Background: European data support the use of low high-sensitivity troponin (hs-cTn) measurements or a 0/1-hour (0/1-h) algorithm for myocardial infarction (MI) or to exclude major adverse cardiac events (MACE) among Emergency Department (ED) patients with possible acute coronary syndrome (ACS). However, modest US data exist to validate these strategies. This study evaluated the diagnostic performance of an initial hs-cTnT measure below the limit of quantification (LOQ: 6 ng/L), a 0/1-h algorithm, and their combination with HEART scores for excluding MACE in a multisite US cohort. Methods: A prospective cohort study was conducted at 8 US sites, enrolling adult ED patients with symptoms suggestive of ACS and without ST-elevation on electrocardiogram. Baseline and 1-hour blood samples were collected and hs-cTnT (Roche, Basel Switzerland) measured. Treating providers blinded to hs-cTnT results prospectively calculated HEART scores. MACE (cardiac death, MI, and coronary revascularization) at 30-days was adjudicated. The proportion of patients with initial hs-cTnT measures <LOQ and risk based on a 0/1-h algorithm was determined. The negative predictive value (NPV) was calculated for both strategies when used alone or with a HEART score. Results: Among 1,462 participants with initial hs-cTnT measures, 46.4% (678/1,462) were women and 37.1% (542/1,462) were African American with a mean age of 57.6 (SD±12.9) years. MACE at 30-days occurred in 14.4% (210/1,462). Initial hs-cTnT measures <LOQ occurred in 32.8% (479/1,462), yielding a NPV of 98.3% (95%CI: 96.7-99.3%) for 30-day MACE. A low risk HEART score with an initial hs-cTnT < LOQ occurred in 20.1% (294/1,462) yielding a NPV of 99.0% (95%CI: 97.0-99.8%) for 30-day MACE. A 0/1-h algorithm was complete in 1,430 patients, ruling-out 57.8% (826/1,430) with a NPV of 97.2% (95%CI: 95.9-98.2%) for 30-day MACE. Adding a low HEART score to the 0/1-h algorithm ruled-out 30.8% (441/1430) with a NPV of 98.4% (95%CI: 96.8-99.4%) for 30-day MACE. Conclusions: In a prospective multisite US cohort, an initial hs-cTnT <LOQ combined with a low risk HEART score has 99% NPV for 30-day MACE. The 0/1-h hs-cTnT algorithm did not achieve a NPV > 99% for 30-day MACE when used alone or with a HEART score. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT02984436

Background For patients resuscitated from out-of-hospital cardiac arrest (OHCA), the American Heart Association recommends regionalized care at cardiac resuscitation centers that are aligned with ST-elevation myocardial infarction (STEMI) centers. The effectiveness of treatment at STEMI centers remains unknown. Objective To evaluate whether good neurologic recovery following OHCA is associated with treatment at a STEMI center, and if volume of admitted OHCA patients is associated with good neurologic recovery. Methods We included patients in the 2011 California Office of Statewide Health Planning and Development database with a “present on admission” diagnosis of cardiac arrest. Primary outcome was good neurologic recovery at hospital discharge. Hierarchical multiple logistic regression models were used to determine the association between treating hospital and good neurologic recovery after adjusting for patient factors (age, sex, race, ethnicity, insurance type, and ventricular arrest rhythm) and hospital factors (hospital size, ICU bed days, trauma center designation, and teaching status). Results We included 7,725 patients; two-thirds (5,202) were treated at a STEMI center and 1,869 (24%, 95%CI 23–25%) had good neurologic recovery. After adjustment, treatment at a STEMI center with ≥40 and <40 OHCA cases/year were associated with good neurologic recovery [OR 1.32 (95%CI 1.06–1.64) and 1.63 (95%CI 1.35–1.97), respectively]. Higher volume of admitted OHCA patients was associated with decreased odds of good neurologic recovery (adjusted OR per 10 patients 0.96, 95%CI 0.92–1.00) but this association was not statistically significant after excluding the highest-volume outlier. Conclusions Treatment at a STEMI center – regardless of its annual OHCA volume – following resuscitation from OHCA is associated with good neurologic recovery. Regionalized systems of care should prioritize STEMI centers as destinations for resuscitated OHCA patients.

Objectives Emergency department (ED) crowding is an increasing problem associated with adverse patient outcomes. ED expansion is one method advocated to reduce ED crowding. The objective of this analysis was to determine the effect of ED expansion on measures of ED crowding. Methods This was a retrospective study using administrative data from two 11-month periods before and after the expansion of an ED from 33 to 53 adult beds in an academic medical center. ED volume, staffing, and hospital admission and occupancy data were obtained from either the electronic health record or administrative records. The primary outcome was the rate of patients who left without being treated (LWBT), and the secondary outcome was total ED boarding time for admitted patients. A multivariable robust linear regression model was used to determine whether ED expansion was associated with the outcome measures. Results The mean daily adult volume was 128 (SD ±14) patients before expansion, and 145 (SD ±17) patients after. The percentage of patients who LWBT was unchanged: 9.0% before expansion, vs 8.3% after expansion (difference 0.6%, 95% CI = −0.16% to 1.4%). Total ED boarding time increased from 160 to 180 hours/day (difference 20 hours, 95% CI = 8 to 32 hours). After adjusting for daily ED volume, low-acuity area volume, daily wait time, daily boarding hours, and nurse staffing, the decrease in patients who LWBT was not independently associated with ED expansion (p = 0.053). After adjusting for ED admissions, ED intensive care unit admissions, elective surgical admissions, hospital occupancy rate, ICU occupancy rate, and number of operational ICU beds, the increase in ED boarding hours was independently associated with the ED expansion (p = 0.005). Conclusions An increase in ED bed capacity was associated with no significant change in the percentage of patients who LWBT, but had an unintended consequence of an increase in ED boarding hours. ED expansion alone does not appear to be an adequate solution to ED crowding.

Background Sex differences exist in the diagnosis and treatment of several cardiovascular diseases. Our objective was to determine whether sex differences exist in the use of guideline-recommended treatments in out-of-hospital cardiac arrest (OHCA). Methods We included adult patients with non-traumatic OHCA treated by emergency medical services (EMS) in the Resuscitation Outcomes Consortium Prehospital Resuscitation using an IMpedance valve and Early versus Delayed (ROC PRIMED) database during 2007–2009. Outcomes included prehospital treatment intervals, procedures, and medications. Data were analysed using multivariable linear and logistic regression models that adjusted for sex, age, witnessed arrest, public location, bystander cardiopulmonary resuscitation (CPR), and first known rhythm of ventricular tachycardia/fibrillation. Results We studied 15,584 patients; 64% were male and median age was 68 years (interquartile range 55–80). In multivariable analyses, intervals from EMS dispatch to first rhythm capture (p=0.001) and first EMS CPR (p=0.001) were longer in women than in men. Women were less likely to receive successful intravenous or intraosseous access (OR 0.78, 95% CI 0.71–0.86) but equally likely to receive a successful advanced airway (OR 0.94, 95% CI 0.86–1.02). Women were less likely to receive adrenaline (OR 0.81, 95% CI 0.74–0.88), atropine (OR 0.86, 95% CI 0.80–0.92), and lidocaine or amiodarone (OR 0.68, 95% CI 0.61–0.75). Conclusion Women were less likely than men to receive guideline-recommended treatments for OHCA. The reasons for these differences require further exploration, and EMS provider education and training should specifically address these sex differences in the treatment of OHCA.

Sex, race, and insurance status were independently associated with post-arrest care interventions, patient outcomes and treatment at a 24/7 PCI center. More studies are needed to fully understand the causes and implications of these disparities.