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2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

https://caltcm.memberclicks.net/assets/documents/acc_aha_chf_2013_guidelines.pdf

2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

ACC/AHA
: American College of Cardiology/American Heart Association
ACCF/AHA
: American College of Cardiology Foundation/American Heart Association
ACE
: angiotensin-converting enzyme
ACEI
: angiotensin-converting enzyme inhibitor
ACS
: acute coronary syndrome
AF
: atrial fibrillation

/pdf/2016-esc-guidelines-for-the-diagnosis-and-treatment-of-acute-z18hg30pp1.pdf

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation : The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC).

/pdf/2015-esc-guidelines-for-the-management-of-acute-coronary-6did6h5nxk.pdf

2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC)

Cocktails for two.


 Introduction:
 AHA guidelines recommend non-invasive cardiac testing (NIT) within 72 hours after an emergency department (ED) evaluation for suspected acute coronary syndrome (ACS), after acute myocardial infarction (AMI) has been excluded. However, the effectiveness of this strategy to reduce the risk of future AMI or death, in low-risk patients is contested.
 
 
 Hypothesis:
 We hypothesized that in patients with low risk based on history, electrocardiogram, age, risk factors and troponin (HEART) based scoring, early NIT may not be beneficial compared to higher risk.
 
 
 Methods:
 We compared the effectiveness of early NIT vs. no early testing, in a retrospective cohort of adult (age ≥18) members of the Kaiser Permanente Southern California health system from 05/2016-12/2020. We included all adults presenting at EDs with suspected ACS and who had data to compute HEART score. We stratified the cohort into low risk (score 0-3); intermediate risk (score 4-6) and high-risk (score ≥7) based on HEART score. Within each group, confounder adjusted instrumental variables models were used to evaluate the marginal effect of early NIT, and the number needed to treat (NNT) was calculated as the inverse of the absolute composite risk reduction in death/AMI within 30 days of ED discharge.
 
 
 Results:
 The cohort included 174,936 patients [61% Low risk (mean age 53; female 58%; early NIT 5%), 36% intermediate risk (mean age 71; female 72%; early NIT 18%), and 3% high risk (mean age 74, female 45%; early NIT 23%)]. The risk reduction in 30-day death/AMI due to early NIT increased progressively through the intermediate-risk (NNT = 59) and high-risk groups (NNT = 24) (Table 1). Risk reduction in the low-risk group was not statistically significant.
 
 
 Conclusions:
 HEART score based high risk patients may benefit the most from early NIT. However, the majority of the suspected ACS cohort was classified as low risk and the benefit of early NIT on 30-day death/AMI was uncertain in this low-risk group.
 
 
 


Abstract 14139: Differential Benefit of Non-Invasive Cardiac Stress Testing by HEART Score Risk Stratification

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(11)61203-8.pdf

Rapid diagnostic protocol for patients with chest pain

Objectives We evaluated the accuracy of using routine health service data to identify hospital-acquired thrombosis (HAT) and major bleeding events (MBE) compared with a reference standard of case note review. Design A multicentre observational cohort study. Setting Four acute hospitals in the UK. Participants A consecutive unselective cohort of general medical and surgical patients requiring hospitalisation for a period of >24 hours during the calendar year 2021. We excluded paediatric, obstetric and critical care patients due to differential risk profiles. Interventions We compared preidentified sources of routinely collected information (using hospital coding data and local contractually mandated thrombosis datasets) to data extracted from case notes using a predesigned workflow methodology. Primary and secondary outcome measures We defined HAT as objectively confirmed venous thromboembolism occurring during hospital stay or within 90 days of discharge and MBE as per international consensus. Results We were able to source all necessary routinely collected outcome data for 87% of 2008 case episodes reviewed. The sensitivity of hospital coding data (International Classification of Diseases 10th Revision, ICD-10) for the diagnosis of HAT and MBE was 62% (95% CI, 54 to 69) and 38% (95% CI, 27 to 50), respectively. Sensitivity improved to 81% (95% CI, 75 to 87) when using local thrombosis data sets. Conclusions Using routinely collected data appeared to miss a substantial proportion of outcome events, when compared with case note review. Our study suggests that currently available routine data collection methods in the UK are inadequate to support efficient study designs in venous thromboembolism research. Trial registration number NIHR127454.

/pdf/accuracy-of-efficient-data-methods-to-determine-the-2xh3773e.pdf

Accuracy of efficient data methods to determine the incidence of hospital-acquired thrombosis and major bleeding in medical and surgical inpatients: a multicentre observational cohort study in four UK hospitals

Objectives & Background We aimed to determine the cost-effectiveness of pre-hospital CPAP compared with standard care for adults presenting to the emergency services with acute respiratory failure. Methods An economic model was developed to explore the costs and health outcomes when pre-hospital CPAP provided by paramedics and standard care (in-hospital non-invasive ventilation (NIV)) were applied to a hypothetical cohort with acute respiratory failure. The model assigned each patient a probability of intubation or death depending upon their characteristics and whether they had pre-hospital CPAP or standard care. The patients that survived accrued lifetime quality-adjusted life year (QALYs) and health care costs according to their age and sex. Costs were accrued through costs of intervention and hospital treatment costs, which depended on patient outcomes. Results Pre-hospital CPAP was more effective than standard care but was also more expensive, with an incremental cost-effectiveness ratio (ICER) of £20,514/QALY and a 49.5% probability of being cost-effective at the £20,000/QALY threshold. The probability of pre-hospital CPAP being cost-effective at the £20,000/QALY threshold depended on the incidence of eligible patients, and varied from 35.4% when a low estimate of incidence was used to 91.3% with a high estimate. If a typical ambulance service treated 175 appropriate patients per year it could save around 11 lives while incurring £241,250 additional costs, whereas if a typical ambulance service treated 2000 appropriate patients per year it could save 124 lives while incurring £876,480 additional costs. Variation in the incidence of eligible patients also had a marked impact on the expected value of sample information for a future randomised trial. Conclusion The cost-effectiveness of pre-hospital CPAP is uncertain and current evidence is insufficient to support widespread implementation. The immediate research priority is to estimate the incidence of patients eligible for pre-hospital CPAP. This appears to be the key determinant of the cost-effectiveness of a future trial and of pre-hospital CPAP itself.

https://emj.bmj.com/content/emermed/31/9/780.2.full.pdf

Steve Goodacre

Papers

Cocktails for two.

Abstract 14139: Differential Benefit of Non-Invasive Cardiac Stress Testing by HEART Score Risk Stratification

Rapid diagnostic protocol for patients with chest pain

Accuracy of efficient data methods to determine the incidence of hospital-acquired thrombosis and major bleeding in medical and surgical inpatients: a multicentre observational cohort study in four UK hospitals

Pre-hospital continuous positive aireway pressure (cpap) for acute respiratory failure: an economic analysis