Critical pathways in cardiology
-
Natriuretic peptides (B-type natriuretic peptide [BNP] and N-terminal pro-B-type natriuretic peptide [NT]-proBNP) have been proven to be strong diagnostic and prognostic tools in the assessment of acutely decompensated heart failure. The emergence of BNP/NT-proBNP testing as a standard of care in this setting has helped to reduce healthcare costs, and may decrease adverse clinical outcomes. The use of BNP and NT-proBNP to "guide" treatment of acutely destabilized heart failure has recently grown. We present an overview of the value of BNP/NT-proBNP in the context of acute heart failure management and therapy optimization, and present an algorithm for natriuretic peptide-guided treatment of acutely destabilized heart failure.
-
It is proposed that contrast-induced nephropathy (CN) correlates with the use of increasing contrast volumes during coronary angiography. This supposition has led to the current recommendation to limit the dose of contrast in patients at high risk for renal dysfunction. Limits in contrast dosing may negatively impact the evaluation of patients undergoing cardiac catheterization for myocardial infarction and acute coronary syndrome. ⋯ In this large population, no association was found between the amount of contrast used during angiography and the incidence of CN in patients at initial high risk. The apparent inverse relation of risk with volume in the overall population is likely explained by clinical practice bias. If confirmed, these results may have important clinical implications.
-
To reduce atherothrombosis-related morbidity and mortality, implementation of guideline-recommended therapies for primary and secondary prevention is necessary. Few data are available for outpatients in actual clinical practice, especially those without known heart disease treated by physicians trained in different specialties across the geographic regions of the United States. ⋯ Adherence to guideline-recommended preventive therapies in the outpatient setting was affected by patient characteristics, geographical region, and treating physician specialty. Novel approaches may be needed to improve the use of evidence-based, guideline-recommended therapies in these outpatient settings.
-
Comparative Study
Low-risk acute heart failure patients: external validation of the Society of Chest Pain Center's recommendations.
Risk-stratification in acute heart failure syndromes (AHFS) is problematic. A recent set of recommendations describes emergency department (ED) patients with AHFS who do not fulfill high-risk criteria and may be good candidates for observation unit (OU) management. The goal of this analysis was to report on the outcomes experienced by ED patients with AHFS who do not have any of these high-risk criteria. ⋯ AHFS patients at low-risk for subsequent morbidity and mortality based on recent consensus guidelines may be good candidates for early discharge after a brief period of observation in the OU or ED. Additional prospective research is needed to determine the impact of implementation of these criteria in ED patients with AHFS.
-
Comparative Study
Utility of the emergency department observation unit in ensuring stress testing in low-risk chest pain patients.
Recent research has noted low rates of compliance among ED chest pain patients referred for outpatient stress testing. The practice at our institution, a 39,000 visits per year emergency department (ED), is to place chest pain patients considered low risk for acute coronary syndrome in an observation unit for serial biomarker testing and provocative cardiac testing. Our objective was to determine the rates of positive stress tests among this group and to extrapolate from this the potential missed positive stress tests if these patients were referred instead for outpatient stress testing. ⋯ Among chest pain patients admitted to an ED observation unit, the rate of positive stress tests was 11%. Approximately 3.3% of patients with positive stress tests may have been missed if these patients were instead referred for outpatient testing.