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We believe this is the first documented case of a critically ill patient managed by telepharmacy in a remote, rural critical access hospital. We outline the case and the benefits of telepharmacy in under-resourced, rural critical access emergency departments. [ABSTRACT FROM AUTHOR]

A reply by the authors is presented in response to letters to the editor on the article "A clinical trial of a chest-pain observation unit for patients with unstable angina," seen in the December 24, 1998 issue.

Background: Nearly half of patients hospitalized with unstable angina eventually receive a non–cardiac-related diagnosis, yet 5 percent of patients with myocardial infarction are inappropriately discharged from the emergency department. We evaluated the safety, efficacy, and cost of admission to a chest-pain observation unit (CPU) located in the emergency department for such patients. Methods: We performed a community-based, prospective, randomized trial of the safety, efficacy, and cost of admission to a CPU as compared with those of regular hospital admission for patients with unstable angina who were considered to be at intermediate risk for cardiovascular events in the short term. A total of 424 eligible patients were randomly assigned to routine hospital admission (a monitored bed under the care of the cardiology service) or admission to the CPU (where patients were cared for according to a strict protocol including aspirin, heparin, continuous ST-segment monitoring, determination of creatine kinase isoenzyme levels, six hours of observation, and a study of cardiac function). The CPU was managed by the emergency department staff. Patients whose test results were negative were discharged, and the others were hospitalized. Primary outcomes (nonfatal myocardial infarction, death, acute congestive heart failure, stroke, or out-of-hospital cardiac arrest) and use of resources were compared between the two groups. Results: The 212 patients in the hospital-admission group had 15 primary events (13 myocardial infarctions and 2 cases of congestive heart failure), and the 212 patients in the CPU group had 7 events (5 myocardial infarctions, 1 death from cardiovascular causes, and 1 case of congestive heart failure). There was no significant difference in the rate of cardiac events between the two groups (odds ratio for the CPU group as compared with the hospital-admission group, 0.50; 95 percent confidence interval, 0.20 to 1.24). No primary events occurred among the 97 patients who were assigned to the CPU and discharged. Resource use during the first six months was greater among patients assigned to hospital admission than among those assigned to the CPU (P=0.003 by the rank-sum test). Conclusions: A CPU located in the emergency department can be a safe, effective, and cost-saving means of ensuring that patients with unstable angina who are considered to be at intermediate risk of cardiovascular events receive appropriate care. (N Engl J Med 1998;339:1882-8.) [ABSTRACT FROM AUTHOR]

Long-term outcomes of unselected patients with angina pectoris and bundle branch block (BBB) on initial electrocardiogram are not well established. The Olmsted County Chest Pain Study is a community-based cohort of 2,271 consecutive patients presenting to 3 Olmsted County emergency departments with angina from 1985 through 1992. Patients were followed for major adverse cardiovascular events (MACEs) including death, myocardial infarction, stroke, and revascularization at 30 days and over a median follow-up period of 7.3 years and for mortality only through a median of 16.6 years. Cox models were used to estimate associations between BBB and cardiovascular outcomes. Mean age of the cohort on presentation was 63 years, and 58% were men. MACEs at 30 days occurred in 11% with right BBB (RBBB), 8.8% with left BBB (LBBB), and 6.4% in patients without BBB (p = 0.17). Over a median follow-up of 7.3 years, patients with BBB were at higher risk for MACEs (RBBB, hazard ratio [HR] 1.85, 95% confidence interval [CI] 1.44 to 2.38, p <0.001; LBBB, HR 2.04, 95% CI 1.62 to 2.56, p <0.001) compared to those without BBB. Over a median of 16.6 years, the 2 BBB groups had lower survival rates than patients without BBB (RBBB, HR 2.19, 95% CI 1.73 to 2.78, p <0.001; LBBB, HR 3.32, 95% CI 2.67 to 4.13, p ≤0.001), but after adjustment for multiple risk factors an increased risk of mortality for LBBB remained significant. In conclusion, appearance of LBBB or RBBB in patients presenting with angina predicts adverse long-term cardiovascular outcomes compared to patients without BBB. [ABSTRACT FROM AUTHOR]

The objective of this study was to determine short- and long-term cardiovascular outcomes in unselected patients with diabetes mellitus (DM) with acute ischemic chest pain (AICP). In patients with DM presenting to the emergency department with AICP, short-term cardiovascular outcomes remain discordant between trials and registries, whereas long-term outcomes are not well-described. A consecutive cohort of all residents of Olmsted County, Minnesota, presenting with AICP from January 1, 1985, to December 31, 1992, was followed for a median duration of 16.6 years. The primary outcome was long-term all-cause mortality. Other outcomes included a composite of death, myocardial infarction, stroke, and revascularization (major adverse cardiovascular and cerebrovascular events [MACCEs]) as well as heart failure (HF) events at 30 days and at a median of 7.3 years, respectively. Of the 2,271 eligible patients, 336 (14.8%) were classified with DM. The crude 30-day MACCE rate was 10.1% in patients with DM and 6.1% in those without DM (p = 0.007). HF events were more common in patients with DM at 30 days (9.8% vs 3.1%, p <0.001). At 7.3 years, patients with DM were more likely to experience MACCEs and HF events than those without DM (71.2% vs 45.1%, unadjusted hazard ratio 2.15%, 95% confidence interval 1.87 to 2.48, p <0.001, and 45.1% vs 18.2%, p <0.001, respectively). Over the follow-up period, 272 patients with DM (81.9%) died, compared with 936 (49.2%) without DM (p <0.001). In conclusion, DM is associated with a higher short-term risk for MACCEs and HF and a higher long-term risk for mortality in unselected patients with AICP. DM should be included as a high-risk variable in national acute coronary syndrome guidelines. [Copyright &y& Elsevier]

Background: Early diagnosis of ischemia is complicated by the poor sensitivity of standard tests and contraindication for stress testing in unstable angina patients. Magnetocardiography (MCG) imaging can be used for the rapid, non-invasive detection of ischemia at rest. Methods: We studied 125 patients with presumed ischemic chest pain. All were chest pain free at the time of scanning. A 6-minute resting MCG scan (CardioMag Imaging, Inc., New York, 9-channel system) was performed. Following the MCG scan, automated software data analysis was performed, and quantitative scores were automatically calculated for each subject. The presence of ischemia was determined after testing with serial troponins, stress testing, and/or coronary angiography. Results: The mean age was 59.4 ± 13.6 years. Most patients (86.4%) had non-ischemic 12-lead ECG and normal troponin (86.2%). Fifty-five patients (44.0%) were determined to be ischemic. The MCG sensitivity, specificity, positive and negative predictive value was 76.4, 74.3, 70.0 and 80.0%, respectively, for the detection of ischemia (p < 0.0001). Conclusions: MCG is a new rapid, non-invasive imaging tool able to detect repolarization abnormalities at rest consistent with ischemia in patients presenting with chest pain syndrome and normal or non-specific 12-lead ECG and normal troponin. Copyright © 2006 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine whether stress imaging for patients who are unsuitable for exercise treadmill testing (ETT) as part of a chest pain unit (CPU) triage strategy resulted in incremental benefit in clinical outcomes and relative costs compared with patients randomized to routine hospital admission. PATIENTS AND METHODS: Clinical outcomes and medical resource utilization were examined at the Mayo Clinic in Rochester, Minn, for 212 Intermediate-risk patients with unstable angina randomized to a CPU and compared with 212 patients randomized to routine admission from November 21, 1995, to March 18,1997. Patients In stable condition in the CPU underwent ETT; if patients were unsuitable for ETT, stress imaging was performed. Costs for CPU evaluation and outcomes were assessed during a &-month follow-up. RESULTS: During the observation period, 60 patients (28%) were admitted to the hospital. Of the 152 remaining patients, 125 (82%) underwent ETT (91 had normal results), and 27 (18%) underwent stress imaging (3 had normal results). Patients with normal ETT or stress imaging results had no primary events at 6-month follow-up. Patients admitted to the hospital who underwent stress imaging had an insignificantly higher 6-month event rate compared with patients who underwent ETT (16.7% vs 8.1%; P=.38). The standardized resource-based relative-value units (RBRVUs) for patients who underwent ETT and stress Imaging during follow-up were 19.4 and 56.4 RBRVUs, respectively, compared with 51.4 (ETT) and 52.1 (stress imaging) RBRVUs for similar numbers of patients randomized to routine admission. CONCLUSIONS: Exercise treadmill testing safety stratified most Intermediate-risk patients with unstable angina and was less costly than routine admission. Patients not suitable for ETT are likely to have abnormal stress Imaging results. They represent a higher-risk cohort that could be routinely admitted to the hospital without reducing the effectiveness of the CPU strategy. [ABSTRACT FROM AUTHOR]