Critical pathways in cardiology
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In 2003, we published our chest pain protocol for the management of acute coronary syndromes (ACSs) and acute myocardial infarction. Our algorithm was specifically designed for our institution, which was primary percutaneous coronary intervention (PCI) for all ST-elevation myocardial infarctions (STEMIs) and a preferred invasive approach for non-STEMIs. ⋯ We present our updated chest pain algorithm with a brief review of the rapidly evolving changes in adjunctive pharmacotherapy for PCI and provide a rationale for the changes that we have made to our institutional protocol. Clinical pathways need to be consistently updated and revises by incorporating new evidence from clinical trials in order to maintain clinical relevance.
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Global risk assessment is the standard of care for coronary artery disease management. In this setting, sleep apnea syndrome, which includes obstructive sleep apnea and central sleep apnea, is being increasingly recognized as a potentially modifiable risk factor for coronary artery disease. ⋯ Continuous positive airway pressure has been shown to decrease inflammatory markers that are elevated in sleep apnea syndrome. Well-designed randomized controlled clinical trials are needed to better establish the role of sleep apnea in the genesis and progression of coronary artery disease.
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Comparative Study
Appropriately screened geriatric chest pain patients in an observation unit are not admitted at a higher rate than nongeriatric patients.
Observation units may exclude geriatric patients (defined as age >or=65) due to the high rate of observation failure (admission to an inpatient unit) among these patients. We evaluated whether geriatric patients on a chest pain protocol are admitted to an inpatient unit from an emergency department (ED) observation unit at a higher rate than nongeriatric patients. ⋯ Geriatric patients without a history of coronary artery disease were admitted to an inpatient unit at a rate consistent with a generally accepted observation failure rate of 10%. When screened appropriately, these patients may be appropriate for chest pain evaluation in the ED observation unit.