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D B Diercks

Publications and source records attributed to D B Diercks.

5 recordsLinked to original sources
PubMed2000

Identification of patients at risk by graded exercise testing in an emergency department chest pain center.

The study applied a retrospective follow-up design to determine the prognostic effect of graded exercise testing (GXT) in patients with low- to moderate-risk chest pain evaluated in an emergency department 9-hour protocol chest pain center (CPC) from January 1, 1993 to August 1, 1996. The cohort of 1,209 patients were followed to the date of death or first adverse cardiac event up to 1 year after CPC admission. Cardiac events were defined as coronary artery bypass graft, percutaneous transluminal coronary angioplasty, cardiogenic shock, cardiac-related death, congestive heart failure admission, ventricular tachycardia/ventricular fibrillation arrest, and myocardial infarction. Patients with acute ST-segment elevation or depression of >1 mm, positive enzyme (creatine kinase myocardial band) testing, or unstable angina during their CPC evaluation were admitted without GXT testing. Statistical analysis included chi-square test for complication rates and Cox proportional-hazards modeling. Nine hundred fifty-eight of 1,209 patients underwent GXT testing. Patients with positive, inconclusive, and normal GXTs had complication rates of 36.8% (7 of 19), 3.4% (9 of 267), and 1.1% (5 of 456), respectively. After adjusting for age, sex, and race, the relative risk of complication was 38.9 (95% confidence interval 11.7 to 129.6) with a positive GXT, and 3.6 (95% confidence interval 1.2 to 10.7) with an inconclusive GXT compared with a normal GXT. The GXT is a good prognostic indicator of adverse cardiac events in low- to moderate-risk chest pain in patients evaluated in an emergency department CPC.

Adolescent↗
PubMed2000

Evaluation of chest pain suspicious for acute coronary syndrome: use of an accelerated diagnostic protocol in a chest pain evaluation unit.

Management of patients presenting to the emergency department with chest pain suggestive of acute myocardial infarction (AMI) remains a continuing challenge. A low threshold for admission has been traditional because of concern for patient welfare and the litigation potential associated with the inadvertent discharge of patients with ischemic events. Because of this approach, < 30% of patients admitted for chest pain ultimately are found to have an acute coronary syndrome. To reduce unnecessary admissions, maintain patient safety, and enhance cost-effectiveness, innovative strategies have been applied to the management of patients with chest pain. It is now recognized that a low-risk group can be identified by the clinical presentation and initial electrocardiogram. Chest-pain centers have been developed to provide further risk stratification and systematic management of these patients. We employ an accelerated diagnostic protocol based on immediate exercise treadmill testing to evaluate low-risk patients. Moderate-risk patients are assessed over a 6-hour observation period with serial electrocardiograms and evaluation of cardiac-injury markers. Patients with positive evaluations are admitted. Those with negative results undergo either exercise echocardiography or rest myocardial perfusion imaging utilizing technetium-99m sestamibi. Patients with positive functional tests are admitted. Those with negative studies are discharged with outpatient follow-up. These strategies have provided a safe and accurate means of patient disposition from the emergency department with the potential for vital cost savings.

Algorithms↗
PubMed2000

Interpretation of immediate exercise treadmill test: interreader reliability between cardiologist and noncardiologist in a chest pain evaluation unit.

STUDY OBJECTIVE: To determine whether attending physicians in a chest pain evaluation unit (CPEU) can perform and interpret exercise testing with the same accuracy as cardiologists. METHODS: Between January 1996 and November 1998, immediate exercise tests were performed and interpreted by internists with additional training in exercise testing who serve as attending physicians in a CPEU at a large university medical center. For quality assurance, all tests were overread by a cardiologist. Test results were compared for each reader, and all tests with discrepant readings were reinterpreted by an independent cardiologist who was blinded to the previous results. Patients' clinical course was monitored for at least 30 days after exercise testing. RESULTS: The study group consisted of 645 patients (347 men, 298 women). Discrepant interpretations were found in 11 (1. 7%) patients. The agreement was 98.4% (kappa value 0.9618). The majority of discrepancies were insignificant and were based on subtle differences in the definition of a nondiagnostic test or the degree of ST-segment shift. Of the 11 discordant readings, the blinded cardiologist concurred with 5 (45%) of the CPEU interpretations and 4 (36%) of the cardiologist interpretations. In 2 cases, there was disagreement by all 3 interpreters. There was no cardiac morbidity or mortality of any patient with a discrepant reading. CONCLUSION: Our results suggest that noncardiologists serving as attending physicians in a CPEU can accurately interpret exercise tests and overreading by cardiologists for quality assurance is unnecessary.

Adult↗
PubMed1998

Measurement of cardiac troponin T is an effective method for predicting complications among emergency department patients with chest pain.

STUDY OBJECTIVES: To determine the test performance characteristics of serum cardiac troponin T (cTnT) measurement for diagnosis of acute myocardial infarction (AMI), and to determine the ability of cTnT to stratify emergency department patients with chest pain into high- and low-risk groups for cardiac complications. METHODS: We conducted a prospective observational cohort study with convenience sampling in a tertiary care, urban ED. The study sample comprised 667 patients presenting to the ED with a complaint of chest pain or other symptoms suggesting acute ischemic coronary syndrome (AICS). Patients were assigned to different blood sampling protocols for cTnT therapy on the basis of their ECG at presentation: nondiagnostic for AMI at 0, 3, 6, 9, 12, and 24 hours after ED presentation; or ECG diagnostic for AMI at 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 18, and 24 hours after ED presentation. RESULTS: Of 667 patients, 34 had AMI diagnosed within 24 hours of ED arrival. Using a .2 microgram/L discrimination level for cTnT, sensitivity for AMI within 24 hours of ED arrival was 97% (95% confidence interval, 91.4% to 99.9%), and specificity was 92% (89.8%-94.1%). When the effects of age, race, sex, and creatine kinase-MB isoenzyme subunit test results were controlled, a patient with cTnT of .2 microgram/L or greater was 3.5 (1.4 to 9.1) times more likely to have a cardiac complication within 60 days of ED arrival than a patient with a cTnT value below .2 microgram/L. CONCLUSION: Measurement of cTnT will accurately identify myocardial necrosis in patients presenting to the ED with possible AICS. Elevated cTnT values identify patients at increased risk of cardiac complications.

Adult↗