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Objective: Delays in care for patients with acute cardiac complaints are associated with increased morbidity and mortality. The objective of this study was to quantify rural and urban differences in prehospital time intervals for patients with cardiac complaints., Methods: The ESO Data Collaborative dataset consisting of records from 1332 EMS agencies was queried for 9-1-1 encounters with acute cardiac problems among adults (age ≥ 18) from 1/1/2013-6/1/2018. Location was classified as rural or urban using the 2010 United States Census. The primary outcome was total prehospital time. Generalized estimating equations evaluated differences in the average times between rural and urban encounters while controlling for age, sex, race, transport mode, loaded mileage, and patient stability., Results: Among 428,054 encounters, the median age was 62 (IQR 50-75) years with 50.7% female, 75.3% white, and 10.3% rural. The median total prehospital, response, scene, and transport times were 37.0 (IQR 29.0-48.0), 6.0 (IQR 4.0-9.0), 16.0 (IQR 12.0-21.0), and 13.0 (IQR 8.0-21.0) minutes. Rural patients had an average total prehospital time that was 16.76 min (95%CI 15.15-18.38) longer than urban patients. After adjusting for covariates, average total time was 5.08 (95%CI 4.37-5.78) minutes longer for rural patients. Average response and transport time were 4.36 (95%CI 3.83-4.89) and 0.62 (95%CI 0.33-0.90) minutes longer for rural patients. Scene time was similar in rural and urban patients (0.09 min, 95%CI -0.15-0.33)., Conclusion: Rural patients with acute cardiac complaints experienced longer prehospital time than urban patients, even after accounting for other key variables, such as loaded mileage., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The HEART Pathway combines a History ECG Age Risk factor (HEAR) score and serial troponins to risk stratify patients with acute chest pain. However, it is unclear whether patients with HEAR scores of < 1 require troponin testing. The objective of this study is to measure the major adverse cardiac event (MACE) rate among patients with < 1 HEAR scores and determine whether serial troponin testing is needed to achieve a miss rate <1%., Methods: A secondary analysis of the HEART Pathway Implementation Study was conducted. HEART Pathway risk assessments (HEAR scores and serial troponin testing at 0 and 3 hours) were completed by the providers on adult patients with chest pain from three US sites between November 2014 and January 2016. MACE (composite of death, myocardial infarction (MI) and coronary revascularisation) at 30 days was determined. The proportion of patients with HEAR scores of < 1 diagnosed with MACE within 30 days was calculated. The impact of troponin testing on patients with HEAR scores of < 1 was determined using Net Reclassification Improvement Index (NRI)., Results: Providers completed HEAR assessments on 4979 patients and HEAR scores<1 occurred in 9.0% (447/4979) of patients. Among these patients, MACE at 30 days occurred in 0.9% (4/447; 95% CI 0.2% to 2.3%) with two deaths, two MIs and 0 revascularisations. The sensitivity and negative predictive value for MACE in the HEAR < 1 was 97.8% (95%CI 94.5% to 99.4%) and 99.1% (95% CI 97.7% to 99.8%), respectively, and were not improved by troponin testing. Troponin testing in patients with HEAR < 1 correctly reclassified two patients diagnosed with MACE, and was elevated among seven patients without MACE yielding an NRI of 0.9% (95%CI -0.7 to 2.4%)., Conclusion: These data suggest that patients with HEAR scores of 0 and 1 represent a very low-risk group that may not require troponin testing to achieve a missed MACE rate <1%. Trial registration number NCT02056964., Competing Interests: Competing interests: SAM receives research funding from Roche Diagnostics, Abbott Point of Care, Ortho Clinical Diagnostics, Creavo Medical Technologies, PCORI, AHRQ and NHLBI (1 R01 HL11826301). He is a consultant for Roche Diagnostics and Amgen. SAM is the chief medical officer for Impathiq. JPS receives research funding from Roche Diagnostics and Abbott Point of Care. LS receives research funding from Forest Devices and the NHLBI (1 R01 HL144624-01). CDM receives research funding from Abbott, Siemens, NHLBI 118263, Creavo Medical Technologies., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Mechanical circulatory support is now widely accepted as a viable long-term treatment option for patients with end-stage heart failure (HF). As the range of indications for the implantation of ventricular assist devices grows, so does the number of patients living in the community with durable support. Because of their underlying disease and comorbidities, in addition to the presence of mechanical support, these patients are at a high risk for medical urgencies and emergencies (Table 1). Thus, it is the responsibility of clinicians to understand the basics of their emergency care. This consensus document represents a collaborative effort by the Heart Failure Society of America, the Society for Academic Emergency Medicine, and the International Society for Heart and Lung Transplantation (ISHLT) to educate practicing clinicians about the emergency management of patients with ventricular assist devices. The target audience includes HF specialists and emergency medicine physicians, as well as general cardiologists and community-based providers., (Copyright © 2019 Elsevier Inc., International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: The Emergency Department Assessment of Chest pain Score-Accelerated Diagnostic Protocol (EDACS-ADP) is a decision aid designed to safely identify emergency department (ED) patients with chest pain for early discharge. Derivation and validation studies in Australasia have demonstrated high sensitivity (99%-100%) for major adverse cardiac events (MACE)., Objectives: To validate the EDACS-ADP in a cohort of US ED patients with symptoms suspicious for acute coronary syndrome (ACS)., Methods: A secondary analysis of participants enrolled in the HEART Pathway Randomized Controlled Trial was conducted. This single-site trial enrolled 282 ED patients≥21 years old with symptoms concerning for ACS, inclusive of all cardiac risk levels. Each patient was classified as low risk or at risk by the EDACS-ADP based on EDACS, electrocardiogram, and serial troponins. Potential early discharge rate and sensitivity for MACE at 30 days, defined as cardiac death, myocardial infarction (MI), or coronary revascularization were calculated., Results: MACE occurred in 17/282 (6.0%) participants, including no deaths, 16/282 (5.6%) with MI, and 1/282 (0.4%) with coronary revascularization without MI. The EDACS-ADP identified 188/282 patients [66.7%, 95% confidence interval (CI): 60.8%-72.1%] as low risk. Of these, 2/188 (1.1%, 95% CI: 0.1%-3.9%) had MACE at 30 days. EDACS-ADP was 88.2% (95% CI: 63.6%-98.5%) sensitive for MACE, identifying 15/17 patients. Of the 2 patients identified as low risk with MACE, 1 had MI and 1 had coronary revascularization without MI., Conclusions: Within a US cohort of ED patients with symptoms concerning for ACS, sensitivity for MACE was 88.2%. We are unable to validate the EDACS-ADP as sufficiently sensitive for clinical use.

Objective: To describe changes in out-of-hospital cardiac arrest (OOHCA) survival before and after the release of the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC)., Methods: Data were extracted from an OOHCA registry for 1,681 adult cases of cardiac arrest treated by one emergency medical services (EMS) system between April 1, 2004, and December 31, 2007, in a large city (2005 population 730,657). The primary endpoint was survival to hospital discharge. A convenience sample of 69 electronic electrocardiogram (ECG) recordings was reviewed to assess CPR quality parameters using impedance waveform analysis during corresponding time periods. Intervention. Implementation of the 2005 AHA guidelines for CPR and ECC in spring 2006., Results: The annual treated OOHCA incidence rate was 68/100,000; and the treated ventricular fibrillation (VF) incidence rate was 15/100,000. Bystanders performed CPR in 28% of cases. Public automated external defibrillator (AED) use was < 2% over the entire study, and few patients received hypothermia therapy. Unadjusted OOHCA survival rates were significantly higher in the postguidelines period at 9.4% (n = 1,021) than in the preguidelines period at 6.1% (n = 660), despite similarities in all major predictors of outcome (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.1 to 2.4). Bystander-witnessed OOHCA survival for victims in VF on EMS arrival was 19 of 78 (24%) in the preguidelines period versus 34 of 112 (30%) in the postguidelines period (OR 1.4; 95% CI 0.7 to 2.6). CPR quality measures showed significant improvement in the postguidelines period. The mean no-flow fraction in the preguidelines group was 0.46 and dropped to 0.34 in the postguidelines group, a difference of 0.12 (95% CI 0.05 to 0.19). Multivariate regression analysis adjusting for significant predictors of survival showed that OOHCA in the postguidelines period was associated with 1.8 greater odds of survival than in the preguidelines period (95% CI 1.2 to 2.7)., Conclusion: In this large city, substantial improvement occurred in overall OOHCA survival rates following the implementation of the 2005 AHA guidelines for CPR and ECC. These changes were associated with improvements in the quality of CPR.

Background: More than one-third of US adults 65 and over fall every year. These falls may cause serious injury including substantial long-term morbidity (due declines in activities of daily living) and death. The emergency department (ED) visit represents an opportunity for identifying high risk elders and potentially instituting falls-related interventions. The unique characteristic of the ED environment and patient population necessitate that risk-assessment modalities be validated in this specific setting. In order to better identify elders at risk of falls, we examined the relationship between patient-provided history of falling and two testing modalities (a balance plate system and the timed up-and-go [TUG] test) in elder emergency department (ED) patients., Methods: We conducted a cross-sectional observational study of patients > or = 60 years old being discharged from the ED. Patient history of falls in the past week, month, 6 months, and year was obtained. Balance plate center of pressure excursion (COP) measurements and TUG testing times were recorded. COP was recorded under four conditions: normal stability eyes open (NSEO) and closed (NSEC), and perturbed stability eyes open and closed. Correlation between TUG and COP scores was measured. Univariate logistic regression was used to identify the relationship between patient-provided falls history and the two testing modalities. Proportions, likelihood ratios, and receiver-operating-characteristic (ROC) curves for prediction of previous falls were reported., Results: Fifty-three subjects were enrolled, 11% had fallen in the previous week and 42% in the previous year. There was no correlation between TUG and any balance plate measurements. In logistic regression, neither testing modality was associated with prior history of falls (p > 0.05 for all time periods). Balance plate NSEO and NSEC testing cutoffs could be identified which were 83% sensitive and had a negative likelihood ratio (LR-) of 0.3 for falls in the past week. TUG testing was not useful for falls in the past week, but performed best for more distant falls in the past month, 6 months, or year. TUG cutoffs with sensitivity over 80% and LR(-) of 0.17-0.32 could be identified for these time periods., Conclusion: Over 40% of community-dwelling elder ED patients report a fall within the past year. Balance plate and TUG testing were feasibly conducted in an ED setting. There is no relationship between scores on balance plate and TUG testing in these patients. In regression analysis, neither modality was significantly associated with patient provided history of falls. These modalities should not be adopted for screening purposes in elders in the ED setting without validation in future studies or as part of multi-factorial risk assessment.

Unlabelled: Numerous studies have documented treatment disparities in patients with acute coronary syndromes based on race and gender. Other causes for treatment disparities may exist., Objectives: To determine if insurance status affects quality of care in patients with acute myocardial infarction (AMI) presenting to academic health centers., Methods: The Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospective multicenter registry of patients with chest pain presenting to the emergency department who receive an electrocardiogram, was used as the database (N = 17,737). A subset of patients who were diagnosed as having AMI were selected from the database (n = 936). Patients were classified as having either ST-segment elevation MI (n = 178) or non-ST-segment elevation MI (n = 758). Insurance status, age, race, and gender were extracted as predictor variables. The influence of predictor variables on treatment modality was investigated using logistic regression, adjusted for clustering within sites., Results: The odds of a self-pay patient with ST-segment elevation MI receiving fibrinolytics were 3.23 (95% CI = 1.56 to 6.69) times higher than for other patients. Patients with Medicare coverage were less likely to receive fibrinolytics (odds ratio [OR] 0.35, 95% CI = 0.19 to 0.65) and tended to undergo percutaneous coronary intervention less often (OR 0.60, 95% CI = 0.36 to 1.01). The odds of a privately insured patient's receiving coronary artery bypass grafting (OR 2.76, 95% CI = 1.62 to 4.72) or percutaneous coronary intervention (OR 1.47, 95% CI = 1.03 to 2.11) were higher than for other patients., Conclusions: Insurance coverage appears to affect treatment in patients with AMI, with self-pay patients more likely to receive less-expensive therapies and insured patients more likely to receive invasive treatments.