AimsThis randomized controlled trial (RCT) evaluated whether a process with single combined testing of copeptin and troponin at admission in patients with low-to-intermediate risk and suspected acute coronary syndrome (ACS) does not lead to a higher proportion of major adverse cardiac events (MACE) than the current standard process (non-inferiority design).Methods and resultsA total of 902 patients were randomly assigned to either standard care or the copeptin group where patients with negative troponin and copeptin values at admission were eligible for discharge after final clinical assessment. The proportion of MACE (death, survived sudden cardiac death, acute myocardial infarction (AMI), re-hospitalization for ACS, acute unplanned percutaneous coronary intervention, coronary artery bypass grafting, or documented life threatening arrhythmias) was assessed after 30 days. Intention to treat analysis showed a MACE proportion of 5.17% [95% confidence intervals (CI) 3.30–7.65%; 23/445] in the standard group and 5.19% (95% CI 3.32–7.69%; 23/443) in the copeptin group. In the per protocol analysis, the MACE proportion was 5.34% (95% CI 3.38–7.97%) in the standard group, and 3.01% (95% CI 1.51–5.33%) in the copeptin group. These results were also corroborated by sensitivity analyses. In the copeptin group, discharged copeptin negative patients had an event rate of 0.6% (2/362).ConclusionAfter clinical work-up and single combined testing of troponin and copeptin to rule-out AMI, early discharge of low- to intermediate risk patients with suspected ACS seems to be safe and has the potential to shorten length of stay in the ED. However, our results need to be confirmed in larger clinical trials or registries, before a clinical directive can be propagated.

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The majority of emergency patients lack diagnosis-specific symptoms. Chief complaints help preselect patients but must not be mistaken as disease specific. Mortality largely differs depending on the chief complaint. In chest pain patients, standardized processes may be one factor that explains the low mortality in this group.

In a pig model for AMI, we observed that selective CRP-apheresis significantly reduces CRP levels and the volume of the infarction zone after AMI. Additionally, it changes the morphology of the scars and preserves cardiac output (LVEF).

ObjectivesThe increasing number of low-acuity visits to emergency departments (ED) is an important issue in Germany, despite the fact that all costs of inpatient and outpatient treatment are covered by mandatory health insurance. We aimed to explore the motives of patients categorised with low-acuity conditions for visiting an ED.MethodsWe conducted a qualitative study in two urban and one rural ED. We recruited a purposive sample of adults, who were assigned to the lowest two categories in the Manchester triage system. One-to-one interviews took place in the ED during patients' waiting time for treatment. Interview transcripts were analysed using the qualitative data management software MAXQDA. A qualitative content analysis approach was taken to identify motives and to compare the rural with the urban sites.ResultsA total of 86 patients were asked to participate; of these, n=15 declined participation and n=7 were excluded because they were admitted as inpatients, leaving a final sample of 40 female and 24 male patients. We identified three pathways leading to an ED visit: (1) without primary care contact, (2) after unsuccessful attempts to see a resident specialist or general practitioner (GP) and (3) recommendation to visit the ED by an outpatient provider. The two essential motives were (1) convenience and (2) health anxiety, triggered by time constraints and focused usage of multidisciplinary medical care in a highly equipped setting. All participants from the rural region were connected to a GP, whom they saw more or less regularly, while more interviewees from the urban site did not have a permanent GP. Still, motives to visit the ED were in general the same.ConclusionsWe conclude that the ED plays a pivotal role in ambulatory acute care which needs to be recognised for adequate resource allocation.Trial registration numberDRK S00006053

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Objective-Soluble fms-like tyrosine kinase 1 (sFlt1) is involved in the pathophysiology of preeclampsia and coronary artery disease.Because sFlt1 has a heparin-binding site, we investigated whether or not heparin releases sFlt1 from the extracellular matrix. Methods and Results-We measured sFlt1 before and after heparin administration in 135 patients undergoing coronary angiography, percutanous coronary intervention, or both. sFlt1 was increased directly after heparin administration (from 254 to 13 440 pg/mL) and returned to baseline within 10 hours. Umbilical veins and endothelial cells treated with heparin released sFlt1. Heparinase I and III also increased sFlt1. Mice treated with heparin had elevated sFlt1 serum levels. Their serum inhibited endothelial tube formation. The time point showing values directly after CA/PCI is divided into CA only (single-dose heparin) and PCI (second dose). nϭ135, Pϭ0.0009. In patients with high sFlt1 values before PCI, blood was drawn after heparin administration. B, Placental growth factor (PLGF) and vascular endothelial growth factor (VEGF) before and after heparin and sFlt1/PLGF and sFlt1/VEGF ratios. nϭ20, *PϽ0.0001 and †PϽ0.05 vs at admission. Conclusion-Heparin

ImportanceBoarding in the emergency department (ED) is a critical indicator of quality of care for hospitals. It is defined as the time between the admission decision and departure from the ED. As a result of boarding, patients stay in the ED until inpatient beds are available; moreover, boarding is associated with various adverse events.