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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)

Background: Numerous studies have evaluated the accuracy of D-dimer in diagnosing suspected deep vein thrombosis (DVT), but results are conflicting.

Aim: To overview estimates of the diagnostic accuracy of D-dimer and identify causes of variation.

Design: Systematic review, meta-analysis and meta-regression.

Methods: We searched Medline, EMBASE, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, Database of Reviews of Effectiveness, the ACP Journal Club, citation lists, and contacted manufacturers. We selected studies that compared D-dimer to a reference standard in patients with suspected DVT. Data were analysed by random effects meta-analysis and meta-regression.

Results: We included 97 studies reporting 198 assays in 99 different patient groups. Overall estimated sensitivity and specificity of D-dimer were 90.5% and 54.7%, but both estimates were subject to significant heterogeneity ( p < 0.001). Meta-regression identified that some heterogeneity was explained by study setting, exclusion criteria, whether recruitment was consecutive or the study prospective, whether D-dimer and the reference standard were measured blind, and whether the D-dimer threshold was determined a priori . Sensitivity and specificity also varied between ELISA (94% and 45% respectively), latex (89% and 55%) and whole blood agglutination assays (87% and 68%). Sensitivity was higher for proximal than distal DVT. Specificity was dependent upon whether clinical probability of DVT was high (specificity 51%), intermediate (67%) or low (78%).

Discussion: D-dimer has good sensitivity, but poor specificity, for DVT. Estimates are subject to substantial heterogeneity from various sources. D-dimer specificity appears to be strongly dependent upon the pre-test clinical probability of DVT.

/pdf/variation-in-the-diagnostic-performance-of-d-dimer-for-4mmrgc8dyp.pdf

Variation in the diagnostic performance of D-dimer for suspected deep vein thrombosis

Objectives: To establish a chest pain observation unit, monitor its performance in terms of appropriate discharge after assessment, and estimate the cost per patient. 

Methods: Prospective, observational, cohort study of patients attending a large, city, teaching hospital accident and emergency department between 1 March 1999 and 29 February 2000 with acute undifferentiated chest pain. Patients were managed on a chest pain observation unit, entailing two to six hours of observation, serial electrocardiograph recording, cardiac enzyme measurement, and, where appropriate, exercise stress test. Patients were discharged home if all tests were negative and admitted to hospital if tests were positive or equivocal. The following outcomes were measured—proportion of participants discharged after assessment; clinical status three days after discharge; cardiac events and procedures during the following six months; and cost of assessment and admission. 

Results: Twenty three participants (4.3%) had a final diagnosis of myocardial infarction. All were detected and admitted to hospital. A total of 461 patients (86.3%) were discharged after assessment, 357 (66.9%) avoided hospital admission entirely. At review three days later these patients had no new ECG changes and only one raised troponin T measurement. In the six months after assessment, three cardiac deaths, two myocardial infarctions, and two revascularisation procedures were recorded among those discharged. The mean cost of assessment and hospital admission was £221 per patient, or £323 if subsequent interventional cardiology costs were included. 

Conclusions: The chest pain observation unit is a practical alternative to routine care for acute chest pain in the United Kingdom. Negative assessment effectively rules out immediate, serious morbidity, but not longer term morbidity and mortality. Costs seem to be similar to routine care.

https://emj.bmj.com/content/emermed/19/2/117.full.pdf

A prospective, observational study of a chest pain observation unit in a British hospital

Objective: To assess if the combination of cardiac troponin (cTn) and Ischemia Modified Albumin (IMA) can be used for early exclusion of acute myocardial infarction (AMI). Methods: Prospective consecutive admissions to the emergency department (ED) with undifferentiated chest pain were assessed clinically and by electrocardiography. A total of 539 patients (335 men, 204 women; median age 51.9 years) considered at low risk of AMI had blood drawn on admission. If the first sample was less than 12 hours from onset of chest pain, a second sample was drawn two hours later, at least six hours from onset of chest pain. Creatine kinase MB isoenzyme (CKMB) mass was measured on the first sample and CKMB mass and cTnT on the second sample. An aliquot from the first available sample was frozen and subsequently analysed for IMA. If cTnT had not been measured on the original sample cTnI was measured (n = 189). Results: Complete data were available for 538/539 patients. IMA or cTn was elevated in the admission sample of all patients with a final diagnosis of AMI (n = 37) with IMA alone elevated in 2/37, cTn alone in 19/37, and both in 16/37. In 173/501 patients in whom AMI was excluded both tests were negative. In the non-AMI group 22 patients had elevation of both IMA and cTn in the initial sample, suggesting ischaemic disease. Conclusion: Admission measurement of cardiac troponin plus IMA can be used for early classification of patients presenting to the ED to assist in patient triage.

/pdf/utility-of-admission-cardiac-troponin-and-ischemia-modified-4tgqlrqq5w.pdf

Utility of admission cardiac troponin and “Ischemia Modified Albumin” measurements for rapid evaluation and rule out of suspected acute myocardial infarction in the emergency department

Objectives —The chest pain observation unit (CPOU) has been developed in the United States to allow rigorous assessment of patients presenting with chest pain, thus expediting their discharge if assessment is negative. This review aims to examine the evidence for effectiveness and economic efficiency of the CPOU and to explore whether data from the United States can be extrapolated to the UK. Method —Search of the literature using Medline and critical appraisal of the validity of the data. Results —Five studies comparing outcomes of CPOU care with routine practice showed no significant difference in objective measures including mortality or missed pathology. Eleven studies described outcomes of a cohort of CPOU patients. Follow up was comprehensive and demonstrated no clinically significant evidence of missed pathology. Nine studies comparing CPOU costs with routine care demonstrated impressive cost savings that were more modest when randomised comparisons were made. Conclusion —CPOU care is safe and costs are well defined. There is no strong evidence that a CPOU will improve outcomes if routine practice is good. Cost savings have been shown when compared with routine care in the United States but may not be reproduced the UK.

https://emj.bmj.com/content/emermed/17/1/1.full.pdf

Should we establish chest pain observation units in the UK? A systematic review and critical appraisal of the literature.

Background:There are many clinical decision rules for adults with minor head injury, but it is unclear how they compare in terms of diagnostic accuracy. This study aimed to systematically identify clinical decision rules for adults with minor head injury and compare the estimated diagnostic accuraci

Steve Goodacre

Papers

Variation in the diagnostic performance of D-dimer for suspected deep vein thrombosis

A prospective, observational study of a chest pain observation unit in a British hospital

Utility of admission cardiac troponin and “Ischemia Modified Albumin” measurements for rapid evaluation and rule out of suspected acute myocardial infarction in the emergency department

Should we establish chest pain observation units in the UK? A systematic review and critical appraisal of the literature.

Clinical decision rules for adults with minor head injury: a systematic review.