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Background: The European Society of Cardiology (ESC) 0/1-h high sensitivity troponin T (hs-cTnT) algorithm does not differentiate risk based on known coronary artery disease (CAD: prior myocardial infarction [MI], coronary revascularization, or ≥ 70% coronary stenosis). We recently evaluated its performance among patients with known CAD at 30-days, but little is known about its longer-term risk prediction. The objective of this study is to determine and compare the performance of the algorithm at 90-days among patients with and without known CAD., Methods: We performed a pre-planned subgroup analysis of the STOP-CP cohort, which prospectively enrolled ED patients ≥21 years old with symptoms suggestive of ACS without ST-elevation on initial ECG across 8 US sites (1/25/2017-9/6/2018). Participants with 0- and 1-h hs-cTnT measures (Roche, Basel, Switzerland) were stratified into rule-out, observe, and rule-in groups using the ESC 0/1-h algorithm. Algorithm performance was tested among patients with or without known CAD, as determined by the treating provider. The primary outcome was cardiac death or MI at 90-days. Fisher's exact tests were used to compare 90-day event and rule-out rates between patients with and without known CAD. Negative predictive values (NPVs) for 90-day cardiac death or MI with exact 95% confidence intervals were calculated and compared using Fisher's exact test., Results: The STOP-CP study accrued 1430 patients, of which 31.4% (449/1430) had known CAD. Cardiac death or MI at 90 days was more common in patients with known CAD than in those without [21.2% (95/449) vs. 10.0% (98/981); p < 0.001]. Using the ESC 0/1-h algorithm, 39.6% (178/449) of patients with known CAD and 66.1% (648/981) of patients without known CAD were ruled-out (p < 0.001). Among rule-out patients, 90-day cardiac death or MI occurred in 3.4% (6/178) of patients with known CAD and 1.2% (8/648) without known CAD (p = 0.09). NPV for 90-day cardiac death or MI was 96.6% (95%CI 92.8-98.8) among patients with known CAD and 98.8% (95%CI 97.6-99.5) in patients without known CAD (p = 0.09)., Conclusion: Patients with known CAD who were ruled-out using the ESC 0/1-h hs-cTnT algorithm had a high rate of missed 90-day cardiac events, suggesting that the ESC 0/1-h hs-cTnT algorithm may not be safe for use among patients with known CAD., Trial Registration: High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP; ClinicalTrials.gov: NCT02984436; https://clinicaltrials.gov/ct2/show/NCT02984436)., Competing Interests: Declaration of competing interest Dr. Ashburn receives funding from AHRQ (R01HS029017). Dr. Snavely receives funding from Abbott, HRSA (1H2ARH399760100), and AHRQ (R01HS029017). Dr. Stopyra receives research funding from HRSA (H2ARH39976–01-00), AHRQ (R01HS029017), AHRQ (1R21HS029234-01A1), The Duke Endowment, Roche Diagnostics, Abbott Laboratories, Pathfast, Genetesis, Cytovale, Forest Devices, Vifor Pharma, and Chiesi Farmaceutici. Dr. Mahler receives funding/support from Roche Diagnostics, Abbott Laboratories, QuidelOrtho, Siemens, Grifols, Pathfast, Beckman Coulter, Genetesis, Cytovale, The Duke Endowment, Brainbox, HRSA (1H2ARH399760100), and AHRQ (R01HS029017). He is a consultant for Roche, Quidel, Abbott, Siemens, Inflammatix, and Radiometer and is the Chief Medical Officer for Impathiq Inc. Dr. Allen receives research funding/support from RocheDiagnostics, Siemens, and Beckman Coulter. He is a consultant for Roche Diagnostics and Beckman Coulter. Dr. Mumma has research support from the NIH (5K08HL130546) and Roche Diagnostics. Dr. McCord receives research funding/support from Beckman Coulter, Roche Diagnostics, Abbott Laboratories, and Siemens. He is a consultant for Beckman Coulter, Roche Diagnostics, and Siemens. Dr. Wilkerson received research funding from Regeneron Pharmaceuticals, Inc., Lilly USA, LLC, BioAge Labs, Inc., Roche Diagnostics, Global Blood Therapeutics, Inc., Novartis Pharmaceuticals, Egetis Therapeutics AB, EndPoint Health, Inc., Blade Therapeutics, Janssen R&D LLC, ProvePharma, Beckton, Dickinson and Company, and Pfizer Inc. He has received research funding from CoapTech, LLC through an NIH/NIDDK grant (R44DK115325). He has received research support in the form of equipment and supplies from Cepheid and Eldon Biologicals A/S. He is an uncompensated advisor to CSL Behring. Dr. Christenson is a consultant for and receives funding/support from Roche Diagnostics, Siemens Healthineers, Beckman Coulter Diagnostics, Beckton Dickinson and Company, Quidel Corp., and Sphingotec GMBH. The other authors report no conflicts., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Hypercholesterolemia (HCL) is common among Emergency Department (ED) patients with chest pain but is typically not addressed in this setting. This study aims to determine whether a missed opportunity for Emergency Department Observation Unit (EDOU) HCL testing and treatment exists., Methods: We conducted a retrospective observational cohort study of patients ≥18 years old evaluated for chest pain in an EDOU from 3/1/2019-2/28/2020. The electronic health record was used to determine demographics and if HCL testing or treatment occurred. HCL was defined by self-report or clinician diagnosis. Proportions of patients receiving HCL testing or treatment at 1-year following their ED visit were calculated. HCL testing and treatment rates at 1-year were compared between white vs. non-white and male vs. female patients using multivariable logistic regression models including age, sex, and race., Results: Among 649 EDOU patients with chest pain, 55.8% (362/649) had known HCL. Among patients without known HCL, 5.9% (17/287, 95% CI 3.5-9.3%) had a lipid panel during their index ED/EDOU visit and 26.5% (76/287, 95% CI 21.5-32.0%) had a lipid panel within 1-year of their initial ED/EDOU visit. Among patients with known or newly diagnosed HCL, 54.0% (229/424, 95% CI 49.1-58.8%) were on treatment within 1-year. After adjustment, testing rates were similar among white vs. non-white patients (aOR 0.71, 95% CI 0.37-1.38) and men vs. women (aOR 1.32, 95% CI 0.69-2.57). Treatment rates were similar among white vs. non-white (aOR 0.74, 95% CI 0.53-1.03) and male vs. female (aOR 1.08, 95% CI 0.77-1.51) patients., Conclusions: Few patients were evaluated for HCL in the ED/EDOU or outpatient setting after their ED/EDOU encounter and only 54% of patients with HCL were on treatment during the 1-year follow-up period after the index ED/EDOU visit. These findings suggest a missed opportunity to reduce cardiovascular disease risk exists by evaluating and treating HCL in the ED or EDOU., Competing Interests: Declaration of Competing Interest Dr. Ashburn receives funding from NHLBI (T32HL076132). Dr. Snavely receives funding from Abbott and HRSA (1H2ARH399760100). Dr. Rikhi receives funding from NHLBI (T32HL076132). Dr. Shapiro has participated in scientific advisory boards with Amgen, Novartis, Ionis, Precision BioSciences and has served as a consultant for Regeneron, Ionis, Novartis, and EmendoBio. Dr. Stopyra receives research funding from NCATS/NIH (KL2TR001421), HRSA (H2ARH39976–01-00), Roche Diagnostics, Abbott Laboratories, Pathfast, Genetesis, Cytovale, Forest Devices, Vifor Pharma, and Chiesi Farmaceutici. Dr. Mahler receives funding/support from Roche Diagnostics, Abbott Laboratories, QuidelOrtho, Siemens, Grifols, Pathfast, Genetesis, Cytovale, and HRSA (1H2ARH399760100). He is a consultant for Roche, Abbott, Beckman Coulter, Siemens, Genetesis, Inflammatix, Radiometer, and Amgen and is the Chief Medical Officer for Impathiq Inc. The other authors report no conflicts., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Emergency Department Observation Unit (EDOU) patients with chest pain have a high prevalence of smoking, a key cardiovascular disease risk factor. While in the EDOU, there is an opportunity to initiate smoking cessation therapy (SCT), but this is not standard practice. This study aims to describe the missed opportunity for EDOU-initiated SCT by determining the proportion of smokers who receive SCT in the EDOU and within 1-year of EDOU discharge and to evaluate if SCT rates vary by race or sex., Methods: We performed an observational cohort study of patients ≥18 years old being evaluated for chest pain in a tertiary care center EDOU from 3/1/2019-2/28/2020. Demographics, smoking history, and SCT were determined by electronic health record review. Emergency, family medicine, internal medicine, and cardiology records were reviewed to determine if SCT occurred within 1-year of their initial visit. SCT was defined as behavioral interventions or pharmacotherapy. Rates of SCT in the EDOU, 1-year follow-up period, and the EDOU through 1-year of follow-up were calculated. SCT rates from the EDOU through 1-year were compared between white vs. non-white and male vs. female patients using a multivariable logistic regression model including age, sex, and race., Results: Among 649 EDOU patients, 24.0% (156/649) were smokers. These patients were 51.3% (80/156) female and 46.8% (73/156) white, with a mean age of 54.4 ± 10.5 years. From the EDOU encounter through 1-year of follow-up, only 33.3% (52/156) received SCT. In the EDOU, 16.0% (25/156) received SCT. During the 1-year follow-up period, 22.4% (35/156) had outpatient SCT. After adjusting for potential confounders, SCT rates from the EDOU through 1-year were similar among whites vs. non-whites (aOR 1.19, 95% CI 0.61-2.32) and males vs. females (aOR 0.79, 95% CI 0.40-1.56)., Conclusions: SCT was rarely initiated in the EDOU among chest pain patients who smoke and most patients who did not receive SCT in the EDOU never received SCT at 1-year of follow-up. Rates of SCT were similarly low among race and sex subgroups. These data suggest an opportunity exists to improve health by initiating SCT in the EDOU., Competing Interests: Conflicts of interest Dr. Ashburn receives funding from NHLBI (T32HL076132). Dr. Snavely receives funding from Abbott and HRSA (1H2ARH399760100). Dr. Rikhi receives funding from NHLBI (T32HL076132). Dr. Stopyra receives research funding from NCATS/NIH (KL2TR001421), HRSA (H2ARH39976-01-00), Roche Diagnostics, Abbott Laboratories, Pathfast, Genetesis, Cytovale, Forest Devices, Vifor Pharma, and Chiesi Farmaceutici. Dr. Mahler receives funding/support from Roche Diagnostics, Abbott Laboratories, Ortho Clinical Diagnostics, Siemens, Grifols, Pathfast, Quidel, Genetesis, Cytovale, and HRSA (1H2ARH399760100). He is a consultant for Roche, Quidel, Abbott, Genetesis, Inflammatix, Radiometer, and Amgen and is the Chief Medical Officer for Impathiq Inc. The other authors report no conflicts., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Delays in care for patients with acute cardiac complaints are associated with increased morbidity and mortality. The objective of this study was to quantify rural and urban differences in prehospital time intervals for patients with cardiac complaints., Methods: The ESO Data Collaborative dataset consisting of records from 1332 EMS agencies was queried for 9-1-1 encounters with acute cardiac problems among adults (age ≥ 18) from 1/1/2013-6/1/2018. Location was classified as rural or urban using the 2010 United States Census. The primary outcome was total prehospital time. Generalized estimating equations evaluated differences in the average times between rural and urban encounters while controlling for age, sex, race, transport mode, loaded mileage, and patient stability., Results: Among 428,054 encounters, the median age was 62 (IQR 50-75) years with 50.7% female, 75.3% white, and 10.3% rural. The median total prehospital, response, scene, and transport times were 37.0 (IQR 29.0-48.0), 6.0 (IQR 4.0-9.0), 16.0 (IQR 12.0-21.0), and 13.0 (IQR 8.0-21.0) minutes. Rural patients had an average total prehospital time that was 16.76 min (95%CI 15.15-18.38) longer than urban patients. After adjusting for covariates, average total time was 5.08 (95%CI 4.37-5.78) minutes longer for rural patients. Average response and transport time were 4.36 (95%CI 3.83-4.89) and 0.62 (95%CI 0.33-0.90) minutes longer for rural patients. Scene time was similar in rural and urban patients (0.09 min, 95%CI -0.15-0.33)., Conclusion: Rural patients with acute cardiac complaints experienced longer prehospital time than urban patients, even after accounting for other key variables, such as loaded mileage., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Expediting the measurement of serum troponin by leveraging EMS blood collection could reduce the diagnostic time for patients with acute chest pain and help address Emergency Department (ED) overcrowding. However, this practice has not been examined among an ED chest pain patient population in the United States., Methods: A prospective observational cohort study of adults with non-traumatic chest pain without ST-segment elevation myocardial infarction was conducted in three EMS agencies between 12/2016-4/2018. During transport, paramedics obtained a patient blood sample that was sent directly to the hospital core lab for troponin measurement. On ED arrival HEART Pathway assessments were completed by ED providers as part of standard care. ED providers were blinded to troponin results from EMS blood samples. To evaluate the potential impact on length of stay (LOS), the time difference between EMS blood draw and first clinical ED draw was calculated. To determine the safety of using troponin measures from EMS blood samples, the diagnostic performance of the HEART Pathway for 30-day major adverse cardiac events (MACE: composite of cardiac death, myocardial infarction (MI), coronary revascularization) was determined using EMS troponin plus arrival ED troponin and EMS troponin plus a serial 3-h ED troponin., Results: The use of EMS blood samples for troponin measures among 401 patients presenting with acute chest pain resulted in a mean potential reduction in LOS of 72.5 ± SD 35.7 min. MACE at 30 days occurred in 21.0% (84/401), with 1 cardiac death, 78 MIs, and 5 revascularizations without MI. Use of the HEART Pathway with EMS and ED arrival troponin measures yielded a NPV of 98.0% (95% CI: 89.6-100). NPV improved to 100% (95% CI: 92.9-100) when using the EMS and 3-h ED troponin measures., Conclusions: EMS blood collection used for core lab ED troponin measures could significantly reduce ED LOS and appears safe when integrated into the HEART Pathway., Competing Interests: Declaration of Competing Interest Dr. Stopyra receives research funding from NCATS/NIH (KL2TR001421), HRSA (H2ARH39976-01-00), NHLBI (U01HL123027), Roche Diagnostics and Abbott Point of Care. He has provided paid consulting to Roche Diagnostics. Dr. Snavely receives research funding from NHLBI (1 R01 HL118263-01) and HRSA (1 H2ARH399760100). Dr. Miller receives research funding/support from Siemens, Abbott Point of Care, Creavo Medical Technologies, Marcus Foundation, RTI International, Grifols, and NHLBI1 R01 HL118263. Dr. Mahler receives research funding from the Donaghue Foundation, Abbott Laboratories, Roche Diagnostics, Siemens, Ortho Clinical Diagnostics, Creavo Medical Technologies, PCORI, AHRQ, NHLBI (1 R01 HL118263-01) and HRSA (1 H2ARH399760100). He was a paid consultant for Roche Diagnostics and Amgen. Dr. Mahler is the Chief Medical Officer for Impathiq Inc., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The HEART Pathway identifies low-risk chest pain patients for discharge from the Emergency Department without stress testing. However, HEART Pathway recommendations are not always followed. The objective of this study is to determine the frequency and diagnostic yield of stress testing among low-risk patients., Methods: An academic hospital's chest pain registry was analyzed for low-risk HEART Pathway patients (HEAR score ≤ 3 with non-elevated troponins) from 1/2017 to 7/2018. Stress tests were reviewed for inducible ischemia. Diagnostic yield was defined as the rate of obstructive CAD among patients with positive stress testing. T-test or Fisher's exact test was used to test the univariate association of age, sex, race/ethnicity, and HEAR score with stress testing. Multivariate logistic regression was used to determine the association of age, sex, race/ethnicity, and HEAR score with stress testing., Results: There were 4743 HEART Pathway assessments, with 43.7% (2074/4743) being low-risk. Stress testing was performed on 4.1% (84/2074). Of the 84 low-risk patients who underwent testing, 8.3% (7/84) had non-diagnostic studies and 2.6% (2/84) had positive studies. Among the 2 patients with positive studies, angiography revealed that 1 had widely patent coronary arteries and the other had multivessel obstructive coronary artery disease, making the diagnostic yield of stress testing 1.2% (1/84). Each one-point increase in HEAR score (aOR 2.17, 95% CI 1.45-3.24) and being male (aOR 1.59, 95% CI 1.02-2.49) were associated with testing., Conclusions: Stress testing among low-risk HEART Pathway patients was uncommon, low yield, and more likely in males and those with a higher HEAR score., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: The HEART Pathway is a diagnostic protocol designed to identify low-risk patients presenting to the emergency department with chest pain that are safe for early discharge. This protocol has been shown to significantly decrease health care resource utilization compared with usual care. However, the impact of the HEART Pathway on the cost of care has yet to be reported., Methods and Results: We performed a cost analysis of patients enrolled in the HEART Pathway trial, which randomized participants to either usual care or the HEART Pathway protocol. For low-risk patients, the HEART Pathway recommended early discharge from the emergency department without further testing. We compared index visit cost, cost at 30 days, and cardiac-related health care cost at 30 days between the 2 treatment arms. Costs for each patient included facility and professional costs. Cost at 30 days included total inpatient and outpatient costs, including the index encounter, regardless of etiology. Cardiac-related health care cost at 30 days included the index encounter and costs adjudicated to be cardiac-related within that period. Two hundred seventy of the 282 patients enrolled in the trial had cost data available for analysis. There was a significant reduction in cost for the HEART Pathway group at 30 days (median cost savings of $216 per individual), which was most evident in low-risk (Thrombolysis In Myocardial Infarction score of 0-1) patients (median savings of $253 per patient) and driven primarily by lower cardiac diagnostic costs in the HEART Pathway group., Conclusions: Using the HEART Pathway as a decision aid for patients with undifferentiated chest pain resulted in significant cost savings., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The objective of the study was to determine if the short-axis approach and long-axis approach to ultrasound-guided peripheral intravenous access (USGPIV) differ in success rate, catheter insertion time, and number of needle sticks., Methods: A convenience sample of emergency department patients aged 18 to 65 years with difficult IV access (2 or more failed landmark attempts) was prospectively randomized to short-axis or long-axis USGPIV. Time from skin puncture to catheter insertion (insertion time) and number of needle sticks were recorded. Number of needle sticks and insertion time were compared using Mann-Whitney U tests., Results: Forty subjects were enrolled; 20 were randomized to the short-axis and 20 to the long-axis approach. Success rate was 95% (19/20; 95% confidence interval, 85%-100%) in the short-axis group compared with 85% (17/20; 95% confidence interval, 69%-100%) in the long-axis group. All 3 subjects with failed IV placement in the long-axis group had successful rescue USGPIV placement in short axis. Median insertion time was 34 seconds (interquartile range, 35 seconds) for the short-axis group compared with 91 seconds (interquartile range, 59 seconds) for the long-axis group (P = .02). Mean number of needle sticks was 1.5 (±SD 0.7) in the short-axis group compared with 1.4 (±SD 0.7) in the long-axis group (P = .82)., Conclusions: Short-axis USGPIV technique required less insertion time than the long-axis technique. Success rate was higher in the short-axis group, but this difference was not statistically significant. However, all of the failed IVs in the long axis were rescued successfully in short axis., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: The objective of the study was to determine if balanced electrolyte solution (BES) prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis (DKA)., Methods: This is a prospective, randomized, double-blind study. A convenience sample of DKA patients aged 18 to 65 years with serum bicarbonate less than or equal to 15 and anion gap greater than or equal to 16 was enrolled at "Louisiana State University Health Sciences Center-Shreveport" an capitalize Emergency Department over a 24-month period (2006-2008). Patients were randomized to standardized resuscitation with normal saline (NS) or BES (Plasma-Lyte A pH 7.4; Baxter International, Deerfield, IL). Every 2 hours, serum chloride and bicarbonate were measured until the patient's anion gap decreased to 12. An intention-to-treat analysis was performed on patients who met inclusion criteria and received at least 4 hours of study fluid. Chloride and bicarbonate measurements from the BES and NS groups were compared using unpaired and paired Student t tests., Results: Of 52 patients enrolled, 45 (22 in BES group and 23 in NS group) met inclusion criteria and received 4 hours of fluid. The mean postresuscitation chloride was 111 mmol/L (95% confidence interval [CI] = 110-112) in the NS group and 105 mmol/L (95% CI = 103-108) in the BES group (P ≤ .001). The mean postresuscitation bicarbonate was 17 mmol/L (95% CI = 15-18) in the NS group and 20 mmol/L (95% CI = 18-21) in the BES group (P = .020)., Conclusions: Resuscitation of DKA patients with BES results in lower serum chloride and higher bicarbonate levels than patients receiving NS, consistent with prevention of hyperchloremic metabolic acidosis., (Copyright © 2011 Elsevier Inc. All rights reserved.)