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Point-of-care ultrasonography is increasingly being used to facilitate accurate abstract and timely diagnoses and to guide procedures. It is important for pediatric emergency medicine (PEM) physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. PEM fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for PEM physicians.

The management of patients with chest pain is a common and challenging clinical problem. Although most of these patients do not have a life-threatening condition, the clinician must distinguish between those who require urgent management of a serious problem such as acute coronary syndrome (ACS) and those with more benign entities who do not require admission. Although clinical judgment continues to be paramount in meeting this challenge, new diagnostic modalities have been developed to assist in risk stratification. These include markers of cardiac injury, risk scores, early stress testing, and noninvasive imaging of the heart. The basic clinical tools of history, physical examination, and electrocardiography are currently widely acknowledged to allow early identification of low-risk patients who have less than 5% probability of ACS. These patients are usually initially managed in the emergency department and transitioned to further outpatient evaluation or chest pain units. Multiple imaging strategies have been investigated to accelerate diagnosis and to provide further risk stratification of patients with no initial evidence of ACS. These include rest myocardial perfusion imaging, rest echocardiography, computed tomographic coronary angiography, and cardiac magnetic resonance imaging. All have very high negative predictive values for excluding ACS and have been successful in reducing unnecessary admissions for patients at low to intermediate risk of ACS. As patients with acute chest pain transition from the evaluation in the emergency department to other outpatient settings, it is important that all clinicians involved in the care of these patients understand the tools used for assessment and risk stratification. [ABSTRACT FROM AUTHOR]

OBJECTIVES: It has been reported that the mortality risk for heart failure differs between men and women. It has been postulated that this is due to differences in comorbid features. Variation in risk profiles by gender may limit the performance of stratification algorithms available for heart failure in women. This analysis examined the ability of a published risk stratification model to predict outcomes in women. METHODS: The Acute Decompensated Heart Failure National Registry Emergency Module (ADHERE-EM) database was used. Characteristics, treatments, and outcomes for men and women were compared. The ADHERE registry classification and regression tree (CART) analysis was used for the risk stratification evaluation. RESULTS: Of 10,984 ADHERE-EM patients, 5,736 (52.2%) were women. In-hospital mortality was similar between men and women (p = 0.727). Significant differences (p < 0.0002) were noted by gender in all three variables in the CART model (blood urea nitrogen [BUN] > or = 43 mg/dL, systolic blood pressure < 115 mm Hg, and serum creatinine > or = 2.75 mg/dL). However, the CART model effectively stratified both genders into distinct risk groups with no significant difference in mortality by gender within stratified groups. CONCLUSIONS: The ADHERE Registry CART tool is effective at predicting risk in ED patients, regardless of gender. [ABSTRACT FROM AUTHOR]

The majority of heart failure hospitalizations in the United States originate in the emergency department (ED). Current strategies for acute heart failure syndromes have largely been tailored after chronic heart failure guidelines and care. Prospective ED-based acute heart failure syndrome trials are lacking, and current guidelines for disposition are based on either little or no evidence. As a result, the majority of ED acute heart failure syndrome patients are admitted to the hospital. Recent registry data suggest there is a significant amount of heterogeneity in acute heart failure syndrome ED presentations, and diagnostics and therapeutics may need to be individualized to the urgency of the presentation, underlying pathophysiology, and acute hemodynamic characteristics. A paradigm shift is necessary in acute heart failure syndrome guidelines and research: prospective trials need to focus on diagnostic, therapeutic, and risk-stratification algorithms that rely on readily available ED data, focusing on outcomes more proximate to the ED visit (5 days). Intermediate outcomes (30 days) are more dependent on inpatient and outpatient care and patient behavior than ED management decisions. Without these changes, the burden of acute heart failure syndrome care is unlikely to change. This article proposes such a paradigm shift in acute heart failure syndrome care and discusses areas of further research that are necessary to promote this change in approach. [ABSTRACT FROM AUTHOR]

STUDY OBJECTIVE: We evaluate the association of emergency department (ED) length of stay with use of guideline-recommended therapies for acute treatments and clinical outcomes. Prolonged ED stays often reflect ED crowding or limited hospital capacity. We hypothesized that patients with non-ST-segment-elevation myocardial infarction who have ED stays of greater than 8 hours may have lower quality of care and worse outcomes. METHODS: Using a secondary analysis of data from an observational registry (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines, CRUSADE), we compared rates of use of 5 individual acute (<24 hours) guideline-recommended therapies in patients with non-ST-segment-elevation myocardial infarction according to ED length of stay. Patients were grouped by length of stay (short [<4 hours], average [4 to 8 hours], or long [>8 hours]). Multivariable analyses were used to determine independent association of ED length of stay with acute medications and inhospital outcomes (death and myocardial infarction). RESULTS: This analysis included 42,780 patients with non-ST-segment-elevation myocardial infarction. The median ED length of stay was 4.3 hours (25th to 75th percentile 2.9, 6.3); 15% of patients stayed longer than 8 hours. Patients who had long ED stays were more likely to be women and nonwhite and less likely to have health maintenance organization or private insurance. After adjustment, patients with long ED stays less often received guideline-recommended acute myocardial infarction therapies. Although risk-adjusted inhospital mortality rates were similar among groups, the rate of recurrent myocardial infarction increased among patients with long ED stays (odds ratio 1.23; 95% confidence interval 1.01 to 1.48) compared with those with average ED length of stay. CONCLUSION: For patients with non-ST-segment-elevation myocardial infarction, long ED stays were associated with decreased use of guideline-recommended therapies and a higher risk of recurrent myocardial infarction. However, there was no observed difference in mortality. Factors associated with prolonged ED length of stay should be evaluated to optimize treatments and outcomes of patients with non-ST-segment-elevation myocardial infarction. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To identify factors that define a low-risk cohort of patients with acute decompensated heart failure who are suitable for management in an observation unit. METHODS: Prospective convenience sample of 538 patients who presented to an ED with a diagnosis of congestive heart failure. Observation unit appropriate was defined as a length of stay less than 24 hours and no adverse events (myocardial infarction, death, arrhythmia, or rehospitalization) during the 30-day follow-up period. RESULTS: Study criteria were met by 499 patients (mean age, 61 +/- 15 years), and 234 (47%) were women. Of these, 133 (27%) met the criteria for observation unit appropriateness. Independent predictors were systolic blood pressure of greater than 160 (odds ratio, 1.8; 95% confidence interval, 1.15-2.7) and normal troponin I (odds ratio, 14.7; 95% confidence interval, 1.9-105). CONCLUSION: Initial blood pressure and troponin I can help identify patients with congestive heart failure at low risk for prolonged hospitalization and adverse events and who are reasonable candidates for observation unit management. © 2006 Elsevier Inc. All rights reserved. [ABSTRACT FROM AUTHOR]

The American College of Cardiology and the American Heart Association last published evidence-based guidelines for the management of ST-segment elevation myocardial infarction (STEMI) in 1999. In mid-2004, in recognition of the evolution and improvement of many of the most basic tenets of clinical management of STEMI since that time, an updated edition of the STEMI guidelines has been published. These guidelines offer many evidence-based recommendations that are pertinent to the out-of-hospital and emergency department care of STEMI patients, including initial evaluation, risk stratification, stabilizing management, and the choice between pharmacologic and mechanical revascularization. These are presented and discussed here. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objectives: Our purpose was to determine the safety and accuracy of immediate exercise testing in low-risk patients presenting to the emergency department (ED) with chest pain suggestive of a cardiac etiology.Background: Safe, efficient management of low-risk patients presenting to the ED with chest pain is a continuing challenge. We have employed immediate exercise testing to evaluate a large, heterogeneous group of low-risk patients presenting with chest pain.Methods: Patients presenting to the ED with chest pain compatible with a cardiac origin and clinical evidence of low risk on initial assessment underwent immediate exercise treadmill testing in our chest pain evaluation unit. Indicators of low clinical risk included no evidence of hemodynamic instability, arrhythmias or electrocardiographic signs of ischemia. Serial measurements of cardiac injury markers were not obtained.Results: Exercise testing was performed to a sign- or symptom-limited end point in 1,000 patients (520 men, 480 women; age range 31 to 82 years) and was positive for ischemia in 13%, negative in 64% and nondiagnostic in 23% of patients. There were no adverse effects of exercise testing, and all patients with a negative exercise test were discharged directly from the ED. At 30-day follow-up there was no mortality in any of the three groups. Cardiac events in the three groups included: negative group, 1 non-Q-wave myocardial infarction (MI); positive group, 4 non-Q-wave MIs and 12 myocardial revascularizations; nondiagnostic group, 7 myocardial revascularizations.Background: Immediate exercise testing of patients presenting to the ED with chest pain and evidence of low clinical risk is safe and accurate for determining those who require admission and those who can be discharged to further outpatient evaluation. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to assess the impact of extreme (class III) obesity (body mass index [BMI] ≥40 kg/m(2)) on care and outcomes in patients with ST-segment elevation myocardial infarction (STEMI).Background: Although its prevalence is increasing rapidly, little is known about the impact of extreme obesity on STEMI presentation, treatments, complication rates, and outcomes.Methods: The relationship between BMI and baseline characteristics, treatment patterns, and risk-adjusted in-hospital outcomes was quantified for 50,149 patients with STEMI from the National Cardiovascular Data Registry (NCDR) ACTION Registry-GWTG.Results: The proportions of patients with STEMI by BMI category were as follows: underweight (BMI <18.5 kg/m(2)) 1.6%, normal weight (18.5 kg/m(2) ≤BMI <25 kg/m(2)) 23.5%, overweight (25 kg/m(2) ≤BMI <30 kg/m(2)) 38.7%, class I obese (30 kg/m(2) ≤BMI <35 kg/m(2)) 22.4%, class II obese (35 kg/m(2) ≤BMI <40 kg/m(2)) 8.7%, and class III obese 5.1%. Extreme obesity was associated with younger age at STEMI presentation (median age 55 years for class III obese vs. 66 years for normal weight); a higher prevalence of diabetes, hypertension, and dyslipidemia; a lower prevalence of smoking; and less extensive coronary artery disease and higher left ventricular ejection fraction. Process-of-care measures were similar across BMI categories, including the extremely obese. Using class I obesity as the referent, risk-adjusted in-hospital mortality rates were significantly higher only for class III obese patients (adjusted odds ratio: 1.64; 95% confidence interval: 1.32 to 2.03).Conclusions: Patients with extreme obesity present with STEMI at younger ages and have less extensive coronary artery disease, better left ventricular systolic function, and similar processes and quality of care. Despite these advantages, extreme obesity remains independently associated with higher in-hospital mortality. [ABSTRACT FROM AUTHOR]

We evaluated the reported contraindications to early beta-blocker use and associated mortality within and across patient age groups. Contraindications to early beta-blocker use were evaluated in patients with non-ST-elevation acute coronary syndrome 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 from February 2003 to December 2006. The prevalence, reasons, and trends in the contraindications were evaluated by age (or=75 years). The associations between the reported contraindications and in-hospital mortality were determined within and compared across age groups using the logistic generalized estimating equations method, adjusting for baseline patient characteristics. Of 112,448 patients, 11,711 (10.4%) had a reported contraindication to early beta-blocker use. The prevalence varied by age (or=75, 13.4%; p <0.0001). No significant changes were seen over time, except for a small increase in patients 40 patients in the registry, the median hospital level rate of reported contraindications was 9.9% (interquartile range 6.7% to 14.3%). The distribution of rates was more widespread among the hospitals' older versus younger patients. In all age groups, a statistically significant greater association was found with in-hospital mortality in those with reported contraindications versus those without contraindications who received a beta blocker (adjusted odds ratio 2.81, 95% confidence interval 2.28 to 3.46; adjusted odds ratio 2.50, 95% confidence interval 2.07 to 3.03; adjusted odds ratio 2.11, 95% confidence interval 1.88 to 2.37, for ages or=75 years, respectively). The strength of the association was similar across all age groups (interaction p = 0.19). The reported contraindications to early beta-blocker use were common and increased with age. The contraindications were independently associated with greater in-hospital mortality, underscoring the importance of accurately identifying contraindications. In conclusion, the results did not indicate any disparity in reporting the contraindications according to patient age. [ABSTRACT FROM AUTHOR]

Purpose: High-sensitivity cardiac troponin I (hs-cTnI) and T (hs-cTnT) have been demonstrated to have lower sex-specific 99th percentiles in healthy females. However, these sex-specific thresholds are not widely adopted in clinical practice which could lead to underdiagnosis of acute myocardial infarction in females. We conducted a systematic review to explore sex-specific 99th percentiles for hs-cTnI and hs-cTnT from healthy reference populations., Methods: The principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to complete this systematic review. We used PubMed and OVID EMBASE to search for original studies published between November 2017 and November 2021 that included reference populations used to establish the 99th percentiles of hs-cTnI and hs-cTnT with the following inclusion criteria: adults; English language; samples taken as part of a healthy, reference population; studies using high-sensitivity troponin assay; and sample size > 300. Studies were excluded if the reference population sample size was < 300, if a conventional troponin assay was used, or if they did not include independently derived, sex-specific 99th percentiles. Data was extracted from the studies through Covidence to perform a qualitative data synthesis. Female-specific, male-specific, and overall 99th percentiles for hs-cTn were compared., Findings: We reviewed 131 articles of which 19 met inclusion criteria. These 19 studies derived sex-specific 99th percentiles for 11 different hs-cTnI assays and 9 different hs-cTnT assays. More than 90% (13 of 14 studies) of hs-cTnI assays found lower female 99th percentiles compared to male and to overall 99th percentiles. One study included nine different hs-cTnI assays, of which only one assay resulted in a higher female 99th percentile compared to male and to overall 99th percentiles. Eight of nine hs-cTnT studies (88.9%) found lower female 99th percentiles compared to male and to overall 99th percentiles., Implications: The data shows significantly lower 99th percentiles in females compared to 99th percentiles in males and overall. Incorporating these sex-specific 99th percentile cut-offs into clinical practice could lead to increased diagnosis and potentially better outcomes for females presenting with acute myocardial infarction., Competing Interests: Declaration of competing interest None declared., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: We evaluated the Vitros® Immunodiagnostic Products N-terminal pro B-type natriuretic peptide (NT-proBNP) II assay for aiding in diagnosis of heart failure (HF) in patients with acute dyspnea., Methods: Serum concentrations of NT-proBNP were measured in patient samples from 20 emergency departments across the United States. Study endpoints included sensitivity, specificity, likelihood ratios, and predictive values for diagnosis of acute HF according to age-stratified cutoffs (450, 900, and 1800 pg/mL), and a rule-out age-independent cutoff (300 pg/mL). Additional measures were area under the curve (AUC) for receiver operating characteristic (ROC) curves. Results were also interpreted in patient subgroups with relevant comorbidities, and gray zone/intermediate assay values., Results: Of 2200 patients, 1095 (49.8%) were diagnosed with HF by clinical adjudication. Sensitivity and specificity for Vitros NT-proBNP II ranged from 84.0% to 92.1%, and 81.4% to 86.5%, respectively, within and across age groups, and positive predictive values were 80.4% to 85.7%. Using the rule-out cutoff, the negative predictive value was 97.9%, with a negative likelihood ratio of 0.02. In subgroups with comorbidities potentially affecting NT-proBNP concentrations, sensitivities ranged from 82.6% to 89.5%, and AUCs for ROC curves were 0.899 to 0.915., Conclusions: The Vitros NT-proBNP II assay demonstrated excellent clinical performance using age-stratified cutoffs along with other clinical information for supporting diagnosis of HF, and can rule out HF with a high negative predictive value using the age-independent cutoff. The assay retained utility in patient subgroups with conditions that influence NT-proBNP concentration, and for those with gray zone results., Clinicaltrials.gov Registration Number: NCT03548909., (© Association for Diagnostics & Laboratory Medicine 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Purpose: To perform a living systematic review and meta-analysis of randomized controlled trials comparing the effectiveness of coronary CT angiography (CCTA) and standard of care (SOC) in the evaluation of acute chest pain (ACP)., Materials and Methods: Multiple electronic databases were systematically searched, with the most recent search conducted on October 31, 2022. Studies were stratified into two groups according to the pretest probability for acute coronary syndrome (group 1 with predominantly low-to-intermediate risk vs group 2 with high risk). A meta-regression analysis was also conducted using participant risk, type of SOC used, and the use or nonuse of high-sensitivity troponins as independent variables., Results: The final analysis included 22 randomized controlled trials (9379 total participants; 4956 assigned to CCTA arms and 4423 to SOC arms). There was a 14% reduction in the length of stay and a 17% reduction in immediate costs for the CCTA arm compared with the SOC arm. In group 1, the length of stay was 17% shorter and costs were 21% lower using CCTA. There was no evidence of differences in referrals to invasive coronary angiography, myocardial infarction, mortality, rate of hospitalization, further stress testing, or readmissions between CCTA and SOC arms. There were more revascularizations (relative risk, 1.45) and medication changes (relative risk, 1.33) in participants with low-to-intermediate acute coronary syndrome risk and increased radiation exposure in high-risk participants (mean difference, 7.24 mSv) in the CCTA arm compared with the SOC arm. The meta-regression analysis found significant differences between CCTA and SOC arms for rate of hospitalization, further stress testing, and medication changes depending on the type of SOC ( P < .05)., Conclusion: The results support the use of CCTA as a safe, rapid, and less expensive in the short term strategy to exclude acute coronary syndrome in low- to intermediate-risk patients presenting with acute chest pain. Keywords: Acute Coronary Syndrome, Chest Pain, Emergency Department, Coronary Computed Tomography, Usual Care Supplemental material is available for this article. Published under a CC BY 4.0 license., Competing Interests: Disclosures of conflicts of interest: M.F.B. No relevant relationships. A.C. Royalties from Elsevier. Y.X. Associate editor and statistician for Radiology: Cardiothoracic Imaging. H.L. Support from Siemens Healthineers and Philips Healthcare to institution; travel support from Siemens Healthineers to institution; deputy editor of Radiology: Cardiothoracic Imaging. D.B.D. Institutional research contracts from Abbott, Siemens Healthineers, Roche, Quidel, and Ortho Clinical Diagnostics; participation on NIH PETAL Network data and safety monitoring board; member of the Academy of Academic Chairs of Emergency Medicine Executive Committee and Emergencies in Medicine Board of Directors. S.A. Royalties from Elsevier; editor of Radiology: Cardiothoraocic Imaging. F.U.K. Grants from the Radiological Society of North America and Edwards Lifesciences; consulting fees from Bayer; honoraria for lecture from the International Society for Cell and Gene Therapy; travel support from UT Southwestern Medical Center; associate editor of Radiology: Cardiothoracic Imaging., (© 2023 by the Radiological Society of North America, Inc.)

This Policy Resource and Education Paper (PREP) from the American College of Emergency Physicians (ACEP) discusses the use of high-sensitivity cardiac troponin (hs-cTn) in the emergency department setting. This brief review discusses types of hs-cTn assays as well as the interpretation of hs-cTn in the setting of various clinical factors such as renal dysfunction, sex, and the important distinction between myocardial injury versus myocardial infarction. In addition, the PREP provides one possible example of an algorithm for the use of a hs-cTn assay in patients in whom the treating clinician is concerned about potential acute coronary syndrome., (© 2023 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Objectives: We characterized real-time patient portal test result viewing among emergency department (ED) patients and described patient characteristics overall and among those not enrolled in the portal at ED arrival., Methods: Our observational study at an academic ED used portal log data to trend the proportion of adult patients who viewed results during their visit from May 04, 2021 to April 04, 2022. Correlation was assessed visually and with Kendall's τ. Covariate analysis using binary logistic regression assessed result(s) viewed as a function of time accounting for age, sex, ethnicity, race, language, insurance status, disposition, and social vulnerability index (SVI). A second model only included patients not enrolled in the portal at arrival. We used random forest imputation to account for missingness and Huber-White heteroskedasticity-robust standard errors for patients with multiple encounters ( α  = 0.05)., Results: There were 60,314 ED encounters (31,164 unique patients). In 7,377 (12.2%) encounters, patients viewed results while still in the ED. Patients were not enrolled for portal use at arrival in 21,158 (35.2%) encounters, and 927 (4.4% of not enrolled, 1.5% overall) subsequently enrolled and viewed results in the ED. Visual inspection suggests an increasing proportion of patients who viewed results from roughly 5 to 15% over the study (Kendall's τ = 0.61 [ p <0.0001]). Overall and not-enrolled models yielded concordance indices ( C ) of 0.68 and 0.72, respectively, with significant overall likelihood ratio χ 2 ( p <0.0001). Time was independently associated with viewing results in both models after adjustment. Models revealed disparate use between age, race, ethnicity, SVI, sex, insurance status, and disposition groups., Conclusion: We observed increased portal-based test result viewing among ED patients over the year since the 21 st Century Cures act went into effect, even among those not enrolled at arrival. We observed disparities in those who viewed results., Competing Interests: C.U.L. reports royalties or licenses from Springer-Verlag (<$20) and stock ownership of Celanese and Markel., (Thieme. All rights reserved.)

Purpose of Review: As the high-sensitivity cardiac troponin (hs-cTn) becomes more broadly used, physicians must understand the strengths and limitations of using the hs-cTn in the hypertensive population., Recent Findings: The most common cause of hs-cTn elevation is cardiac myocyte injury and death; alternate mechanisms for hs-cTn elevation in the absence of cardiac myocyte death are not clearly understood. Hs-cTn elevation has been found in significant proportions of patients with asymptomatic hypertension, in patients with acute hypertensive crisis, and has even been used to predict patients who will go on to develop hypertension. While the mechanisms remain undefined, there is evidence that elevations in hs-cTn are associated with both short- and long-term morbidity and mortality. While ongoing research further defines the relationship between hypertension and hs-cTn, the emergency medicine physician must make clinical decisions today regarding the utility of this increasingly used biomarker. Given the current evidence, clinical context must be utilized including a complete clinical picture, EKGs findings, and importantly serial hs-cTn when needed to establish whether myocardial injury or myocardial infarction is occurring., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Cardiac troponin (cTn) can be elevated in many patients presenting to the emergency department (ED) with chest pain but without a diagnosis of acute coronary syndrome (ACS). We compared the prognostic significance of cTn in these different populations., Methods: We retrospectively analyzed the CHOPIN study, which enrolled patients who presented to the ED with chest pain. Patients were grouped as ACS, non-ACS cardiovascular disease, noncardiac chest pain and chest pain not otherwise specified (NOS). We examined the prognostic ability of cTnI for the clinical endpoints of mortality and major adverse cardiovascular event (MACE; a composite of acute myocardial infarction, unstable angina, revascularization, reinfarction, and congestive heart failure and stroke) at 180-day follow-up., Results: Among 1982 patients analyzed, 14% had ACS, 21% had non-ACS cardiovascular disease, 31% had a noncardiac diagnosis and 34% had chest pain NOS. cTnI elevation above the 99th percentile was observed in 52, 18, 6 and 7% in these groups, respectively. cTnI elevation was associated with mortality and MACE, and their relationships were more prominent in noncardiac diagnosis and chest pain NOS than in ACS and non-ACS cardiovascular diagnoses for mortality, and in non-ACS patients than in ACS patients for MACE (hazard ratio for doubling of cTnI 1.85, 2.05, 8.26 and 4.14, respectively; P for interaction 0.011 for mortality; 1.04, 1.23, 1.54 and 1.42, respectively; P for interaction <0.001 for MACE)., Conclusion: In patients presenting to the ED with chest pain, cTnI elevation was associated with a worse prognosis in non-ACS patients than in ACS patients., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: During the COVID-19 pandemic, a substantial number of emergency health care workers (HCWs) have screened positive for anxiety, depression, risk of posttraumatic stress disorder, and burnout. The purpose of this qualitative study was to describe the impact of COVID-19 on emergency care providers' health and well-being using personal perspectives. We conducted in-depth interviews with emergency physicians, emergency medicine nurses, and emergency medical services providers at 10 collaborating sites across the United States between September 21, 2020, and October 26, 2020., Methods: We developed a conceptual framework that described the relationship between the work environment and employee health. We used qualitative content analysis to evaluate our interview transcripts classified the domains, themes, and subthemes that emerged from the transcribed interviews., Results: We interviewed 32 emergency HCWs. They described difficult working conditions, such as constrained physical space, inadequate personnel protective equipment, and care protocols that kept changing. Organizational leadership was largely viewed as unprepared, distant, and unsupportive of employees. Providers expressed high moral distress caused by ethically challenging situations, such as the perception of not being able to provide the normal standard of care and emotional support to patients and their families at all times, being responsible for too many sick patients, relying on inexperienced staff to treat infected patients, and caring for patients that put their own health and the health of their families at risk. Moral distress was commonly experienced by emergency HCWs, exacerbated by an unsupportive organizational environment., Conclusions: Future preparedness efforts should include mechanisms to support frontline HCWs when faced with ethical challenges in addition to an adverse working environment caused by a pandemic such as COVID-19., (© 2022 Society for Academic Emergency Medicine.)

Background: During the COVID-19 pandemic, health care provider well-being was affected by various challenges in the work environment. The purpose of this study was to evaluate the relationship between the perceived work environment and mental well-being of a sample of emergency physicians (EPs), emergency medicine (EM) nurses, and emergency medical services (EMS) providers during the pandemic., Methods: We surveyed attending EPs, resident EPs, EM nurses, and EMS providers from 10 academic sites across the United States. We used latent class analysis (LCA) to estimate the effect of the perceived work environment on screening positive for depression/anxiety and burnout controlling for respondent characteristics. We tested possible predictors in the multivariate regression models and included the predictors that were significant in the final model., Results: Our final sample included 701 emergency health care workers. Almost 23% of respondents screened positive for depression/anxiety and 39.7% for burnout. Nurses were significantly more likely to screen positive for depression/anxiety (adjusted odds ratio [aOR] 2.04, 95% confidence interval [CI] 1.11-3.86) and burnout (aOR 2.05, 95% CI 1.22-3.49) compared to attendings. The LCA analysis identified four subgroups of our respondents that differed in their responses to the work environment questions. These groups were identified as Work Environment Risk Group 1, an overall good work environment; Risk Group 2, inadequate resources; Risk Group 3, lack of perceived organizational support; and Risk Group 4, an overall poor work environment. Participants in the two groups who perceived their work conditions as most adverse were significantly more likely to screen positive for depression/anxiety (aOR 1.89, 95% CI 1.05-3.42; and aOR 2.04, 95% CI 1.14-3.66) compared to participants working in environments perceived as less adverse., Conclusions: We found a strong association between a perceived adverse working environment and poor mental health, particularly when organizational support was deemed inadequate. Targeted strategies to promote better perceptions of the workplace are needed., (© 2022 Society for Academic Emergency Medicine.)

Objective: To determine the utility of a highly sensitive troponin assay when utilized in the emergency department., Methods: The FAST-TRAC study prospectively enrolled >1,500 emergency department patients with suspected acute coronary syndrome within 6 hours of symptom onset and 2 hours of emergency department presentation. It has several unique features that are not found in the majority of studies evaluating troponin. These include a very early presenting population in whom prospective data collection of risk score parameters and the physician's clinical impression of the probability of acute coronary syndrome before any troponin data were available. Furthermore, two gold standard diagnostic definitions were determined by a pair of cardiologists reviewing two separate data sets; one that included all local troponin testing results and a second that excluded troponin testing so that diagnosis was based solely on clinical grounds. By this method, a statistically valid head-to-head comparison of contemporary and high sensitivity troponin testing is obtainable. Finally, because of a significant delay in sample processing, a unique ability to define the molecular stability of various troponin assays is possible., Trial Registration: ClinicalTrials.gov Identifier NCT00880802.

Dyspnea is the symptom of perceived breathing discomfort and is commonly encountered in a variety of clinical settings. Cardiac etiologies of dyspnea are an important consideration; among these, valvular heart disease (Variant 1), arrhythmia (Variant 2), and pericardial disease (Variant 3) are reviewed in this document. Imaging plays an important role in the clinical assessment of these suspected abnormalities, with usually appropriate procedures including resting transthoracic echocardiography in all three variants, radiography for Variants 1 and 3, MRI heart function and morphology in Variants 2 and 3, and CT heart function and morphology with intravenous contrast for Variant 3. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2022 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of competing interest Disclosure information for all authors is available in Supplemental Table S1.