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The Impact of Depression on ED Stays in ACS Patients

The Impact of Depression on ED Stays in ACS Patients

Studies suggest that about 30% of patients with acute coronary syndrome (ACS) experience symptoms of depression during hospitalization. These patients are nearly twice as likely to die from ACS or have recurrent cardiac disease when compared with those who aren’t depressed. The ED is often the first point of contact for treating ACS patients, and recent research suggests that psychosocial factors may impact aspects of care in the ED, including length of stay (LOS). Depression, ACS, & LOS It has been hypothesized that longer ED LOS may be associated with adverse clinical outcomes for those with ACS, especially among those with depression. In a recent issue of BMC Emergency Medicine, my colleagues and I sought to determine if depressed ACS patients experienced different ED care than those without depression. After reviewing data from 120 participants, we found that currently depressed ACS patients spent an average of 5.4 more hours in the ED than those who had never been depressed. Not surprisingly, our study also revealed that presentation to the ED during off-peak hours was associated with longer ED LOS. Interestingly, no significant associations were observed with other demographic variables that might be expected to influence ED LOS, including race, ethnicity, or neighborhood income. Furthermore, these variables did not appear to account for the association between depression and ED LOS. Making Interpretations Data from our study are preliminary, but indicate that there is likely an association between depression and longer ED LOS. There are several possible explanations for this finding. Depression may influence how ACS patients present to the ED, report their symptoms, recruit family members or friends to accompany...

Trends in AF Among Hospitalized ACS Patients

Among patients hospitalized with an acute coronary syndrome (ACS), overall rates of atrial fibrillation (AF) and mortality from it decreased between 2000 and 2007, according to a study from Massachusetts.  Despite the findings, investigators noted that AF still exerts a significant adverse effect on survival among patients hospitalized with an ACS. Improving the identification and treatment of ACS patients who have AF or are at risk for it may reduce the incidence and resultant complications of the dysrhythmia. Abstract: American Journal of Medicine, November...

Optimizing Chest Pain Diagnoses in the ED

An estimated 8 million people present to EDs in the United States with chest pain each year, 15% to 25% of whom receive a diagnosis of acute coronary syndrome (ACS). Of this group, between 2% and 5% are discharged home without an ACS diagnosis but receive one within 30 days. Due to a fear of missing this subset of patients, many people presenting to the ED with chest pain are unnecessarily admitted to the hospital for observation and further investi­gation. These cases can clog EDs, increase the likelihood of unneeded testing, and increase healthcare costs (see also, A New Look at Leaving Without Being Seen in EDs). Algorithm to Manage Chest Pain Put to the Test My colleagues and I in the department of emergency medi­cine collaborated with the cardiology and nuclear medicine departments at our hospital. We developed an algorithm designed to streamline approaches for managing patients with potential cardiac chest pain. Our algorithm was evaluated in a study published in the April 2012 Annals of Emergency Medicine. With the algorithm, patients who presented to the ED with chest pain underwent a full history and physical examina­tion, along with EKG and biomarker testing. Patients with high-risk clinical features (eg, worsening angina or an EKG suspicious for ischemia or positive troponins) were referred to the cardiology department immediately. The remainder of patients had tests repeated at both 2 and 6 hours. Those who developed new pain, had ongoing pain, had changes on EKG, or had subsequent positive troponin levels were referred to the cardiology department as well. If patients did not have high-risk clinical features, had a normal EKG,...

Revascularizing Occluded Arteries: Assessing the Influence of Guidelines

The Occluded Artery Trial (OAT) was a large, randomized controlled study funded by the National Heart, Lung, and Blood Institute that tested routine percutaneous recanalization of persistently totally occluded infarct-related arteries identified a minimum of 24 hours after myocardial infarction (MI) in stable patients who did not have triple vessel disease or severe inducible ischemia. In 2006, results from OAT were released, showing that there appears to be no benefit to routinely using PCI for persistently totally occluded infarct-related arteries in this patient population. Routine PCI for these arteries did not reduce mortality, reinfarction, or class IV heart failure. These results subsequently led to updates of guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) on unstable angina/non-STEMI, STEMI, and PCI in 2007. The revised guidelines recommended that PCI not be performed in this context. Prior to OAT data being released, clinicians tended to favor using PCI for persistent infarct-related artery occlusions largely because of experimental and observational data. “OAT results demonstrated that use of PCI did not lead to a reduction in clinical events,” explains Judith S. Hochman, MD. “The beneficial effect on angina and quality of life was small and not durable. OAT also suggested that PCI was more costly than optimal medical therapy alone. As a result, these findings should have discouraged routine PCI in this setting.” Assessing the Impact of the OAT Study In the October 10, 2011 Archives of Internal Medicine, Dr. Hochman and colleagues had a study published in which they examined whether PCI use for treating occluded infarct-related arteries after an MI decreased following the publication of OAT...

ACC.12 Highlights for Surgeons

New research was recently presented at ACC.12, the annual scientific meeting of the American College of Cardiology, from March 24-27 in Chicago. The features below highlight just some of the studies that emerged from the meeting that pertain specifically to the surgeon audience.  >> Positive Outcomes Observed With TAVI >> Assessing the Safety of On- & Off-Pump CABG >> TAVR Comparable to Open-Heart Surgery at 2 Years >> Bariatric Surgery Yields Big Rewards for Obese Diabetics >> Underweight Patients at Increased Risk During ICD Procedures >> Improving the Quality of ACS Care       Positive Outcomes Observed With TAVI The Particulars: Transcatheter aortic valve implantation (TAVI) involves insertion of a bioprosthetic valve into a diseased native aortic valve and represents a potentially less invasive option than surgical replacement. Currently, TAVI has been used mostly in non-operable patients. Data Breakdown: A study was conducted in high-risk patients with severe aortic stenosis who underwent TAVI at 44 centers. Major adverse cardiac and cerebrovascular events at 30-days follow-up occurred in 8.3% of patients receiving TAVI. Total mortality, cardiac mortality, stroke, and life-threatening or disabling bleeding rates were 4.5%, 2.2%, 2.9%, and 4.9%, respectively. Persistent, significant improvements in aortic valve function were also observed. Take Home Pearl: In high operative risk and non-operable patients, TAVI appears to be safe and effective. Assessing the Safety of On- & Off-Pump CABG The Particulars: CABG is one of the most commonly performed cardiac operations, but small randomized trials and meta-analyses have yet to determine conclusively if less-invasive off-pump CABG has better outcomes than on-pump CABG. Data Breakdown: A trial of nearly 5,000 patients with coronary artery disease...
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