Search Results (35)

Background: Electrocardiograms (EKGs) are essential tools in emergency medicine, often used to evaluate chest pain, dyspnea, and other symptoms suggestive of cardiac dysfunction. Yet, EKGs are not universally administered to all emergency department (ED) patients. Understanding and predicting which patients receive an EKG may offer insights into clinical decision making, resource allocation, and potential disparities in care. This study examines whether integrating structured clinical data with free-text patient narratives can improve prediction of EKG utilization in the ED. Methods: We conducted a retrospective observational study to predict electrocardiogram (EKG) utilization using data from 13,115 adult emergency department (ED) visits in the nationally representative 2021 National Hospital Ambulatory Medical Care Survey–Emergency Department (NHAMCS-ED), leveraging both structured features—demographics, vital signs, comorbidities, arrival mode, and triage acuity, with the most influential selected via Lasso regression—and unstructured patient narratives transformed into numerical embeddings using Clinical-BERT. Four supervised learning models—Logistic Regression (LR), Support Vector Machine (SVM), Random Forest (RF) and Extreme Gradient Boosting (XGB)—were trained on three inputs (structured data only, text embeddings only, and a late-fusion combined model); hyperparameters were optimized by grid search with 5-fold cross-validation; performance was evaluated via AUROC, accuracy, sensitivity, specificity and precision; and interpretability was assessed using SHAP values and Permutation Feature Importance. Results: EKGs were administered in 30.6% of adult ED visits. Patients who received EKGs were more likely to be older, White, Medicare-insured, and to present with abnormal vital signs or higher triage severity. Across all models, the combined data approach yielded superior predictive performance. The SVM and LR achieved the highest area under the ROC curve (AUC = 0.860 and 0.861) when using both structured and unstructured data, compared to 0.772 with structured data alone and 0.823 and 0.822 with unstructured data alone. Similar improvements were observed in accuracy, sensitivity, and specificity. Conclusions: Integrating structured clinical data with patient narratives significantly enhances the ability to predict EKG utilization in the emergency department. These findings support a personalized medicine framework by demonstrating how multimodal data integration can enable individualized, real-time decision support in the ED. Full article

Background/Objectives: This study aimed to evaluate a regional implementation project for rural emergency care (RuralRescue) and to examine how its components and outcomes may support personalized approaches in emergency medicine. While not originally designed as a personalized medicine intervention, the project combined digital, educational, and organizational innovations that enable patient-specific adaptation of care processes. Methods: Conducted in the rural district of Vorpommern-Greifswald (Mecklenburg–Western Pomerania, Germany), the intervention included (1) standardized cardiopulmonary resuscitation (CPR) training for laypersons, (2) a geolocation-based first responder app for medically trained volunteers, and (3) integration of a tele-emergency physician (TEP) system with prehospital emergency medical services (EMSs). A multi-perspective pre–post evaluation covered medical, economic, and organizational dimensions. Primary and secondary outcomes included bystander CPR rates, responder arrival times, telemedical triage decisions, diagnostic concordance, hospital transport avoidance, economic simulations, workload, and technology acceptance. Results: Over 12,600 citizens were trained in CPR and the responder app supported early intervention in hundreds of cases. TEPs remotely assisted 3611 emergency calls, including delegated medication in 17.8% and hospital transport avoidance in 24.3% of cases. Return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA) was achieved in 35.6% of cases with early CPR. Diagnostic concordance reached 84.9%, and documentation completeness 92%. Centralized coordination of TEP units reduced implementation costs by over 90%. Psychological evaluation indicated variable digital acceptance by role and experience. Conclusions: RuralRescue demonstrates that digitally supported, context-aware, and regionally integrated emergency care models can contribute significantly to personalized emergency medicine and can be cost-effective. The project highlights how intervention intensity, responder deployment, and treatment decisions can be tailored to patient needs, professional capacity, and regional structures—even in resource-limited rural areas. Full article

Introduction: The prevention of heart failure (HF) exacerbation is crucial for patient prognosis, and preventive treatment for potential symptoms and warning signs is essential in this context. The TriageHF © algorithm has been retrospectively validated and has demonstrated good correlation with HF episodes. This study analyzes the effectiveness of the TriageHF © algorithm in routine clinical practice, emphasizing the role of episode duration in its predictive capacity. Materials and methods: From October 2017 to October 2020, all patients who received a Medtronic Amplia DR implant were prospectively selected for analysis. To evaluate the algorithm’s diagnostic capacity, it was compared with the clinical diagnosis of HF episodes during follow-up. Results: The sustained moderate-risk (more than 7 days) and high-risk alerts both showed high positive predictive values (11.25% and 27.27%, respectively), along with an increase in the relative risk of HF, particularly in high-risk alerts (hazard ratio is 46.21 times higher than for sustained moderate-risk alerts). Furthermore, there was higher event-free survival in real low-risk alerts than in both sustained medium-risk and high-risk alerts (p < 0.01). Conclusions: TriageHF © can predict the worsening of patients with ICD CRT. Medium-risk alerts lasting less than 7 days do not pose a greater risk of HF episodes, while high-risk alerts, regardless of their duration, are highly correlated with HF episodes. Full article

Introduction: Implantable defibrillator devices (ICDs) can be used for remote monitoring of different variables, including some related to Heart Failure (HF). Two different algorithms (TriageHF and HeartLogic) arise by combining some of these variables to generate an estimation of HF decompensation risk in the following days. Until now, no other trial has evaluated both algorithms in a head-to-head comparison. The primary objective is to compare diagnostic accuracy of both algorithms in a similar cohort of patients. Material and Methods: Descriptive monocentric cohort study of a series of 64 patients who have been implanted with a Medtronic or Boston Scientific ICD with the TriageHF or Heart Logic algorithm available during the period between January 2020 and June 2022, with a total of 27 patients in the HeartLogic group and 37 patients in the TriageHF group. Results: During the period of the study there were a total of 1142 alarms analyzed. There were no differences in the basal characteristics of both groups. We reported a risk alarm–patient ratio of 1.31 ± 1.89 in the HeartLogic group and of 3.32 ± 3.08 in the TriageHF group (p < 0.01). In the TriageHF group, we reported a lower specificity with (0.76), with higher sensitivity (0.97) and PPV (0.18), and similar NPV (1). Survival analysis shows no statistical differences between both algorithms in the 30 days following the alert. Conclusions: TriageHF algorithm had higher sensibility and PPV, leading to a higher number of alerts/patients, while HeartLogic algorithm had a better specificity. These differences should be considered to optimize patient follow-ups in home monitoring. Full article

Background/Objective: The measurement of troponin is recommended for acute myocardial infarction (AMI) diagnosis. Yet, hs-cardiac troponin T (hs-cTnT) can be elevated due to non-cardiac conditions, such as skeletal muscle injury, chronic kidney disease (CKD) or pulmonary embolism. The aim of our study was to compare the diagnostic accuracy of a bedside rapid hs-cardiac troponin I (hs-cTnI) assay (Quidel TriageTrue^®) with hs-cTnT measured in a routine laboratory (Roche Elecsys). Methods: This prospective monocentric study was conducted in an acute cardiac outpatient unit at a tertiary hospital. Hs-cTnI was measured via a point-of-care test from whole blood, while hs-cTnT was measured from plasma through the routine laboratory facility. Results: In 129 patients (65.1% male, 61.8 ± 15.6 years) with acute chest pain, results for hs-cTnI were available 14 ± 11 min after the first clinical presentation, which was 74 ± 54 min earlier than for hs-cTnT. Coronary angiography confirmed AMI in 17 patients (13.28%). The relative risk of AMI patients with elevated hs-cTnI results was 6.59 compared to 2.29 for hs-cTnT. Hs-cTnI exhibited an equivalent negative predictive value to hs-cTnT (99%) for AMI but had a comparatively higher positive predictive value (50.0 vs. 25.8%). In 39 patients with at least CKD stage 3a, median hs-cTnT was pathological (27.0 ng/L), in contrast with hs-cTnI (11.2 ng/L). Further, hs-cTnI was less likely elevated in patients with CKD and no AMI. Conclusions: The diagnostic value of hs-cTnI was comparable to that of hs-cTnT, and the blood sampling-to-result time was shorter than routine hs-cTnT. Full article

Background: Long-distance running impacts many organ systems. Aside from musculoskeletal and cardiopulmonary events, the gastrointestinal and renal system as well as metabolic homeostasis and electrolyte balance can be affected. A respective medical support strategy enabling rapid diagnosis, triage, and treatment in the context of large sports events is thus of utmost importance. Incidents can be assessed and graded via point-of-care (POC) blood gas analysis (BGA). We thus aimed to evaluate the feasibility and benefits of its use during a large sports event. Methods: All documented patient contacts during the race of the Vienna City Marathon (VCM) 2023 were retrospectively assessed. Additionally, the BGAs conducted in all patients requiring intravenous access were analyzed. Data are presented in a descriptive manner. Results: There were 39,871 participants at the VCM 2023. Of these, 277 (0.7%) required medical support, localized most commonly in the finishing area of the race (n = 239, 86% of all incidents). Fifty-eight (20.9%) patients had to be hospitalized. The most frequent chief complaints were syncope or collapse (24.9%), followed by general pain (20.6%) and trauma (14.8%). Five patients (1.8%) suffered from seizures, and one experienced (0.4%) from spontaneous pneumothorax. Thirty-one patients (11.2%) received venous blood gas analyses, showing mean creatinine levels of 1.82 (±0.517) mg/dL, mean lactate concentrations of 6.03 (±4.5) mmol/L, mean pH of 7.42 (±0.0721), and a mean base excess of −0.72 (±3.72) mmol/L. No cases of hyponatremia occurred in the documented samples. In eight cases (25.8%), sodium concentrations were above 145 mmol/L, with a maximum of 149 mmol/L. No cardiac arrests occurred. Conclusions: The physical exertion during the assessed long-distance running race resulted in numerous contacts with the medical support teams. The use of POC BGA at a large-scale marathon event was shown to be easy and feasible, allowing for more extensive diagnostics on-site. It can be integrated into a medical support strategy and might be beneficial for decision-making regarding patient triage, treatment, hospitalization, or patient discharge. Full article

Background and Objectives: Cardiac tamponade is managed through echo- or fluoroscopy-guided percutaneous pericardiocentesis. The European Society of Cardiology’s Working Group on Myocardial and Pericardial Diseases proposed a triage strategy for these patients. This study evaluated the triage score and compared the safety and efficacy of fluoroscopy- versus echo-guided procedures without additional visualization control. Materials and Methods: This prospective observational study included 71 patients with cardiac tamponade from February 2021 to June 2022. Pericardiocentesis was performed using fluoroscopy or echo guidance based on clinical assessment and catheterization laboratory availability, without the additional control of needle/guidewire position or ECG monitoring. Patients were followed for three months. Results: The study included 71 patients (52.1% female, mean age 59.7 ± 15.7 years). Malignancy was the most common comorbidity (59.2%). Echo criteria led to urgent procedures in 47.9%, with subcostal access used most often (60.6%), particularly in fluoroscopy-guided procedures (93.8%, p = 0.003). The success rate was 97.1%, with minor complications in 14% of patients. Diabetes and malignancy predicted complications regardless of access site or guiding method. The triage score did not affect complication rates or short-term mortality. Conclusions: Fluoroscopy- and echo-guided pericardiocentesis without additional visualization control showed no difference in safety or efficacy. Delaying the procedure for patients with a triage score ≥6, or performing it early for those with a low score, did not impact complication rates or mortality, which were more influenced by the progression of the underlying disease. Full article

Laboratory-based high-sensitivity cardiac troponin testing has been the pillar for emergency stratification of suspected acute coronary syndrome for well over a decade. Point-of-care troponin assays achieving the requisite analytical sensitivity have recently been developed and could accelerate such assessment. This review summarises the latest assays and describes their potential diverse clinical utility in the emergency department, community healthcare, pre-hospital, and other hospital settings. It outlines the current clinical data but also highlights the evidence gap, particularly the need for clinical trials using whole blood, that must be addressed for safe and successful implementation of point-of-care troponin analysis into daily practice. Additionally, how point-of-care troponin testing can be coupled with advances in biosensor technology, cardiovascular screening, and triage algorithms is discussed. Full article

Pericardial effusions, especially large ones, have traditionally been regarded with concern by clinicians due to the sometimes unpredictable development of life-threatening cardiac tamponade. In the European Society of Cardiology Guidelines on pericardial diseases, the simplified algorithm for pericardial effusion triage and management recommends pericardial drainage in cases of cardiac tamponade and/or suspicion of bacterial or neoplastic etiology. In the presence of acute pericarditis, empiric anti-inflammatory treatment should be given, while when a specific indication known to be associated with pericardial effusion is found, then treatment of the underlying cause is indicated. Notably, the most challenging subgroup of patients includes those with large, asymptomatic, C-reactive-protein-negative, idiopathic effusions. In the latter subjects, pericardial drainage is proposed in cases of chronic effusions (lasting more than three months). However, this recommendation is based on scant data stemming from small-sized non-randomized studies. Nevertheless, recent evidence in a larger cohort of patients pointed out that a watchful waiting strategy is a safe option in terms of complication-free survival. This review summarizes the contemporary evidence on this challenging topic and provides recommendations for tailoring individual patient treatments. Full article

Heart failure (HF) admissions are burdensome, and the mainstay of prevention is the timely detection of impending fluid retention, creating a window for medical treatment intensification. This study evaluated the accuracy and performance of a Triage-HF-guided carepath in real-world ambulatory HF patients in daily clinical practice. In this prospective, observational study, 92 adult HF patients (71 males (78%), with a median age of 69 [IQR 59–75] years) with the Triage-HF algorithm activated in their cardiac implantable electronic devices (CIEDs), were monitored. Following high-risk alerts, an HF nurse contacted patients to identify signs and symptoms of fluid retention. The sensitivity and specificity were 83% and 97%, respectively. The positive predictive value was 89%, and negative predictive value was 94%. The unexplained alert rate was 0.05 alerts/patient year, and the false negative rate was 0.11 alerts/patient year. Ambulatory diuretics were initiated or escalated in 77% of high-risk alert episodes. In 23% (n = 6), admission was ultimately required. The median alert handling time was 2 days. Fifty-eight percent (n = 18) of high-risk alerts were classified as true positives in the first week, followed by 29% in the second–third weeks (n = 9), and 13% (n = 4) in the fourth–sixth weeks. Common sensory triggers included an elevated night ventricular rate (84%), OptiVol (71%), and reduced patient activity (71%). The CIED-based Triage-HF algorithm-driven carepath enables the timely detection of impending fluid retention in a contemporary ambulatory setting, providing an opportunity for clinical action. Full article

Background: Though out-of-hospital CA (OHCA) is widely reported, data on in-hospital CA (IHCA) and especially cardiac arrest (CA) in the emergency department (CAED) are scarce. This study aimed to determine the frequency, prevalence, and clinical features of unexpected CAED and compare the data with those of expected CAED. Methods: We defined unexpected CAED as CA occurring in patients in non-critical ED-care areas; classified as not requiring strict monitoring. This classification was the modified Japanese Triage and Acuity Scale and physician assessment. A retrospective analysis of cases from 2016 to 2018 was performed, in comparison to other patients experiencing CAED. Results: The 38 cases of unexpected CA in this study constituted 34.5% of CA diagnosed in the ED and 8.4% of all CA treated in the ED. This population did not differ significantly from other CAED regarding demographics, comorbidities, and survival rates. The commonest symptoms were dyspnoea, disorders of consciousness, generalised weakness, and chest pain. The commonest causes of death were acute myocardial infarction, malignant neoplasms with metastases, septic shock, pulmonary embolism, and heart failure. Conclusions: Unexpected CAED represents a group of potentially avoidable CA and deaths. These patients should be analysed, and ED management should include measures aimed at reducing their incidence. Full article

The rising prevalence of cardiovascular disease (CVD) and the impact of the SARS-CoV-2 pandemic have both led to increased mortality rates, affecting public health and the global economy. Therefore, it is essential to find accessible, non-invasive prognostic markers capable of identifying patients at high risk. One encouraging avenue of exploration is the potential of mid-regional proadrenomedullin (MR-proADM) as a biomarker in various health conditions, especially in the context of CVD and COVID-19. MR-proADM presents the ability to predict mortality, heart failure, and adverse outcomes in CVD, offering promise for improved risk assessment and treatment strategies. On the other hand, an elevated MR-proADM level is associated with disease severity and cytokine storms in patients with COVID-19, making it a predictive indicator for intensive care unit admissions and mortality rates. Moreover, MR-proADM may have relevance in long COVID, aiding in the risk assessment, triage, and monitoring of individuals at increased risk of developing prolonged cardiac issues. Our review explores the potential of MR-proADM as a predictor of enduring cardiovascular complications following COVID-19 infection. Full article

Prehospital field triage often fails to accurately identify the need for emergent surgical or non-surgical procedures, resulting in inefficient resource utilization and increased costs. This study aimed to analyze prehospital factors associated with the need for emergent procedures (such as surgery or interventional angiography) within 6 h of hospital admission. Additionally, our goal was to develop a prehospital triage tool capable of estimating the likelihood of requiring an emergent procedure following hospital admission. We conducted a retrospective observational study, analyzing both prehospital and in-hospital data obtained from the Lombardy Trauma Registry. We conducted a multivariable logistic regression analysis to identify independent predictors of emergency procedures within the first 6 h from admission. Subsequently, we developed and internally validated a triage score composed of factors associated with the probability of requiring an emergency procedure. The study included a total of 3985 patients, among whom 295 (7.4%) required an emergent procedure within 6 h. Age, penetrating injury, downfall, cardiac arrest, poor neurological status, endotracheal intubation, systolic pressure, diastolic pressure, shock index, respiratory rate and tachycardia were identified as predictors of requiring an emergency procedure. A triage score generated from these predictors showed a good predictive power (AUC of the ROC curve: 0.81) to identify patients requiring an emergent surgical or non-surgical procedure within 6 h from hospital admission. The proposed triage score might contribute to predicting the need for immediate resource availability in trauma patients. Full article

(1) Background: patients who meet current rapid rule-out criteria for myocardial infarction (MI) are considered low risk, yet their management remains nebulous, especially among women. We aimed to examine sex differences in the diagnosis, management, and outcomes of patients meeting the rapid rule-out criteria. (2) Methods: by simulating application of the rapid rule-out MI criteria, we analyzed consecutively triaged men and women with suspected NSTE-ACS who had high-sensitivity cardiac troponin T (hs-cTnT) values that met criteria (n = 11,477), in particular, those who were admitted (n = 3775). (3) Results: men constituted ~55% of triaged patients who met the rule-out criteria, whether admitted or discharged. Men were more likely to be admitted (33.7% vs. 31.9%, p = 0.04), more commonly with hs-cTnT values between level of detection (LOD, 5 ng/ml) and the 99th percentile (59.4% of all admissions vs. 40.5% for women), whereas women were more likely to be admitted with values < level of blank (LOB, 3 ng/mL; 22.9% vs. 9.2% for men). Thirty-day mortality (1 man and 1 woman) and in-hospital MI (9 men vs. 1 woman) were uncommon among admitted patients, yet resource utilization during 3–4 hospitalization days was substantial for both sexes, with men undergoing coronary angiography (6.8% vs. 2.9%) and revascularization (3.4% vs. 1.1%) more commonly. Long-term survival for both men and women, whether admitted or discharged, was significantly worse for hs-cTnT values between LOD and the 99th percentile, even after adjusting for age and cardiovascular comorbidities. (4) Conclusions: reporting actual hs-cTnT values < 99th percentile allows for better risk stratification, especially for women, possibly closing the sex gap. Full article

Despite recent developments, heart failure (HF) remains to be a great burden to the individual patient, entailing major morbidity and mortality. Moreover, HF is a great burden to overall healthcare, mainly because of frequent hospitalizations. Timely diagnosis of HF deterioration and implementation of appropriate therapy may prevent hospitalization and eventually improve a patient’s prognosis; however, depending on the patient’s presentation, the signs and symptoms of HF often offer too little therapeutic window to prevent hospitalizations. Cardiovascular implantable electronic devices (CIEDs) can provide real-time physiologic parameters and remote monitoring of these parameters can potentially help to identify patients at high risk. However, routine implementation of remote monitoring of CIEDs has still not been widely used in daily patient care. This review gives a detailed description of available metrics for remote HF monitoring, the studies that provide evidence of their efficacy, ways to implement them in clinical HF practice, as well as lessons learned on where to go on from where we currently are. Full article