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1.
Circulation ; 137(4): 354-363, 2018 01 23.
Artigo em Inglês | MEDLINE | ID: mdl-29138293

RESUMO

BACKGROUND: Efforts to safely reduce length of stay for emergency department patients with symptoms suggestive of acute coronary syndrome (ACS) have had mixed success. Few system-wide efforts affecting multiple hospital emergency departments have ever been evaluated. We evaluated the effectiveness of a nationwide implementation of clinical pathways for potential ACS in disparate hospitals. METHODS: This was a multicenter pragmatic stepped-wedge before-and-after trial in 7 New Zealand acute care hospitals with 31 332 patients investigated for suspected ACS with serial troponin measurements. The implementation was a clinical pathway for the assessment of patients with suspected ACS that included a clinical pathway document in paper or electronic format, structured risk stratification, specified time points for electrocardiographic and serial troponin testing within 3 hours of arrival, and directions for combining risk stratification and electrocardiographic and troponin testing in an accelerated diagnostic protocol. Implementation was monitored for >4 months and compared with usual care over the preceding 6 months. The main outcome measure was the odds of discharge within 6 hours of presentation RESULTS: There were 11 529 participants in the preimplementation phase (range, 284-3465) and 19 803 in the postimplementation phase (range, 395-5039). Overall, the mean 6-hour discharge rate increased from 8.3% (range, 2.7%-37.7%) to 18.4% (6.8%-43.8%). The odds of being discharged within 6 hours increased after clinical pathway implementation. The odds ratio was 2.4 (95% confidence interval, 2.3-2.6). In patients without ACS, the median length of hospital stays decreased by 2.9 hours (95% confidence interval, 2.4-3.4). For patients discharged within 6 hours, there was no change in 30-day major adverse cardiac event rates (0.52% versus 0.44%; P=0.96). In these patients, no adverse event occurred when clinical pathways were correctly followed. CONCLUSIONS: Implementation of clinical pathways for suspected ACS reduced the length of stay and increased the proportions of patients safely discharged within 6 hours. CLINICAL TRIAL REGISTRATION: URL: https://www.anzctr.org.au/ (Australian and New Zealand Clinical Trials Registry). Unique identifier: ACTRN12617000381381.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Serviço Hospitalar de Cardiologia/normas , Procedimentos Clínicos/normas , Serviço Hospitalar de Emergência/normas , Hospitalização , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/terapia , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Tomada de Decisão Clínica , Eletrocardiografia , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Nova Zelândia/epidemiologia , Valor Preditivo dos Testes , Prevalência , Prognóstico , Medição de Risco , Fatores de Risco , Fatores de Tempo , Troponina/sangue
2.
J Electrocardiol ; 47(1): 52-8, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-23993862

RESUMO

BACKGROUND: Measures of vectorcardiographic changes and LV remodelling have been associated with arrhythmic risk. However the correlation between the two modalities is not well characterised. METHODS: We correlated spatial QRS-T angle and ventricular gradient with cardiac MRI derived LV global measures and scar pattern in 66 ICD recipients. RESULTS: Spatial QRS-T angle was significantly larger in patients with ischaemic scar than those without scar (150°±22° vs. 119°±46°, p=0.01). Larger spatial QRS-T angle was also correlated with more depressed LV function, more dilated LV and larger LV mass. Ventricular gradient azimuth was significantly different between patients with no scar, non-ischaemic scar and ischaemic scar (20°±49° vs. 38°±62° vs. 65°±48°, p=0.009), but independent of spatial QRS-T angle and LV structure. CONCLUSIONS: Spatial QRS-T angle and ventricular gradient are partially related to LV structural properties. Further investigation is warranted to examine their comparative and combined prognostic value in risk stratification of ventricular arrhythmias.


Assuntos
Desfibriladores Implantáveis , Imagem Cinética por Ressonância Magnética/métodos , Vetorcardiografia/métodos , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/prevenção & controle , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Estatística como Assunto , Resultado do Tratamento
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