Biomedical subjects

Deborah Diercks

Publications and source records attributed to Deborah Diercks.

7 recordsLinked to original sources

PubMed2006

The Internet Tracking Registry of Acute Coronary Syndromes (i*trACS): a multicenter registry of patients with suspicion of acute coronary syndromes reported using the standardized reporting guidelines for emergency department chest pain studies.

STUDY OBJECTIVE: Observational studies of well-described patient populations presenting to emergency departments (EDs) with suspicion of acute coronary syndrome are necessary to understand the relationships between patients' signs and symptoms, cardiac risk profile, test results, practice patterns, and outcomes. We describe the methods for data collection and the ED population enrolled in a multicenter registry of patients with chest pain. METHODS: Patients older than 18 years, presenting to one of 8 EDs in the United States or 1 ED in Singapore, and with possible acute coronary syndrome were enrolled in the Internet Tracking Registry of Acute Coronary Syndromes between June 1999 and August 2001. Prospective data, including presenting signs and symptoms, ECG findings, and the ED physician's initial impression of risk, were systematically collected. Medical record review or daily follow-up was used to obtain cardiac biomarker results, invasive and noninvasive testing, treatments, procedures, and inhospital outcomes. Thirty-day outcomes were determined by telephone follow-up and medical record review. RESULTS: The registry includes 15,608 patients, with 17,713 visits. Chest pain was the chief complaint in 71% of visits. The ECG was diagnostic of ischemia or infarction in 10.1% and positive cardiac biomarkers were observed in 10% of visits. Forty-three percent of patients were sent home directly from the ED. Of admitted patients, 5% died by 30 days, and 3% had documented coronary artery disease or had undergone percutaneous coronary intervention or coronary artery bypass grafting within 30 days. For patients discharged directly from the ED, 0.4% died or had a documented myocardial infarction within 30 days. Coronary artery bypass graft surgery, percutaneous coronary intervention, or a diagnosis of coronary artery disease was found in 0.5% of discharged patients. CONCLUSION: A unique description of undifferentiated ED chest pain patients with suspected acute coronary syndrome is provided. The data set can be used to generate and explore hypotheses to improve understanding of the complex relationships between presentation, treatment, testing, intervention and outcomes.

Biomarkers↗

PubMed2006

Prospective multicenter study of quantitative pretest probability assessment to exclude acute coronary syndrome for patients evaluated in emergency department chest pain units.

STUDY OBJECTIVE: We compare the diagnostic accuracy of 3 methods--attribute matching, physician's written unstructured estimate, and a logistic regression formula (Acute Coronary Insufficiency-Time Insensitive Predictive Instrument, ACI-TIPI)--of estimating a very low pretest probability (< or = 2%) for acute coronary syndromes in emergency department (ED) patients evaluated in chest pain units. METHODS: We prospectively studied 1,114 consecutive patients from 3 academic EDs, evaluated for acute coronary syndrome. Physicians collected data required for pretest probability assessment before protocol-driven chest pain unit testing. A pretest probability greater than 2% was considered "test positive." The criterion standard was the outcome of acute coronary syndrome (death, myocardial infarction, revascularization, or > 60% stenosis prompting new treatment) within 45 days, adjudicated by 3 independent reviewers. RESULTS: Fifty-one of 1,114 enrolled patients (4.5%; 95% confidence interval [CI] 3.4% to 6.0%) developed acute coronary syndrome within 45 days, including 4 of 991 (0.4%; 95% CI 0.1% to 1.0%) patients, discharged after a negative chest pain unit evaluation result, who developed acute coronary syndrome. Unstructured estimate identified 293 patients with pretest probability less than or equal to 2%, 2 had acute coronary syndrome, yielding sensitivity of 96.1% (95% CI 86.5% to 99.5%) and specificity of 27.4% (95% CI 24.7% to 30.2%). Attribute matching identified 304 patients with pretest probability less than or equal to 2%; 1 had acute coronary syndrome, yielding a sensitivity of 98.0% (95% CI 89.6% to 99.9%) and a specificity of 26.1% (95% CI 23.6% to 28.7%). ACI-TIPI identified 56 patients; none had acute coronary syndrome, yielding sensitivity of 100% (95% CI 93.0% to 100%) and specificity of 6.1% (95% CI 4.7% to 7.9%). CONCLUSION: In a low-risk ED population with symptoms suggestive of acute coronary syndrome, patients with a quantitative pretest probability less than or equal to 2%, determined by attribute matching, unstructured estimate, or logistic regression, may not require additional diagnostic testing.

Acute Disease↗

PubMed2005

Heart failure observation units: optimizing care.

Heart failure causes substantial morbidity and mortality in the United States and accounts for a higher proportion of Medicare costs than any other disease. Most of these costs result from the high rate of hospital admissions and protracted length of stay associated with episodes of acute decompensation of heart failure. Thus, effective clinical strategies to obviate hospitalization and readmission can result in substantial savings. A specialized heart failure observation unit, in which patients receive rapid, goal-directed emergency care for heart failure symptoms, can be a critical component in this effort, providing intensive therapeutic monitoring and education. In institutions with specialized heart failure observation units, patients are triaged to this setting shortly after presentation to the emergency department (ED), and clinic referrals can be directed to this unit after minimal ED evaluation. Aggressive follow-up is also arranged at discharge. Recent additions to the therapeutic armamentarium and future advances in diagnostics and monitoring will continue to improve patient care and prevent avoidable hospitalizations.

Coronary Care Units↗

PubMed2005

Influence of timing of troponin elevation on clinical outcomes and use of evidence-based therapies for patients with non-ST-segment elevation acute coronary syndromes.

STUDY OBJECTIVE: Previous studies in clinical trial populations have demonstrated that patients presenting with positive troponin levels have a higher risk of mortality than patients with later positive troponin levels, but the influence of the timing of troponin elevation has not been previously characterized. We evaluate the impact of the timing of troponin elevation on clinical outcomes and adherence to the American College of Cardiology/American Heart Association acute care guidelines for patients with non-ST-segment elevation acute coronary syndromes. METHODS: We examined inhospital outcomes and use of acute (<24 hours) medications and invasive cardiac procedures in 23,184 high-risk patients with non-ST-segment elevation acute coronary syndromes (positive cardiac markers or ischemic ST-segment changes) during 2001 to 2002 from 396 US hospitals participating in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) Initiative. Baseline and peak troponin values were recorded and were designated as positive if above the cutoff value used at each institution to designate definite myocardial necrosis. RESULTS: In the study cohort, 53.2% of patients presented with baseline positive troponin levels, 30.6% had baseline negative/later positive troponin levels, and 16.2% had negative troponin levels during the entire hospitalization. Patients with baseline positive troponin levels had a higher risk of inhospital mortality than patients with baseline negative/later positive troponin levels (6.5% versus 4.1%) and were less likely to undergo early cardiac catheterization or percutaneous coronary intervention. The use of acute aspirin (in approximately 91% of patients), heparin (85%), and beta-blockers (78%) was similar in patients with baseline-positive versus later-positive troponin levels. CONCLUSION: These findings demonstrate that evidence-based therapies and interventions for non-ST-segment elevation acute coronary syndromes are underused in patients with elevated troponin levels, but baseline troponin elevations, which are associated with a higher risk of inhospital mortality, do not stimulate more aggressive care.

Acute Disease↗

PubMed2003

The impact of race on the acute management of chest pain.

OBJECTIVES: African Americans with acute coronary syndromes receive cardiac catheterization less frequently than whites. The objective was to determine if such disparities extend to acute evaluation and non interventional treatment. METHODS: Data on adults with chest pain (N = 7,935) presenting to eight emergency departments (EDs) were evaluated from the Internet Tracking Registry of Acute Coronary Syndromes. Groups were selected from final ED diagnosis: 1) acute myocardial infarction (AMI), n = 400; 2) unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI), n = 1,153; and 3) nonacute coronary syndrome chest pain (non-ACS CP), n = 6,382. American College of Cardiology/American Heart Association guidelines for AMI and UA/NSTEMI were used to evaluate racial disparities with logistic regression models. Odds ratios (ORs) were adjusted for age, gender, guideline publication, and insurance status. Non-ACS CP patients were assessed by comparing electrocardiographic (ECG)/laboratory evaluation, medical treatment, admission rates, and invasive and noninvasive testing for coronary artery disease (CAD). RESULTS: African Americans with UA/NSTEMI received glycoprotein IIb/IIIa receptor inhibitors less often than whites (OR, 0.41; 95% CI = 0.19 to 0.91). African Americans with non-ACS CP underwent ECG/laboratory evaluation, medical treatment, and invasive and noninvasive testing for CAD less often than whites (p < 0.05). Other nonwhites with non-ACS CP were admitted and received invasive testing for CAD less often than whites (p < 0.01). African Americans and other nonwhites with AMI underwent catheterization less frequently than whites (OR, 0.45; 95% CI = 0.29 to 0.71 and OR, 0.40; 95% CI = 0.17 to 0.92, respectively). A similar disparity in catheterization was noted in UA/NSTEMI therapy (OR, 0.53; 95% CI = 0.40 to 0.68 and OR, 0.68; 95% CI = 0.47 to 0.99). CONCLUSIONS: Racial disparities in acute chest pain management extend beyond cardiac catheterization. Poor compliance with recommended treatments for ACS may be an explanation.

Black or African American↗

PubMed2002

Reducing the knowledge-practice gap in the management of patients with cardiovascular disease.

Despite major progress in the development of effective therapy to reduce mortality and morbidity from cardiovascular disease, it remains the leading cause of mortality in this country. One aspect of this problem is represented by the lag in adoption of treatments with documented efficacy in large clinical trials. This "knowledge-practice gap" has been attributed to factors at multiple levels of the health care system that impede implementation of optimal therapy. Although there is evidence of progress in the use of recommended therapeutic modalities in the past decade, this has been modest. Recent approaches to assessment of patient care by physicians, health plans, and institutions through the tracking of clinical performance have been instituted to promote optimal patient care. They are being increasingly utilized for purposes of accreditation and will also provide guidance for consumer purchasing of health care. Such methods have the potential to promote increased adherence to current standards of care.

Cardiovascular Diseases↗

PubMedDate not supplied

Management of acute decompensated heart failure in the emergency department.

Heart failure, a disease of epidemic proportions, has a tremendous clinical and financial impact on the US health care system. With more than 5 million Americans diagnosed with heart failure and 5-year mortality approaching 50%, it is the most common cause of hospitalization in patients older than 65 years and is the single most expensive diagnosis in the US health care system. Because the average US hospital loses more than 1000 dollars per heart failure admission, effective therapies that decrease length of stay, reduce hospital costs, and prevent 30-day readmissions are needed. This article reviews the relevant pathophysiology of heart failure, discusses the newest diagnostic strategies for emergency department diagnoses, evaluates recent advances and effects of early aggressive therapies, and presents a suggested algorithm for the treatment of acutely decompensated heart failure in emergency departments.

Aged↗