and long-term clinical outcomes, defined as 5- and 10-year incidences of subsequent acute MI or death. Results: In this retrospective cohort study of 5,655 patients presenting with a first MI and found to have significant CAD during angiography, lower HDL-C levels was modestly associated with a younger age at the time of a first acute MI, with an adjusted Pearson correlation coefficient of 0.13 (p< 0.0001). There was no association between lower HDL-C levels, and the severity of CAD and long-term morbidity and mortality. Conclusions: Lower HDL-C levels is associated with an earlier age at presentation with a first MI, but do not appear to be associated with more severe coronary disease or a higher risk of long-term clinical outcomes. Within this context, the utility of treatments designed to raise HDL-C levels for the primary and secondary prevention of CAD remains uncertain.
316
Can GRACE Score Reduce Cardiac Testing in Low-Risk Chest Pain Patients?
Domanski K, Coppola M, Burton M, Akin A, Overstreet S, Delaney K, Wang H/JPS, Fort Worth, TX
Study Objectives: Clinical decision rules, such as the Thrombosis in Myocardial Infarction (TIMI) risk score or Global Registry of Acute Coronary Events (GRACE) score are widely used. Studies have shown the superiority of GRACE scores to predict short term outcomes of both in-hospital and 6-month follow-up periods. However, using GRACE scores to risk stratify low risk chest pain patients that are unlikely to benefit from objective cardiac testing is unknown. The goal of this study was to determine if GRACE scores are predictive of the occurrence of myocardial infarction (MI) and/or mortality, and to evaluate its potential for safely reducing cardiac testing in emergency department (ED) chest pain patients at low risk for acute coronary syndrome (ACS). Methods: From August 2011 till February 2012, a prospective pilot study was conducted with 6 months of short-term follow-up. Patients who presented to the ED with chest pain and who were considered low-risk by the emergency physician and placed in a chest pain observation unit were enrolled in the study. Clinical data including demographics, past medical history, laboratory test results, imaging, EKG, and objective cardiac testing were collected. Patients' GRACE scores were calculated upon their admission. Enrollees received a 6-month follow-up telephone survey. MI and/or mortality
Annals of Emergency Medicine S113