Cardiology Corner - The Things We Do for Chest Pain Part 2

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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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Benjamin S. -

The summary listed looks like the later critical care mailbag on vents. Just a heads up!

Thomas B. -

Dr. Mattu, I work in a "certified" chest pain center. The organization that certifies chest pain centers started tracking arrival to troponin result times with a goal of <60 minutes. What are your thoughts on this metric? Is it patient centered? Any data supporting earlier troponin result leading to better outcomes?
Thank you!

Amal M., M.D. -

Thomas,
Are they tracking the arrival-to-TN times for research purposes? Or are they actually using it as a "quality" metric?

If it's the latter, it doesn't make any sense to me whatsoever. I'd be very interested in knowing the justification, and I really have to wonder if this is simply being pushed by the TN assay company which may be heavily funding the organization you refer to.

The purpose of pushing providers to obtain a test as early as possible as a quality metric only makes sense if the earlier acquisition of the test is (1) going to lead to earlier intervention/treatment that (2) makes a difference in outcome. For example, we all know that getting ECGs ASAP is important because it can potentially lead to earlier cath lab activation, AND we know that early CLA is associated with better outcome.

But how does earlier acquisition of a TN influence management? Are your cardiologists recommending CLA now purely based on a positive TN? There's no data to support this, and this would lead to numerous unnecessary caths and increased morbidity. Additionally, there are SO many causes of TN elevation that are not related to acute coronary occlusions that you are going to end up with tons of TNs that don't influence MI care and outcome. And if this is being pushed as a metric, there's going to be a huge tendency for providers to just go ahead and order TNs on practically anyone that shows up, which will lead to huge numbers of false negatives, unnecessary workups, increased ED and hospital length of stay, boarding, and expenses. I've never seen or heard of any literature supporting this.

I just can't imagine that this is true...if it is, it's not good for patient care, it's not good for ED throughput, and it's not good for the system. It's only good for the TN assay company.

Please tell me I misunderstood what you are saying....!!!
Amal

Thomas B. -

Dr. Mattu,
I don't think you misunderstood. As you can see here on page 6 of the ACC chest pain center accreditation services guidelines for troponin testing "percent compliance TAT arrival to result in 60 minutes" is being assessed as part of the accreditation process. I agree with what you write-huge tendency for providers to order TNs without context if this is being tracked as a metric. Just wanted to make sure I wasn't missing a key piece of outcomes data that supported this focus.
I think you can also see from this brochure that the troponin assay company is featured prominently as well.

http://accreditation.acc.org/resources/PDFs/Troponin_Brochure_2017.pdf

Warmest regards and thank you for your response.
TB

Amal M., M.D. -

Ahhhh....I now understand. Yes, there is a misunderstanding.

TAT refers to the laboratory TurnAround Time. So if you look at the document, what they are saying is that a "certified chest pain center" must have a lab that can turnaround the TN within 60 minutes. So from the time the blood arrives in the lab until the lab reports the result must be < 60 minutes.

They are not suggesting that patients need to have TNs sent within 60 minutes of ED arrival.
Amal

Thomas B. -

WAAA, WAAA, Waaaa....insert sad trumpet sound here...
I just confirmed with our Quality department today. The metric is indeed from patient arrival to TN result...unfortunately not from when specimen arrives in lab.
They provided me with the two troponin metrics:
CM.M10.1: median time from arrival to initial troponin result
CM.M11.1: percentage of patients with initial troponin results within 60 minutes of arrival.
Not sure how to best to address this with ACC Accreditation Services. As you write...it's not good for patient care.
Any suggestions appreciated.
Regards,
TB

Amal M., M.D. -

For all the reasons I've noted above and based on reading the document you sent, it seems more likely to me that your quality department has misinterpreted the ACC document than the likelihood that the ACC is recommending now that everyone showing up get immediate TNs sent, based on no data that it will improve outcomes. In fact they even acknowledge the lack of specificity of TN. The recommendation for TAT within 60min is in the section on lab requirements.

I suggest you have your quality people confirm with the ACC and the cardiologists what is intended.

I haven't heard of this issue at any other hospital. If it were really the ACC making such a ridiculous recommendation, it would be creating a national firestorm in the EM and cardiology community.
AM

Thomas B. -

Yes!! You are correct. I agree that this should be creating a national firestorm. I have confirmed this directly with the ACC that the metric is for ED arrival...not specimen arrival in the lab.
I'd be happy to chat offline and discuss. Maybe I can provide you with some of the contacts of the folks at ACC I've been corresponding with? Agree, seems misguided. Apparently they are going to be releasing a "goal" for this metric as well.
Thank you for your awesome work.
Sincerely,
TB
tboyd@srhs.com

Matthew C. -

Dr. Mattu,
I have a question regarding the recommendation of immediate PCI for refractory angina. I understand that this has been the recommendation but is this based on best evidence? I am always somewhat skeptical of practice based solely on guideline recommendations, especially since the whole tPA fiasco. Is immediate PCI for refractory angina an evidence based approach and if so, is this based on patient centered outcomes, i.e. CRACE vs MACE?
Thank you for all your work!
Matt Christensen
ED physician in Troy, MI

Amal M., M.D. -

Matt,
I haven't evaluated the full details of the studies they have used, as I'm not part of their guidelines committee. As with all guidelines, I'm sure there are shortcomings. However, this is listed as Class I (highest level of recommendation), level of evidence A (highest level of evidence). They don't label things IA easily.

I think intuitively, also, it is a reasonable recommendation to push for cath if a patient has persistent ischemia despite medications. In such a patient, you have to worry that the ischemia will turn into infarction (or produce arrest) if the artery is not opened up soon. The caveat here is that this is intended for patients that truly do have ischemia (e.g. ECG evidence of ischemia, or evolving changes, and a pretty good story, patient often "looks" ischemic) and not for the patients with chest pain in whom you really are not worried.

In our practice, we've really had no argument from the cardiologists about taking these patients emergently to cath. For comparison, many of them still do argue about Sgarbossa, aVR issues, etc. But no argument on this topic.

If you want to view the recommendation, pull up the guideline at http://circ.ahajournals.org/content/130/25/e344 and scroll down to section 4.4.4 and you can see the Class I recommendation.
If you scroll down just a bit further it is summarized in Table 8 (note it specifically calls for cath lab activation within 2 hours).
I hope that helps.
AM

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