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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Evidence-based guidelines call for advanced and definitive therapy for patients with non-ST-elevation myocardial infarction (NSTEMI). It is not known whether these guidelines are follow more diligently when patients arrive in the ED during regular hours, during which hospital resources including cardiology consultation may be more readily available. To determine whether patients with NSTEMI who present to the ED outside of usual hours have prolonged times to advanced and definitive therapy and poorer short-term outcomes. ⋯ Despite these differences, in-hospital outcomes were similar. Time of patient presentation has a modest impact on the timeliness of intervention in NSTEMI but was not associated with lower mortality. Although intensity of medical management was similar between groups, it was generally lower than current guidelines recommend, indicating potential for improvement in NSTEMI outcomes, regardless of time of presentation.
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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.
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Although treatment guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) have been published and widely accepted, barriers to the optimal management of patients with acute coronary syndromes (ACS) still exist. Adherence to guidelines has been correlated with improvements in patient outcomes in ACS, including reduced mortality, yet data demonstrate that 25% of opportunities to provide guideline-recommended care are missed. This article describes a performance improvement (PI) initiative designed to address gaps in process-related ACS care and improve patient outcomes. ⋯ In this ACS PI initiative, physicians will assess their practice using performance measures defined by the 2007 ACC/AHA ST-segment elevation myocardial infarction and unstable angina or non-ST-segment elevation myocardial infarction guideline updates within 3 general benchmark areas: (1) patient risk assessment, (2) initial pharmacologic management, and (3) time-to-treatment (ie, "door-to-needle," "door-to-balloon," and "door-in-door-out" times). After completing a self-assessment and identifying 1 or more areas of improvement, participants can complete educational interventions and access benchmark-specific tools that provide guidance on improving adherence with the ACC/AHA guidelines. This PI initiative supplements other ongoing quality improvement initiatives in ACS, but is unique in that it is the first to use individual physician self-assessment, benchmark-focused continuing medical education, and self-developed PI plans to improve process-related ACS care.