Critical pathways in cardiology
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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.
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We describe the case of a 73 year-old woman presenting with symptoms compatible with myocardial ischemia/injury and left bundle branch block in whom the electrocardiogram fulfilled Sgarbossa criteria for ST-elevation myocardial infarction. Coronary angiography revealed an acute coronary occlusion and she was successfully revascularized. The value and limitations of the Sgarbossa criteria are discussed and the importance of considering ST-elevation myocardial infarction in patients presenting with chest discomfort and new left bundle branch block is emphasized.
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Comparative Study
Wireless cardiac event alert monitoring is feasible and effective in the emergency department and adjacent waiting areas.
The need for vigilance for unexpected clinical deterioration in the emergency department (ED) waiting area and in unmonitored treatment areas of the ED continues to increase. We sought to determine in an observational study the feasibility and relative false-alarm burden of, and satisfaction with, a novel wireless automated clinician alert device for cardiac rate and rhythm derangements in a teaching hospital ED. Patients presenting with a variety of complaints who after ED triage were not placed on conventional telemetric monitoring (by standard triage policy) were considered for inclusion. ⋯ There were 10 false-positive asystole or ventricular fibrillation alarms in 4 patients (1.3%), all of which were readily attributable to nonclinical origins, such as poor lead adherence. There was excellent satisfaction with the device from both patients and clinical personnel. Wireless cardiac event monitoring is feasible in the ED, and improves the throughput of ED patients with worsening vital signs, and may improve overall patient safety, without an onerous burden of nonproductive alarms.
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Comparative Study
Improvements in time to reperfusion: do women have an advantage?
Several studies demonstrate that women have greater delays in primary percutaneous coronary intervention (PCI). To improve care for women, the Women's Heart Advantage at Yale-New Haven Hospital (YNHH) developed patient- and physician-level interventions to improve knowledge about chest pain syndromes to promote early presentation, diagnosis, and timely management of ST-elevation myocardial infarction (STEMI) in women presenting to the emergency department. Specifically, we analyzed chart-abstracted data from all patients undergoing PCI for STEMI at YNHH from January 2004 to July 2007 and assessed quality of care for STEMI and trends in time to reperfusion. ⋯ In this single-site study of men and women undergoing primary PCI at a large, urban teaching hospital, where ongoing interventions to increase both patient and physician awareness regarding heart disease in women were initiated, time to reperfusion for women improved to a greater degree than in men. These results are encouraging, showing that significant improvements can be made over a relatively short time frame. It is hoped these reductions in time to reperfusion are associated with improved outcomes; however, further studies are needed to verify this potential benefit.
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Comparative Study
Physician documentation of nonspecific EKG changes predicts hospital admission among observation unit chest pain patients.
Our emergency department (ED) observation unit specifically excludes patients with "significant" electrocardiogram (EKG) findings, but patients may be admitted with "nonspecific" EKG findings. We evaluated whether physician documentation of nonspecific findings predicted eventual admission to an inpatient unit from the observation unit. We reviewed the charts of all chest pain patients admitted to our ED observation unit over a 14-month period. ⋯ Patients with documented nonspecific EKG changes also had higher rates of positive stress testing (17.5% vs. 10.5%, P = 0.103) and stent placement (5.1% vs. 3.3%, P = 0.309), although these were not statistically significant. Patients with documented nonspecific EKG findings were admitted to an inpatient unit from the observation unit at higher rates than those without these findings. Physicians may wish to use the ED EKG more effectively in screening patients for admission to the ED observation unit.