Background: Cardiac troponins are highly sensitive for detection of myocardial necrosis and considered the reference standard for diagnosing acute coronary syndromes (ACS). Due to high sensitivity and widespread use in patients with low likelihood of ACS, the positive predictive value (PPV) of elevated troponin for determining ACS may be limited. Methods: From 2006-2007, all patients with elevated troponin ( > 0.03 ng/dL) at our facility were evaluated by an attending cardiologist within 24 hours of a positive troponin in order to determine the presence or absence of ACS. Patients were tracked during their hospitalization with data gathered prospectively in a database maintained for quality purposes. We conducted a cross sectional investigation of patients in this database to ascertain the PPV of elevated troponin for diagnosing ACS. Baseline characteristics and symptoms for patients with and without ACS were compared. Multivariate logistic regression was performed to determine correlations between the diagnosis of ACS and patient characteristics, symptoms and other objective findings. Results: 1018 patients were included. Mean initial troponin value was higher for patients with ACS (0.42 versus 0.13, p < 0.0001). Overall, the PPV of elevated troponin for diagnosing ACS was only 29.8%. The PPV varied widely depending on the initial symptom reported (highest, chest pain 48.8%; lowest, low energy 2.3%). In multivariate logistic regression, few patient characteristics were correlated with ACS, including smoking (odds ratio [OR] 4.36, 95% confidence interval [CI] 2.45-7.76, p < 0.0001) and hyperlipidemia (OR 1.62, 95% CI 1.16-2.27, p=0.005). New electrocardiogram changes (OR 5.43, 95% CI 3.49-8.46, p<0.0001) and troponin value greater than 10 fold above upper limit of normal (OR 2.79, 95% CI 1.12-6.96, p=0.028) were correlated with ACS. The only symptom correlated with ACS was chest pain (OR 5.00, 95% CI 3.51-7.13). Conclusion: Elevated troponin alone has weak PPV for diagnosing ACS when adjudicated by an attending cardiologist. Troponin elevations were observed with various presenting symptoms, and the PPV was dependent on chief complaint. New electrocardiogram changes, level of troponin elevation, chest pain, and smoking were strongly correlated with the diagnosis of ACS.
The American College of Cardiology (ACC) Foundation, along with key specialty and subspecialty societies, conducted an appropriate use review of stress testing and anatomic diagnostic procedures for risk assessment and evaluation of known or suspected chronic coronary disease (CCD), formerly referred to as stable ischemic heart disease (SIHD). This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging, stress echocardiography (echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. As with the prior version of this document, rating of test modalities is provided side-by-side for a given clinical scenario. These ratings are explicitly not considered competitive rankings due to the limited availability of comparative evidence, patient variability, and the range of capabilities available in any given local setting1–4. This version of the AUC for CCD is a focused update of the prior version of the AUC for SIHD4. Key changes beyond the updated ratings based on new evidence include the following: The 64 clinical scenarios rated in this document are limited to the detection and risk assessment of CCD and were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines.5 These clinical scenarios do not specifically address patients having acute chest pain episodes. They may, however, be applicable in the inpatient setting if the patient is not having an acute coronary syndrome and warrants evaluation for CCD. Using standardized methodology, clinical scenarios were developed to describe common patient encounters in clinical practice focused on common applications and anticipated uses of testing for CCD. Where appropriate, the scenarios were developed on the basis of the most current ACC/American Heart Association guidelines. A separate, independent rating panel scored the clinical scenarios in this document on a scale of 1 to 9, following a modified Delphi process consistent with the recently updated AUC development methodology. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented, midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is rarely appropriate.
Cardiac rehabilitation after transcatheter aortic valve replacement (TAVR) safely improves exercise tolerance, functional independence, and quality of life. However, barriers such as transportation, cost, and limited access to rehabilitation programs prohibits participation. In 2010, the Veterans Affairs Medical Center (VAMC) started a 12-week home-based cardiac rehabilitation (HBCR) program at 13 sites around the country to increase participation by reducing such barriers. We present the findings of HBCR in post-TAVR patients from the VAMC in Gainesville, FL, USA. Fifty-nine patients who underwent TAVR between 2015 and 2018 at the Gainesville VA were offered HBCR. Forty-one patients enrolled, 28 completed the program, and 14 completed the surveys. We used various performance measures including Life's Simple 7 survey, 6-min Walk (6-MW), Duke Activity Survey Index (DASI), and Short Form-36 (SF-36) health survey to assess the pre and post-HBCR changes in emotional, functional, and physical well-being of the patients. Paired comparison of pre and post-HBCR using Wilcoxon signed-rank test revealed a statistically significant difference in the pre and post-HBCR scores for DASI, DASI-Mets, and SF-36 physical functioning (p values 0.05, 0.034, and 0.016, respectively), suggesting an improvement in the patients' physical functioning after participating in the HBCR program. In conclusion, our pilot study offers novel insight into the role of HBCR in improving physical health and well-being in post-TAVR patients while eliminating the barriers of transportation and access to cardiac rehabilitation programs.
Background Preprocedural cardiac evaluation is a common reason for outpatient cardiology visits. Many patients who are referred to cardiology clinics for preprocedural evaluation are at low risk of perioperative events and do not require any further management. Our facility treats patients over a large geographic area; avoiding low-value consultations reduces time and travel burdens for patients. Objective Our study objective was to assess the impact of a novel algorithm in the electronic order entry system aimed to guide clinicians toward patients who may benefit from cardiovascular referral. Methods We retrospectively reviewed in-person consultations and electronic consultations (e-consults) to our cardiology service before and after implementation of the novel algorithm to assess changes in patterns of care. Data were stored in a custom electronic database on internal servers. Results We reviewed 603 consultations to our cardiology clinic and found that 89 (14.7%) were sent for preprocedural evaluation. Of these, 39 (43.8% of preprocedural consultations) were e-consults. After implementation, we reviewed 360 consultations. The proportion of consultations for preprocedural evaluation did not decrease (n=47, 13.0%; P=.39). We observed an absolute increase of 13.6% in the proportion of consultations ordered as e-consults (27/47, 57.4%). During the postintervention period, we received no remarks, concerns, or criticisms from ordering clinicians about the process change and no reports of adverse events. Conclusions Implementation of an ordering algorithm to reduce low-value preprocedural cardiology evaluations did not lead to a reduction in the number of overall preprocedural cardiology consultations. The number of patients seen electronically increased, potentially improving clinic access and reducing travel burden for patients.
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