The treatment of acute cardiac disease is a mainstay of emergency medicine practice. There are several faculty within the department active in cardiovascular research including Acute Coronary Syndromes (ACS) and Congestive Heart Failure (CHF).
Several major trials have been conducted or are ongoing related to diagnostic methods. We have recently completely enrollment of 2000 patients into the Diagnosis and Treatment of Acute Coronary Syndromes in the Emergency Department – The Impact of Rapid Bedside cTnl Testing on Outcomes (DISPO ACS) trial.
This multi-center investigation was coordinated by us and explored whether or not point-of-care testing achieves its goals of reduced test turnaround time and increased patient throughput. The primary results of this study were published in Annals of Emergency Medicine in August 2008, and ongoing analyses are exploring outcomes and cost-effectiveness of point-of-care testing.
To complement this, we have presented data at the Society for Academic Emergency Medicine (SAEM) conference and written a manuscript demonstrating changes in patient throughput as a result of transitioning to a POC marker approach.
As well as collecting data for primary study endpoints, studies such as these include a collection and storage of samples in our Biological Specimen Banking Center. This blood is available to evaluate new potential biomarkers for ACS.
Recently, samples have been used to determine whether or not human Fatty Acid Binding Protein provides early indication of infarction. Other projects using these banked samples are also underway, all of which may yield important work in the future.
While cardiac biomarkers are used for detecting infarction, the 12-lead ECG is a mainstay of evaluating patients with chest pain. We are conducting a multi-center study of the Prime ECG machine, which expanded on the usual 12-leads with a vest applicator that incorporates 80 leads to provide a more detailed image of the heart. Building on this, we participated in OCCULT-MI, in which we enrolled 411 patients.
The study tested the hypothesis that the extra information improves the sensitivity and specificity of electrocardiography to ACS.
In addition to studies of diagnostic methods for ACS, our faculty has been instrumental in developing major registries for describing practice patterns and treatment pathways for ACS patients.
We are actively engaged in the leadership for the ACTION registry. Primarily a quality initiative designed to maximize appropriate treatment rates; the registry data are sufficiently extensive to characterize such things as gender disparities in care of the ACS patient. We also coordinated the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS).
Eight United States’ and one Singapore emergency department enrolled 17,713 patients being evaluated for ACS across the entire spectrum of risk.
With over a dozen publications already, we continue to work with investigators across the country to explore these data. Most recently we have explored risk stratification using cardiac biomarkers below the usual institutional upper limits of normal, the outcomes of chest pain patients without objective evidence of ACS allocated to low, medium or high risk by emergency physicians in an unstructured way, and how various risk scores work in this unselected patient population.
Congestive heart failure results in about a million hospital admissions each year with health care expenditures exceeding $ 2.5 billion. The majority of admissions are through the emergency room.
Over the last five years, we have developed programs of research on the diagnosis, treatment and risk evaluation of acutely decompensated heart failure (ADHF) to address three foci: i) risk evaluation of patients with ADHF, ii) response to early therapy in ADHF, and iii) treatment trials in ADHF.
Collaborating with cardiologists and emergency physicians across the United States has resulted in multiple peer-reviewed publications and the development of a collaborative acute heart failure research network – EMERG-HF.
Currently, we participate and lead components of the NHLBI-funded studies DECIDE and STRATIFY, which aim to improve heart failure risk evaluation in the ED. The aim is to identify patients who are at low-risk of adverse events and encourage early discharge of this cohort.
Decreasing admission rates by a mere 5% would be expected to result in substantial healthcare resource savings. Up to 1800 patients are being enrolled over a 4-year period, and we will derive and validate a prediction rule that will assist physicians in dispositioning patients with ADHF from the ED.
A subset of these is being followed through hospitalization to determine the earliest time point after admission when patients can be safely discharged from the hospital. Currently there are no standardized guidelines to assist physicians with determining objective, safe endpoints of hospital admission. Decreasing hospital lengths-of-stay by a mere one day in half of the current admissions would result in a significant saving.
As well as funding from the NIH, these studies are being augmented by support from Abbott POC and BRAHMS for additional enrollments, and for exploring novel biomarkers in ADHF.
Our investigators are active members of the newly formed UC Cardiovascular Center of Excellence and are collaborating with faculty from the Department of Molecular Genetics, Biochemistry and Microbiology.
This has resulted in a pilot study investigating a new ELISA of a Tropomyosin isoform is able to detect tropomyosin in ED patients with and without ADHF.
Emergency Medicine Cardiac Research and Education Group (EMCREG-international)
Several faculty members from the University of Cincinnati Department of Emergency medicine sit on the EMCREG-international steering committee.
EMCREG was founded by Dr. Gibler in 1989 as a group of likeminded individuals dedicated to improving patient care through research and education. In 1998, EMCREG became an international collaboration of 18 physician-investigators representing 15 leading institutions throughout the world.
Since then, EMCREG has evolved into an international research and education network boasting 44 international academic researchers from 31 leading academic research facilities. EMCREG remains centrally coordinated through the University of Cincinnati Department of Emergency Medicine, and the organization provides state-of-the-art education in acute cardiac care, and coordinates participation in cardiac studies in the emergency setting.EMCREG-International is also well-known forit's hot topic and comprehensive CME monographs on evidence-based emergency cute care topics. These monographs are enjoyed by more 30,000 acute care providers including emergency physicians, nurses, hospitalists and mid-level provders.
Visit the EMCREG website for more information.