Cost-effectiveness of routine coagulation testing in the evaluation of chest pain in the ED.

INTRODUCTION: Approximately 5% of all US emergency department (ED) visits are for chest pain, and coagulation testing is frequently utilized as part of the ED evaluation. OBJECTIVE: The objective was to assess the cost-effectiveness of routine coagulation testing of patients with chest pain in the ED. METHODS: We conducted a retrospective chart review of patients evaluated for chest pain in a community ED between August 1, 2010, and October 31, 2010. Charts were reviewed to determine the number and results of coagulation studies ordered, the number of coagulation studies that were appropriately ordered, and the number of patients requiring a therapeutic intervention or change in clinical plan (withholding of antiplatelet/anticoagulant, delayed procedure, or treatment with fresh frozen plasma or vitamin K) based on an unexpected coagulopathy. We considered it appropriate to order coagulation studies on patients with cirrhosis, known/suspected coagulopathy, active bleeding, use of warfarin, or ST-elevation myocardial infarction. RESULTS: Of the 740 patients included, 406 (55%) had coagulation studies ordered. Of those 406, 327 (81%) patients with coagulation studies ordered had no indications for testing. One of the 327 patients (0.31%; 95% confidence interval, 0.05%-1.7%) tested without indication had a clinically significant coagulopathy (internationalized normalization ratio >1.5, partial thromboplastin time >50 seconds), but none (0%; 95% confidence interval, 0%-1.2%) of the patients with coagulation testing performed without indication required a therapeutic intervention or change in clinical plan. The cost of coagulation testing in these 327 patients was $16780. CONCLUSIONS: Coagulation testing on chest pain patients in the ED is not cost-effective and should not be routinely performed.

Directed vascular expression of human cysteinyl leukotriene 2 receptor modulates endothelial permeability and systemic blood pressure.

BACKGROUND: The proinflammatory and vascular actions of cysteinyl leukotrienes (CysLTs) are mediated by 2 receptors: cysteinyl leukotriene 1 receptor (CysLT1R) and cysteinyl leukotriene 2 receptor (CysLT2R). However, the distinct contribution of CysLT2R to the vascular actions of CysLTs has not been addressed. METHODS AND RESULTS: We generated an endothelial cell-specific human CysLT2R (EC-hCysLT2R) transgenic (TG) mouse model using the Tie2 promoter/enhancer. Strong expression of hCysLT2R in TG lung and endothelial cells, detected by real-time polymerase chain reaction, markedly enhanced CysLT-stimulated intracellular calcium mobilization compared with endogenous expression in cells from nontransgenic mice. The permeability response to exogenous LTC4 and to endogenous CysLTs evoked by passive cutaneous anaphylaxis was augmented in TG mice. The rapid, systemic pressor response to intravenous LTC4 was also diminished in TG mice coincidentally with augmented production of nitric oxide. CONCLUSIONS: The development of EC-hCysLT2R mice has permitted detection of distinct vascular effects of CysLTs, which can be mediated via the CysLT2R in vivo.