HomeCirculationVol. 139, No. 19Response by Mahler et al to Letter Regarding Article, "Safely Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge: HEART Pathway Accelerated Diagnostic Protocol" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse by Mahler et al to Letter Regarding Article, "Safely Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge: HEART Pathway Accelerated Diagnostic Protocol" Simon A. Mahler, MD, MS, Kristin M. Lenoir, MPH, Brian J. Wells, MD, PhD, Gregory L. Burke, MD, MSc, Pamela W. Duncan, PhD, L. Douglas Case, PhD, David M. Herrington, MD, MHS, Jose-Franck Diaz-Garelli, PhD, Wendell M. Futrell, BS, Brian C. Hiestand, MD, MPH and Chadwick D. Miller, MD, MS Simon A. MahlerSimon A. Mahler Departments of Emergency Medicine (S.A.M., B.C.H., C.D.M.), Wake Forest School of Medicine, Winston-Salem, NC. Implementation Science and Epidemiology and Prevention (S.A.M.), Wake Forest School of Medicine, Winston-Salem, NC. , Kristin M. LenoirKristin M. Lenoir Biostatistical Sciences (K.M.L., B.J.W., L.D.C.), Wake Forest School of Medicine, Winston-Salem, NC. , Brian J. WellsBrian J. Wells Biostatistical Sciences (K.M.L., B.J.W., L.D.C.), Wake Forest School of Medicine, Winston-Salem, NC. , Gregory L. BurkeGregory L. Burke Public Health Sciences (G.L.B.), Wake Forest School of Medicine, Winston-Salem, NC. , Pamela W. DuncanPamela W. Duncan Departments of Neurology, Sticht Center on Aging, Gerontology, and Geriatric Medicine (P.W.D.), Wake Forest School of Medicine, Winston-Salem, NC. , L. Douglas CaseL. Douglas Case Biostatistical Sciences (K.M.L., B.J.W., L.D.C.), Wake Forest School of Medicine, Winston-Salem, NC. , David M. HerringtonDavid M. Herrington Department of Internal Medicine, Division of Cardiovascular Medicine (D.M.H.), Wake Forest School of Medicine, Winston-Salem, NC. , Jose-Franck Diaz-GarelliJose-Franck Diaz-Garelli Department of Physiology and Pharmacology (J.-F.D.-C.), Wake Forest School of Medicine, Winston-Salem, NC. Clinical and Translational Science Institute (J.-F.D.-C., W.M.F.), Wake Forest School of Medicine, Winston-Salem, NC. , Wendell M. FutrellWendell M. Futrell Clinical and Translational Science Institute (J.-F.D.-C., W.M.F.), Wake Forest School of Medicine, Winston-Salem, NC. , Brian C. HiestandBrian C. Hiestand Departments of Emergency Medicine (S.A.M., B.C.H., C.D.M.), Wake Forest School of Medicine, Winston-Salem, NC. and Chadwick D. MillerChadwick D. Miller Departments of Emergency Medicine (S.A.M., B.C.H., C.D.M.), Wake Forest School of Medicine, Winston-Salem, NC. Originally published6 May 2019https://doi.org/10.1161/CIRCULATIONAHA.119.039922Circulation. 2019;139:e915–e916In Response:Dr Mueller et al, we appreciate your interest in our recently published pragmatic evaluation of the safety and effectiveness of HEART Pathway (history, ECG, age, risk factors, and troponin) implementation.1 We agree that serial cardiac troponin (cTn) measurement has an important impact on the safety and efficacy of chest pain risk stratification. That is why serial cTn testing at 0 and 3 hours is an integral part of the HEART Pathway. HEART Pathway implementation was associated with a 17% increase in obtaining 3-hour serial cTn measures (49% versus 66%, P<0.001) and a 9% increase in obtaining any serial cTn measurements (75% versus 84%, P<0.001). Thus, it is not surprising that use of the HEART Pathway increased detection of index-visit myocardial infarctions.Another important component of the HEART Pathway is a systematic and objective method of determining the suspicion of acute coronary syndrome based on the patient's chest pain history. In our preimplementation cohort, providers did not have a structured or objective method of making this assessment. Multiple studies have shown that clinician gestalt is a poor predictor of acute coronary syndrome.2,3 Therefore, we agree with you that use of the HEART Pathway systematic and objective assessment of the patient's chest pain presentation likely affected outcomes.Our pragmatic design, which used electronic health record surveillance, claims, and death index data, rather than traditional phone follow-up, had a slightly higher loss-to-follow-up rate than traditional cardiovascular clinical trials. However, we conducted robust sensitivity analyses with a variety of reasonable assumptions (available in the online-only Data Supplement), which did not substantively change our odds ratios for safety outcomes. Furthermore, our analysis of the completeness of follow-up data found that most safety events were captured in the electronic health record, with the death index and claims data identifying only 16 safety events that were not already accounted for in the electronic health record data. This makes it unlikely that many adverse events were missed and completely implausible that all patients with incomplete follow-up had unrecognized deaths. Thus, it is not practical to conduct a sensitivity analysis in which all patients lost to follow-up are considered dead.Finally, we disagree that risk scores and accelerated diagnostic pathways no longer provide incremental value in the era of high-sensitivity cTn (hs-cTn). Although we appreciate that hs-cTn protocols are excellent at detecting index visit myocardial infarctions, hs-cTn measures are best used within the context of a pathway for detection of 30-day adverse cardiac events. In a study by Mokhtari et al4, the European Society of Cardiology 0/1 hour rule (hs-cTn alone) was only 87.6% sensitive for major adverse cardiac events, but improved to 97.5% sensitive when used within the context of a pathway. In the TRAPID-AMI cohort (High-Sensitivity Cardiac Troponin T Assay for Rapid Rule Out of Acute Myocardial Infarction), hs-cTnT below the limit of detection had a missed 30-day adverse event rate (prevalent or incident myocardial infarction, all-cause mortality, or revascularization following rehospitalization for acute coronary syndrome) of 1.4%. However, if coronary revascularization procedures during their index hospitalization were included in the composite event rate, the miss rate would have been 3.6% (95% CI, 2.2%–5.7%), well above what most providers find acceptable.5DisclosuresThis project was funded by the Donaghue Foundation and the Association of American Medical Colleges (AAMC). Dr Mahler also receives research funding from Abbott Point of Care, Roche Diagnostics, Siemens, Ortho Clinical Diagnostics, Creavo Medical Technologies, Patent-Centered Outcomes Research Institute, and National Heart, Lung, and Blood Institute (1 R01 HL118263-01, L30 HL120008). He has received consulting honoraria from Roche Diagnostics, and is the Chief Medical Officer for Impathiq Inc. Dr Mahler has a conflict of interest management plan in place for research, through the Conflict of Interest Office at the Wake Forest School of Medicine. Dr Miller receives research support from Siemens, Abbott Point of Care, Creavo Medical Technologies, and 1 R01 HL118263. The other authors report no conflicts.Footnoteshttps://www.ahajournals.org/journal/circReferences1. Mahler SA, Lenoir KM, Wells BJ, Burke GL, Duncan PW, Case LD, Herrington DM, Diaz-Garelli JF, Futrell WM, Hiestand BC, Miller CD. Safely identifying emergency department patients with acute chest pain for early discharge.Circulation. 2018; 138:2456–2468. doi: 10.1161/CIRCULATIONAHA.118.036528LinkGoogle Scholar2. Mahler SA, Miller CD, Hollander JE, Nagurney JT, Birkhahn R, Singer AJ, Shapiro NI, Glynn T, Nowak R, Safdar B, Peberdy M, Counselman FL, Chandra A, Kosowsky J, Neuenschwander J, Schrock JW, Plantholt S, Diercks DB, Peacock WF. Identifying patients for early discharge: performance of decision rules among patients with acute chest pain.Int J Cardiol. 2013; 168:795–802. doi: 10.1016/j.ijcard.2012.10.010CrossrefMedlineGoogle Scholar3. Body R, Cook G, Burrows G, Carley S, Lewis PS. Can emergency physicians 'rule in' and 'rule out' acute myocardial infarction with clinical judgement?Emerg Med J. 2014; 31:872–876. doi: 10.1136/emermed-2014-203832CrossrefMedlineGoogle Scholar4. Mokhtari A, Borna C, Gilje P, Tydén P, Lindahl P, Nilsson HJ, Khoshnood A, Björk J, Ekelund U. A 1-h Combination Algorithm Allows Fast Rule-Out and Rule-In of Major Adverse Cardiac Events.J Am Coll Cardiol. 2016; 67:1531–1540. doi: 10.1016/j.jacc.2016.01.059CrossrefMedlineGoogle Scholar5. Body R, Mueller C, Giannitsis E, Christ M, Ordonez-Llanos J, de Filippi CR, Nowak R, Panteghini M, Jernberg T, Plebani M, Verschuren F, French JK, Christenson R, Weiser S, Bendig G, Dilba P, Lindahl B; TRAPID-AMI Investigators. The use of very low concentrations of high-sensitivity troponin t to rule out acute myocardial infarction using a single blood test.Acad Emerg Med. 2016; 23:1004–1013. doi: 10.1111/acem.13012CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Ng M, Tan H, Gao F, Tan J, Lim S, Ong M and Ponampalam R (2020) Comparative prospective study of the performance of chest pain scores and clinical assessment in an emergency department cohort in Singapore, Journal of the American College of Emergency Physicians Open, 10.1002/emp2.12242, 1:5, (723-729), Online publication date: 1-Oct-2020. May 7, 2019Vol 139, Issue 19 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.119.039922PMID: 31059320 Originally publishedMay 6, 2019 PDF download Advertisement SubjectsAcute Coronary SyndromesAnginaHealth ServicesQuality and Outcomes

BACKGROUND The European Society of Cardiology (ESC) recommends the O/1-h algorithm for rapid triage of patients with suspected non-ST-segment elevation myocardial infarction (MI). However, its impact on patient management and safety when routinely applied is unknown. OBJECTIVES This study sought to determine these important real-world outcome data. METHODS In a prospective international study enrolling patients presenting with acute chest discomfort to the emergency department (ED), the authors assessed the real-world performance of the ESC O/1-h algorithm using high-sensitivity cardiac troponin T embedded in routine clinical care and its associated 30-day rates of major adverse cardiac events (MACE) (the composite of cardiovascular death and MI). RESULTS Among 2,296 patients, non-ST-segment elevation MI prevalence was 9.8%. In median, 1-h blood samples were collected 65 min after the O-h blood draw. Overall, 94% of patients were managed without protocol violations, and 98% of patients triaged toward rule-out did not require additional cardiac investigations including high-sensitivity cardiac troponin T measurements at later time points or coronary computed tomography angiography in the ED. Median ED stay was 2 h and 30 min. The ESC O/1-h algorithm triaged 62% of patients toward rule-out, and 71% of all patients underwent outpatient management. Proportion of patients with 30-day MACE were 0.2% (95% confidence interval: 03% to 0.5%) in the rule-out group and 0.1% (95% confidence interval: 0% to 0.2%) in outpatients. Very low MACE rates were confirmed in multiple subgroups, including early presenters. CONCLUSIONS These real-world data document the excellent applicability, short time to ED discharge, and low rate of 30-day MACE associated with the routine clinical use of the ESC O/1-h algorithm for the management of patients presenting with acute chest discomfort to the ED. (C) 2019 by the American College of Cardiology Foundation.

Objective: We aimed to investigate the association of retinal microvascular health with cardiorespiratory fitness (VO(2)peak) and cardiovascular risk factors. Methods: In a population of 260 obesity-enriched participants we investigated the association of retinal vessel diameters with cardiorespiratory fitness (CRF), body mass index (BMI) and blood pressure (BP). Retinal vessel imaging was performed by use of a fundus camera and a semi-automated processing software, calculating the central retinal arteriolar (CRAE) and venular equivalent (CRVE) as well as the arteriolar-to-venular diameter ratio (AVR). Results: Participants had a mean age of 45.8 +/- 12.5 years and a BMI of 35.8 +/- 6.8 kg/m(2). 45% of patients were diagnosed with hypertension, 26% with diabetes and 30% with dyslipidemia. Increasing VO(2)peak was independently associated with lower CRVE (beta = -0.600; CI -1.141, -0.060; p = 0.030). Higher BMI and mean arterial pressure were independently associated with narrower CRAE (beta = -0.492; CI -0.909, -0.076; p = 0.021 and beta = -0.268; CI -0.471, -0.066; p = 0.009, respectively) and lower AVR (beta = -0.002; CI -0.003, -0.000; p = 0.026 and beta = -0.001; CI -0.002, -0.000; p = 0.001, respectively). Conclusions: Higher cardiorespiratory fitness is associated with beneficial retinal microvascular health. Higher BMI and BP were associated with an impairment of retinal microvascular health. Exercise is known for its potential to improve body composition and reduce BP but may also prove to be an efficient therapy to counteract small vessel disease in cardiometabolic disease.

Objective Cardiopulmonary exercise testing is clinically used to estimate cardiorespiratory fitness (CRF). The relation to total body mass (TBM) leads to an underestimation of CRF in people with obesity and to inappropriate prognostic and therapeutic decisions. This study aimed to determine body composition‐derived bias in the estimation of CRF in people with obesity. Methods Two hundred eleven participants (58.8% women; mean BMI 35.7 kg/m 2 [± 6.94; 20.7‐58.6]) were clinically examined, and body composition (InBody720; InBody Co., Ltd., Seoul, South Korea) and spiroergometrical peak oxygen consumption (VO 2 peak) were assessed. The impacts of TBM, lean body mass (LBM), and skeletal muscle mass (SMM) on CRF estimates were analyzed by the application of respective weight models. Linear regression and plotting of residuals against BMI were performed on the whole study population and two subgroups (BMI < 30 kg/m 2 and BMI ≥ 30 kg/m 2 ). Results For every weight model, Δmean VO 2 peak (expected − measured) was positive. LBM and SMM had a considerable impact on VO 2 peak demand ( P = 0.001; ΔR 2 = 2.3%; adjusted R 2 = 56% and P = 0.001; ΔR 2 = 2.7%; adjusted R 2 = 56%), whereas TBM did not. Confounding of body composition on VO 2 peak did not differ in LBM and SMM. Conclusions TBM‐adjusted overestimation of relative VO 2 demand is much higher in people with obesity than in those without. LBM or SMM adjustment may be superior alternatives, although small residual body composition‐derived bias remains.

BACKGROUND AND AIMS:Higher cardiorespiratory fitness is associated with lower pulse wave velocity and arterial stiffness in normal weight individuals, and this has not been examined in obese individuals. It is unclear whether an altered body composition acts as a modifier of the association between cardiorespiratory fitness and arterial stiffness. We examined the association between peak oxygen uptake and brachial-ankle pulse wave velocity and analysed whether body composition attenuates this association in obese middle-aged individuals. METHODS:Bio-impedance analysis-derived body composition assessment in 212 healthy and sedentary either overweight or obese individuals was followed by measurement of brachial-ankle pulse wave velocity and spiroergometric peak oxygen uptake. Multivariate analysis was performed to analyse the association between peak oxygen uptake and brachial-ankle pulse wave velocity and to assess the moderating effect of several body composition-related interaction terms (BMI, total body mass, body fat mass, waist circumference, waist-to-height ratio) on this association. RESULTS:Peak oxygen uptake was inversely associated with brachial-ankle pulse wave velocity (β = -0.059, 95% CI = -0.099; -0.018, p = 0.005). Testing for the impact of different body composition-related interaction terms on this association showed no significance, 95% CI lateralized towards positivity. CONCLUSIONS:This study shows an inverse association between cardiorespiratory fitness and arterial stiffness in middle-aged obese individuals. We also found a tendency towards an attenuating impact of an obese body composition on this association. Physical fitness seems to be a stronger modulator of cardiovascular risk than body composition but the success of training efforts may be compromised by obesity.