BackgroundAcute pulmonary embolism (PE) can worsen quality of life due to persistent dyspnea or exercise intolerance.ObjectiveTest if tenecteplase increases the probability of a favorable composite patient-oriented outcome after submassive PE.MethodsNormotensive patients with PE and right ventricular (RV) strain (by echocardiography or biomarkers) were enrolled from eight hospitals. All patients received low-molecular-weight heparin followed by random assignment to either a single weight-based bolus of tenecteplase or placebo, administered in a double-blinded fashion. The primary composite outcome included: (i) death, circulatory shock, intubation or major bleeding within 5days or (ii) recurrent PE, poor functional capacity (RV dysfunction with either dyspnea at rest or exercise intolerance) or an SF36((R)) Physical Component (PCS) scoreResultsEighty-three patients were randomized; 40 to tenecteplase and 43 to placebo. The trial was terminated prematurely. Within 5days, adverse outcomes occurred in three placebo-treated patients (death in one and intubation in two) and one tenecteplase-treated patient (fatal intracranial hemorrhage). At 90days, adverse outcomes occurred in 13 unique placebo-treated patients and five unique tenecteplase-treated patients Thus, 16 (37%) placebo-treated and six (15%) tenecteplase-treated patients had at least one adverse outcome (exact two-sided P=0.017).ConclusionsTreatment of patients with submassive pulmonary embolism with tenecteplase was associated with increased probability of a favorable composite outcome.

To describe the impact of out-of-hospital ECG use on emergency department (ED) processes of care for Non-ST-Elevation Myocardial Infarction (NSTEMI) patients and to assess the use and characteristics associated with out-of-hospital ECG use.

Objective: Morphine is a long-standing therapy in acute decompensated heart failure ( ADHF), despite few supporting data. A study was undertaken to compare the outcomes of patients who did and did not receive morphine for ADHF.Methods: The study was a retrospective analysis of the Acute Decompensated Heart Failure National Registry ( ADHERE) which enrols hospitalised patients with treatment for, or a primary discharge diagnosis of, ADHF. Patients were stratified into cohorts based on whether or not they received intravenous morphine. ANOVA, Wilcoxon and chi(2) tests were used in univariate analysis, followed by multivariate analysis controlling for parameters previously associated with mortality. Analyses were repeated for ejection fraction subgroups and in patients not on mechanical ventilation.Results: There were 147 362 hospitalisations in ADHERE at December 2004, 20 782 of whom ( 14.1%) received morphine and 126 580 ( 85.9%) did not. There were no clinically relevant differences between the groups in the initial age, heart rate, blood pressure, blood urea nitrogen, creatinine, haemoglobin, ejection fraction or atrial fibrillation. A higher prevalence of rest dyspnoea, congestion on chest radiography, rales and raised troponin occurred in the morphine group. Patients on morphine received more inotropes and vasodilators, were more likely to require mechanical ventilation ( 15.4% vs 2.8%), had a longer median hospitalisation ( 5.6 vs 4.2 days), more ICU admissions ( 38.7% vs 14.4%), and had greater mortality ( 13.0% vs 2.4%) ( all p<0.001). Even after risk adjustment and exclusion of ventilated patients, morphine was an independent predictor of mortality ( OR 4.84 ( 95% CI 4.52 to 5.18), p<0.001).Conclusions: Morphine is associated with increased adverse events in ADHF which includes a greater frequency of mechanical ventilation, prolonged hospitalisation, more ICU admissions and higher mortality.

Study Objectives: The incidence stimulant abuse related emergency department (ED) visits is increasing, however, the epidemiology and patient characteristics of methamphetamine (meth) users is ill-defined compared to cocaine (coc) users. The objective of this study is to compare the presenting characteristics of patients with documented meth use to those with documented coc use. Methods: Retrospective analysis of patients less than 60 years old who presented to our tertiary urban ED between 1/1/2004-10/30/2004. Chief complaints were categorized according to 10 categories based on the triage complaint. The triage narrative and computer generated category were reviewed by 2 independent physicians. Discrepancies between the categorization was decided by a third physicians blinded to the initial results. Objective verification of meth coc use was based on urine toxicologic screen. The laboratory database and the triage database were linked to create a final dataset. Results:A total of 34, 544 patients <60 years old were registered. Urine tox screen identified meth in 693 (2%) patients and coc in 294 (1%). Meth and coc patients were predominately male (59% vs 69%, respectively, RR 0.9, 95% CI 0.8-1.1). Meth patients were younger ((37 yrs vs 54 yrs, respectively) diff 3 yrs, 95% CI 1-4) and less likely to be admitted than coc users. (41% vs 43%, respectively, RR 0.(.7-1.0). There was no difference in presenting complaints. Conclusion: The majority of meth and coc users presented to the ED with an acute injury and a substantial portion were admitted to the hospital. There was no difference in presenting complaint between the meth and coc users.This information may be useful for future studies aimed at secondary preventive measures and reduction in resource utilization. Reprinted with permission from Elsevier Inc. Ann Emerg Med 2005;46(3)Suppl 1:51. Tabled 1Demographics and Presenting Complaint Category Methamphetamine N=692 Cocaine N=294 Trauma 224 (26%) 107 (28%) Cardiopulmonary 120 (17%) 53 (18%) Gastrointestinal and genitourinary 109 (16%) 46 (16%) Psychiatric 95 (14%) 26 (9%) General and constitutional 20 (3%) 8 (3%) Neurologic 32 (5%) 16 (5%) Dermologic 31 (5%) 9 (3%) ENT/optho 6 (1%) 2 (1%) other 65 (9%) 27 (9%) Open table in a new tab

The prevalence of cocaine and methamphetamine use is increasing. The cardiovascular consequences from chronic use of these agents includes cardiomyopathy. Although there is substantial data on cocaine induced cardiomyopathy, there is a paucity of data surrounding methamphetamine induced cardiomyopathy. Clinical publications suggest that the etiology of the cardiac complications from these agents are similar, however this has not be shown

Study objectives: The diagnosis of congestive heart failure (CHF) is difficult because physical examination and chest radiograph findings are not reliably identified. We describe the frequency of specific physical examination findings and chest radiograph evidence of CHF in an emergency department (ED) population and determine whether traditional heart failure risk factors affect the presence of these findings. Methods: Patients were identified from a convenience sample of patients with an ED or inpatient diagnosis of CHF according to medical record review who initially presented with a chief complaint of chest discomfort, dyspnea, or leg edema from October 2000 to December 2003. The presence of the physical examination findings of rales, S3, and jugular venous distention (JVD) was based on physician documentation in the ED. The presence of chest radiograph evidence of CHF was based on the radiologist interpretation, which was not collected until January 2002. Traditional risk factors for CHF analyzed were age older than 60 years, sex, history of diabetes, hypertension, coronary artery disease, CHF, and renal insufficiency (creatinine >1.7 mg/dL). In some instances, these risk factors were based on patient self-report. A univariate analysis was performed to determine whether any of the traditional risk factors were significant predictors of physical examination findings or evidence of CHF on chest radiograph. Any significant variables were entered into a multivariate analysis for each endpoint. Descriptive statistics were used, including χ2 testing; odds ratios (ORs) and 95% confidence intervals (CIs) are given. Results: CHF was diagnosed in 537 patients who met study criteria. Of these patients, the presence of rales was documented in 67% (176/537), S3 2% (10/537), JVD 11% (61/537), and CHF on chest radiograph in 51% (165/321). History of hypertension was a significant multivariate predictor of CHF on chest radiograph. There were no predictors of the presence of an S3. History of CHF and renal insufficiency were predictors of JVD on physical examination. Only age was predictive of the presence of rales (Table). Table, abstract 325 Univariate Analysis, OR (95% CI) Multivariate Analysis, OR (95% CI) CHF on chest radiograph Hypertension 1.8 (1.3–2.9) 1.7 (1.1–2.7) Renal insufficiency 1.6 (1.0–2.6) 1.5 (0.9–3.6) JVD History of CHF 2.2 (1.2–4.1) 2.1 (1.2–4.1) Renal insufficiency 1.9 (1.1–3.2) 1.9 (1.1–3.2) Rales Age >60 y 2.5 (2.7–2.7) 2.4 (1.7–3.6) Renal insufficiency 1.5 (1.0–2.1) 1.4 (0.9–2.0) Open table in a new tab Study objectives: The diagnosis of congestive heart failure (CHF) is difficult because physical examination and chest radiograph findings are not reliably identified. We describe the frequency of specific physical examination findings and chest radiograph evidence of CHF in an emergency department (ED) population and determine whether traditional heart failure risk factors affect the presence of these findings. Methods: Patients were identified from a convenience sample of patients with an ED or inpatient diagnosis of CHF according to medical record review who initially presented with a chief complaint of chest discomfort, dyspnea, or leg edema from October 2000 to December 2003. The presence of the physical examination findings of rales, S3, and jugular venous distention (JVD) was based on physician documentation in the ED. The presence of chest radiograph evidence of CHF was based on the radiologist interpretation, which was not collected until January 2002. Traditional risk factors for CHF analyzed were age older than 60 years, sex, history of diabetes, hypertension, coronary artery disease, CHF, and renal insufficiency (creatinine >1.7 mg/dL). In some instances, these risk factors were based on patient self-report. A univariate analysis was performed to determine whether any of the traditional risk factors were significant predictors of physical examination findings or evidence of CHF on chest radiograph. Any significant variables were entered into a multivariate analysis for each endpoint. Descriptive statistics were used, including χ2 testing; odds ratios (ORs) and 95% confidence intervals (CIs) are given. Results: CHF was diagnosed in 537 patients who met study criteria. Of these patients, the presence of rales was documented in 67% (176/537), S3 2% (10/537), JVD 11% (61/537), and CHF on chest radiograph in 51% (165/321). History of hypertension was a significant multivariate predictor of CHF on chest radiograph. There were no predictors of the presence of an S3. History of CHF and renal insufficiency were predictors of JVD on physical examination. Only age was predictive of the presence of rales (Table).

Study objectives: Aspirin blocks the synthesis of thromboxane A2 and platelet aggregation, making it a potent platelet inhibitor. In the setting of an acute myocardial infarction and unstable angina, these antithrombotic actions facilitate reperfusion of thrombosed coronary vessels. Experimentally, 100 mg of aspirin can inhibit platelet function within 60 minutes of ingestion. According to this, one would expect early aspirin use to decrease cardiac infarct size and, consequently, mortality in the setting of acute myocardial infarction. The goal of this study is to determine whether there is a difference in 30-day mortality between acute myocardial infarction and unstable angina patients ingesting aspirin within 1 hour of emergency department (ED) presentation and those given aspirin after 1 hour of presentation. Methods: This was a retrospective study of prospectively collected data from a registry of undifferentiated chest pain patients presenting to an urban tertiary care ED. The database is composed of a convenience sample of patients enrolled from September 1, 2001, to December 30, 2003, by trained research assistants from 8 am to 2 am 7 days a week. Patients were included in the database if they were older than 30 years, had an ECG performed, and presented with symptoms suggestive of acute coronary syndrome. Patients were included in this study if they had a final diagnosis of acute myocardial infarction or unstable angina. Patients were excluded if data on aspirin administration, aspirin time, or triage time were incomplete. Information collected included patient demographics, cardiac risk factors, medication use, treatments, diagnosis, and disposition. Myocardial infarction was defined in accordance with the World Health Organization criteria, including characteristic chest discomfort and serial elevation of cardiac markers. Unstable angina was defined as chest pain associated with a troponin level in the indeterminate range, a positive diagnostic test, or a stenosis greater than or equal to 70% in 1 or more epicardial coronary arteries on angiography. Follow-up was completed on all patients by telephone contact, medical record review, or death registry review. All reported deaths were included, regardless of cause. Univariate analysis was done to determine the association with cardiac risk factors, ED treatments, cardiac interventions, and final diagnosis with 30-day death. Significant variables (P≤.05) were then entered into a multivariate analysis using logistic regression. Results: The cohort of patients diagnosed with acute myocardial infarction or unstable angina included 527 patients, of whom 19 were excluded. Of these 527 patients, 75% ingested aspirin at home, in the ambulance, or in the ED. Forty-nine percent of patients were diagnosed with acute myocardial infarction, 51% with unstable angina. A total of 21 patients died. Aspirin use less than or equal to 1 hour of ED triage time (P=.008, odds ratio [OR] 0.3, 95% confidence interval [CI] 0.1 to 0.7), percutaneous coronary intervention (P=.01, OR 0.1, 95% CI 0.0 to 0.7), and a diagnosis of acute myocardial infarction (P=.01, OR 3.2, 95% CI 1.3 to 8.0) were significant on univariate analysis. Only aspirin use less than or equal to 1 hour of ED triage time (P=.04, OR 0.35, 95% CI 0.13 to 0.96) was significant on multivariate analysis. There was no difference in sex, age, ethnicity, cardiac risk factors, and ED administration of heparin, nitroglycerin, or β-blockers in patients who died at 30-day follow-up and those who survived. Conclusion: Aspirin use within 1 hour of ED presentation by patients with acute myocardial infarction or unstable angina is associated with a reduction in 30-day mortality compared with those given aspirin 1 hour after presentation. These results suggest that a protocol incorporating the triage administration of aspirin may improve 30-day survival in patients presenting with acute myocardial infarction or unstable angina. Study objectives: Aspirin blocks the synthesis of thromboxane A2 and platelet aggregation, making it a potent platelet inhibitor. In the setting of an acute myocardial infarction and unstable angina, these antithrombotic actions facilitate reperfusion of thrombosed coronary vessels. Experimentally, 100 mg of aspirin can inhibit platelet function within 60 minutes of ingestion. According to this, one would expect early aspirin use to decrease cardiac infarct size and, consequently, mortality in the setting of acute myocardial infarction. The goal of this study is to determine whether there is a difference in 30-day mortality between acute myocardial infarction and unstable angina patients ingesting aspirin within 1 hour of emergency department (ED) presentation and those given aspirin after 1 hour of presentation. Methods: This was a retrospective study of prospectively collected data from a registry of undifferentiated chest pain patients presenting to an urban tertiary care ED. The database is composed of a convenience sample of patients enrolled from September 1, 2001, to December 30, 2003, by trained research assistants from 8 am to 2 am 7 days a week. Patients were included in the database if they were older than 30 years, had an ECG performed, and presented with symptoms suggestive of acute coronary syndrome. Patients were included in this study if they had a final diagnosis of acute myocardial infarction or unstable angina. Patients were excluded if data on aspirin administration, aspirin time, or triage time were incomplete. Information collected included patient demographics, cardiac risk factors, medication use, treatments, diagnosis, and disposition. Myocardial infarction was defined in accordance with the World Health Organization criteria, including characteristic chest discomfort and serial elevation of cardiac markers. Unstable angina was defined as chest pain associated with a troponin level in the indeterminate range, a positive diagnostic test, or a stenosis greater than or equal to 70% in 1 or more epicardial coronary arteries on angiography. Follow-up was completed on all patients by telephone contact, medical record review, or death registry review. All reported deaths were included, regardless of cause. Univariate analysis was done to determine the association with cardiac risk factors, ED treatments, cardiac interventions, and final diagnosis with 30-day death. Significant variables (P≤.05) were then entered into a multivariate analysis using logistic regression. Results: The cohort of patients diagnosed with acute myocardial infarction or unstable angina included 527 patients, of whom 19 were excluded. Of these 527 patients, 75% ingested aspirin at home, in the ambulance, or in the ED. Forty-nine percent of patients were diagnosed with acute myocardial infarction, 51% with unstable angina. A total of 21 patients died. Aspirin use less than or equal to 1 hour of ED triage time (P=.008, odds ratio [OR] 0.3, 95% confidence interval [CI] 0.1 to 0.7), percutaneous coronary intervention (P=.01, OR 0.1, 95% CI 0.0 to 0.7), and a diagnosis of acute myocardial infarction (P=.01, OR 3.2, 95% CI 1.3 to 8.0) were significant on univariate analysis. Only aspirin use less than or equal to 1 hour of ED triage time (P=.04, OR 0.35, 95% CI 0.13 to 0.96) was significant on multivariate analysis. There was no difference in sex, age, ethnicity, cardiac risk factors, and ED administration of heparin, nitroglycerin, or β-blockers in patients who died at 30-day follow-up and those who survived. Conclusion: Aspirin use within 1 hour of ED presentation by patients with acute myocardial infarction or unstable angina is associated with a reduction in 30-day mortality compared with those given aspirin 1 hour after presentation. These results suggest that a protocol incorporating the triage administration of aspirin may improve 30-day survival in patients presenting with acute myocardial infarction or unstable angina.

Study Objectives: To determine the test performance characteristics of serum cardiac troponin T (cTnT) measurement for diagnosis of acute myocardial infarction (AMI), and to determine the ability of cTnT to stratify emergency department patients with chest pain into high- and low-risk groups for cardiac complications. Methods: We conducted a prospective observational cohort study with convenience sampling in a tertiary care, urban ED. The study sample comprised 667 patients presenting to the ED with a complaint of chest pain or other symptoms suggesting acute ischemic coronary syndrome (AICS). Patients were assigned to different blood sampling protocols for cTnT therapy on the basis of their ECG at presentation: nondiagnostic for AMI at 0, 3, 6, 9, 12, and 24 hours after ED presentation; or ECG diagnostic for AMI at 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 18, and 24 hours after ED presentation. Results: Of 667 patients, 34 had AMI diagnosed within 24 hours of ED arrival. Using a .2 μg/L discrimination level for cTnT, sensitivity for AMI within 24 hours of ED arrival was 97% (95% confidence interval, 91.4% to 99.9%), and specificity was 92% (89.8%-94.1%). When the effects of age, race, sex, and creatine kinase–MB isoenzyme subunit test results were controlled, a patient with cTnT of .2 μg/L or greater was 3.5 (1.4 to 9.1) times more likely to have a cardiac complication within 60 days of ED arrival than a patient with a cTnT value below .2 μg/L. Conclusion: Measurement of cTnT will accurately identify myo cardial necrosis in patients presenting to the ED with possible AICS. Elevated cTnT values identify patients at increased risk of cardiac complications. [Sayre MR, Kaufmann KH, Chen I-W, Sperling M, Sidman RD, Diercks DB, Liu T, Gibler WB: Measurement of cardiac troponin T is an effective method for predicting complications among emergency department patients with chest pain. Ann Emerg Med May 1998;31:539-549.]