Prehospital use of a modified HEART Pathway and point-of-care troponin to predict cardiovascular events.
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ABSTRACT:
SUBMITTER: Stopyra JP
PROVIDER: S-EPMC7540888 | biostudies-literature | 2020
REPOSITORIES: biostudies-literature
Publications
Prehospital use of a modified HEART Pathway and point-of-care troponin to predict cardiovascular events.
Stopyra Jason P JP Snavely Anna C AC Smith Lane M LM Harris R David RD Nelson Robert D RD Winslow James E JE Alson Roy L RL Pomper Gregory J GJ Riley Robert F RF Ashburn Nicklaus P NP Hendley Nella W NW Gaddy Jeremiah J Woodrum Tyler T Fornage Louis L Conner David D Alvarez Manrique M Pflum Adam A Koehler Lauren E LE Miller Chadwick D CD Mahler Simon A SA
PloS one 20201007 10
<h4>Clinical trial registration</h4>clinicaltrials.gov (NCT02709135). ...[more]
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Project description:ImportancePrehospital point-of-care troponin testing and paramedic risk stratification might improve the efficiency of chest pain care pathways compared with existing processes with equivalent health outcomes, but the association with health care costs is unclear.ObjectiveTo analyze whether prehospital point-of-care troponin testing and paramedic risk stratification could result in cost savings compared with existing chest pain care pathways.Design, setting, and participantsIn this economic evaluation of adults with acute chest pain without ST-segment elevation, cost-minimization analysis was used to assess linked ambulance, emergency, and hospital attendance in the state of Victoria, Australia, between January 1, 2015, and June 30, 2019.InterventionsParamedic risk stratification and point-of-care troponin testing.Main outcomes and measuresThe outcome was estimated mean annualized statewide costs for acute chest pain. Between May 17 and June 25, 2022, decision tree models were developed to estimate costs under 3 pathways: (1) existing care, (2) paramedic risk stratification and point-of-care troponin testing without prehospital discharge, or (3) prehospital discharge and referral to a virtual emergency department (ED) for low-risk patients. Probabilities for the prehospital pathways were derived from a review of the literature. Multivariable probabilistic sensitivity analysis with 50 000 Monte Carlo iterations was used to estimate mean costs and cost differences among pathways.ResultsA total of 188 551 patients attended by ambulance for chest pain (mean [SD] age, 61.9 [18.3] years; 50.5% female; 49.5% male; Indigenous Australian, 2.0%) were included in the model. Estimated annualized infrastructure and staffing costs for the point-of-care troponin pathways, assuming a 5-year device life span, was $2.27 million for the pathway without prehospital discharge and $4.60 million for the pathway with prehospital discharge (incorporating virtual ED costs). In the decision tree model, total annual cost using prehospital point-of-care troponin and paramedic risk stratification was lower compared with existing care both without prehospital discharge (cost savings, $6.45 million; 95% uncertainty interval [UI], $0.59-$16.52 million; lower in 94.1% of iterations) and with prehospital discharge (cost savings, $42.84 million; 95% UI, $19.35-$72.26 million; lower in 100% of iterations).Conclusions and relevancePrehospital point-of-care troponin and paramedic risk stratification for patients with acute chest pain could result in substantial cost savings. These findings should be considered by policy makers in decisions surrounding the potential utility of prehospital chest pain risk stratification and point-of-care troponin models provided that safety is confirmed in prospective studies.
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| S-EPMC9613836 | biostudies-literature
Project description:Indoxyl sulfate (IS) is associated with either chronic kidney disease or renal failure, which may predict cardiovascular events via cardiorenal syndrome. The present study aimed to elucidate whether the plasma levels of IS can predict the occurrence of cardiovascular events in patients with chronic heart failure (CHF) and investigate which causes of CHF leading to cardiovascular events are highly influenced by plasma IS levels. We measured the plasma IS levels in 165 patients with CHF [valvular disease: 78, dilated cardiomyopathy: 29, hypertrophic cardiomyopathy (HCM): 25 and others: 33] admitted to our hospital in 2012, and we followed up these patients for more than 5 years (the median follow-up period: 5.3 years). We measured the plasma IS level in 165 patients with CHF, and Kaplan-Meier analyses showed that high plasma IS levels (≥ 0.79 µg/mL, the median value) could predict the occurrence of cardiovascular events, i.e., cardiovascular death or rehospitalization due to the worsening of CHF. The sub-analyses showed that the high IS level could predict cardiovascular events in patients with CHF due to HCM and that the plasma IS levels were closely associated with left ventricular (LV) dimension, LV systolic dysfunction, and plasma B-type natriuretic peptide levels, rather than LV diastolic dysfunction. Plasma IS level predicts cardiovascular events in patients with CHF, especially those with HCM along with cardiac dysfunction. Besides, IS may become a proper biomarker to predict cardiovascular events in patients with CHF.
| S-EPMC7536212 | biostudies-literature
Project description:BackgroundThe composite Model for End-Stage Liver Disease Excluding International Normalized Ratio Score (MELD-XI) is a novel tool to evaluate cardio-renal and cardio-hepatic interactions in patients with advanced heart failure (HF). However, its prognostic ability remains unclear in elderly HF patients.Methods and resultsFrom July 2014 to July 2018, patients hospitalized for HF were prospectively recruited at 16 centers. Clinical features, laboratory findings, and echocardiography results were assessed prior to discharge. Cardiovascular (CV) death and HF re-hospitalization were recorded. Of the 676 patients enrolled, 264 (39.1%) experienced CV events throughout a 1-year median follow-up period. Patients with high MELD-XI were predominantly male and had a higher prevalence of NYHA III/IV, history of HF admission, hyperuricemia, ventricular tachycardia, anemia, and ischemic heart disease. In Kaplan-Meyer analysis, patients with higher MELD-XI (≥11) scores showed a worse prognosis than did those with lower (<11) scores (log-rank p≤0.001). Multivariate Cox proportional hazards testing revealed MELD-XI as an independent predictor of CV events (HR: 1.033, 95% CI: 1.006-1.061, p = 0.015) after adjusting for age, gender, body mass index, NYHA III/IV, prior HF hospitalization, systolic blood pressure, ischemic etiology, ventricular tachycardia, anemia, BNP, and left ventricular ejection fraction.ConclusionsCardio-renal and cardio-hepatic interactions predicted CV events in aged HF patients.
| S-EPMC7584193 | biostudies-literature
Project description:BackgroundThe HEART score is a validated risk stratification tool for chest pain patients presenting to the emergency department and was recently investigated for implementation in a pre-hospital setting. Fingerstick (capillary blood) point-of-care (POC) troponin testing enables quick measurements outside the hospital and seems easier to implement than the current venous blood sampling techniques. This study investigates the diagnostic accuracy of the modified HEART score, integrating fingerstick POC troponin testing, in ruling out acute coronary syndrome (ACS).MethodsThe data of 96 patients with chest pain, included in a study investigating a novel POC troponin device under development at the cardiac emergency department, were analysed retrospectively. Based on the patients' admission data and capillary POC high-sensitivity troponin I (hs-cTnI) results, the modified HEART score was determined. The outcome measure, for evaluating the diagnostic accuracy of the modified HEART score, was the occurrence of ACS.ResultsOf the total study population, 33 patients (34%) were diagnosed with ACS. Seventeen patients (18%) were classified as low risk (0-3 points) and one patient (6%) in this group was diagnosed with ACS. The sensitivity and negative predictive value of the modified HEART score was 97.0 and 97.6%, respectively.ConclusionThe modified HEART score, integrating capillary POC hs-cTnI results, is a promising tool for ruling out ACS in patients with chest pain presenting to the cardiac emergency department. These results encourage prospective investigation into the integration of fingerstick POC troponin testing in the modified HEART score in a pre-hospital setting.
| S-EPMC9270546 | biostudies-literature
Project description:Background
| S-EPMC10207698 | biostudies-literature
Project description:IntroductionTo date, identifying emergent large vessel occlusion (ELVO) patients in the prehospital stage is important but still challenging. In this present study, we aimed to design a modified prehospital acute stroke severity (mPASS) scale to identify ELVO patients and compared the scale to the PASS scale which has been published.MethodsWe retrospectively evaluated a consecutive cohort of acute ischemic stroke (AIS) in our stroke unit who visited the emergercy department. These patients underwent CT angiography (CTA), MR angiography (MRA), or digital subtraction angiography (DSA) at admission. The mPASS scale was calculated based on the National Institutes of Health Stroke Scale (NIHSS) items retrospectively, including the level of consciousness commands, gaze, arm weakness, and aphasia/dysarthria. Receiver operating characteristic (ROC) analysis was used to obtain the area under the curve (AUC) of the mPASS scale, NIHSS, and PASS scale. U-statistics was used to compare the AUC of the mPASS scale to the NIHSS and PASS scale.ResultsA total of 382 AIS patients were enrolled. The AUC and specificity of the mPASS scale (0.92, 84.4) were all higher than those of the PASS scale. Cortical symptoms such as gaze palsy and consciousness disorder were more specific indicators for ELVO than motor deficits.ConclusionsThe mPASS scale had a better discrimination for identifying ELVO than the PASS scale in our retrospective cohort. It might predict ELVO in an effective and simple way for paramedics in the prehospital triage stage or emergency stage. Moreover, cortical symptoms might have relatively high specificities to predict ELVO on their own.
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Project description:BackgroundCardiac troponin concentrations are used to identify patients who would benefit from urgent revascularization for acute coronary syndromes. We hypothesized that they might be used in patients with stable ischemic heart disease to identify those at high risk for cardiovascular events who might also benefit from prompt coronary revascularization.MethodsWe measured the cardiac troponin T concentration at baseline with a high-sensitivity assay in 2285 patients who had both type 2 diabetes and stable ischemic heart disease and were enrolled in the Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes trial. We tested for an association between the troponin T concentration and a composite end point of death from cardiovascular causes, myocardial infarction, or stroke; we then evaluated whether random assignment to prompt revascularization reduced the rate of the composite end point in patients with an abnormal troponin T concentration (≥14 ng per liter) as compared with those with a normal troponin T concentration (<14 ng per liter).ResultsOf the 2285 patients, 2277 (99.6%) had detectable (≥3 ng per liter) troponin T concentrations and 897 (39.3%) had abnormal troponin T concentrations at baseline. The 5-year rate of the composite end point was 27.1% among the patients who had had abnormal troponin T concentrations at baseline, as compared with 12.9% among those who had had normal baseline troponin T concentrations. In models that were adjusted for cardiovascular risk factors, severity of diabetes, electrocardiographic abnormalities, and coronary anatomy, the hazard ratio for the composite end point among patients with abnormal troponin T concentrations was 1.85 (95% confidence interval [CI], 1.48 to 2.32; P<0.001). Among patients with abnormal troponin T concentrations, random assignment to prompt revascularization, as compared with medical therapy alone, did not result in a significant reduction in the rate of the composite end point (hazard ratio, 0.96; 95% CI, 0.74 to 1.25).ConclusionsThe cardiac troponin T concentration was an independent predictor of death from cardiovascular causes, myocardial infarction, or stroke in patients who had both type 2 diabetes and stable ischemic heart disease. An abnormal troponin T value of 14 ng per liter or higher did not identify a subgroup of patients who benefited from random assignment to prompt coronary revascularization. (Funded by the National Institutes of Health and Roche Diagnostics; BARI 2D ClinicalTrials.gov number, NCT00006305.).
| S-EPMC4627639 | biostudies-literature
Project description:BackgroundThere is a need for simple, noninvasive solutions to remotely monitor and predict worsening heart failure (HF) events. SCALE-HF 1 (Surveillance and Alert-Based Multiparameter Monitoring to Reduce Worsening Heart Failure Events) is a prospective, multicenter study that will develop and assess the accuracy of the heart function index-a composite algorithm of noninvasive hemodynamic biomarkers from a cardiac scale-in predicting worsening HF events.MethodsApproximately 300 patients with chronic HF and recent decompensation will be enrolled in this observational study for model development. Patients will be encouraged to take daily cardiac scale measurements.ResultsApproximately 50 HF events, defined as an urgent, unscheduled clinic, emergency department, or hospitalization for worsening HF will be used for model development. The composite index will be developed from hemodynamic biomarkers derived from ECG, ballistocardiogram, and impedance plethysmogram signals measured from the cardiac scale. Biomarkers of interest include weight, peripheral impedance, pulse rate and variability, and estimates of stroke volume, cardiac output, and blood pressure captured through the cardiac scale. The sensitivity, unexplained alert rate, and alerting time of the index in predicting worsening HF events will be evaluated and compared with the performance of simple weight-based rule-of-thumb algorithms (eg, weight increase of 3 lbs in 1 day or 5 lbs in 7 days) that are often used in practice.ConclusionsSCALE-HF 1 is the first study to develop and evaluate the performance of a composite index derived from noninvasive hemodynamic biomarkers measured from a cardiac scale in predicting worsening HF events. Subsequent studies will validate the heart function index and assess its ability to improve patient outcomes.RegistrationURL: https://www.Clinicaltrialsgov; Unique identifier: NCT04882449.
| S-EPMC10180020 | biostudies-literature