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L Goldman

Publications and source records attributed to L Goldman.

At least 37 records · Page 2Linked to original sources
PubMed2001

Safety makes sense: a program to prevent unintentional injuries in New York City public schools.

Estimates suggesting that 10% to 25% of unintentional injuries to school-aged children occur in and around American schools are alarming. Information from the National Health Information Survey indicates as many as 3.7 million children are injured in schools annually. To address these concerns, The New York Academy of Medicine and the Board of Education of the City of New York in 1998 launched Safety Makes Sense, a multidimensional school-based, injury prevention initiative. The Safety Makes Sense program integrates unintentional injury prevention into comprehensive school health education in elementary and middle school classrooms and is implemented by interdisciplinary teams within a coordinated school health program. The multifaceted program also integrates safety and music education, and includes development of a handbook for teachers and staff, student booklets, staff development training workshops, and evaluation.

Accident Prevention↗
PubMed2001

A pneumonia practice guideline and a hospitalist-based reorganization lead to equivalent efficiency gains.

OBJECTIVE: To compare the impact of a practice guideline for a common inpatient disorder with that of a hospitalist-based reorganization of an academic medical service. STUDY DESIGN: Retrospective cohort study. PATIENTS AND METHODS: In July 1995 we introduced a clinical practice guideline for the treatment of community-acquired pneumonia at University of California San Francisco Moffitt-Long Hospital. Simultaneously, we implemented a structural change for half of the inpatient medical service, requiring earlier and more intensive faculty intervention, primarily by hospitalists. For 1 year, we studied the effect of these interventions on hospital costs, length of stay, and resource use. RESULTS: As reported previously, the hospitalist-based intervention resulted in significant decreases in average adjusted cost ($7777 vs $7007, P = .05) and length of stay (4.9 days vs 4.3 days, P = .01) compared with both concurrent and historical controls. For patients with community-acquired pneumonia, a similar savings occurred when fiscal year 1996 was compared with fiscal year 1995 ($8164 vs $6282, P= .015; 5.0 vs 4.2 days, P= .04). However, the effect was identical for the hospitalist and nonhospitalist groups. The reduced length of stay was associated with a borderline significant reduction in readmission rates (from 4.8% to 0.7%, P = .055) and no change in mortality rates. CONCLUSIONS: In this study, a hospitalist-based reorganization improved efficiency, with its greatest impact on the care of patients with disorders not covered by a practice guideline. The introduction of a guideline for a common diagnosis improved efficiency on both hospitalist- and nonhospitalist-based services. For common diagnoses amenable to practice guidelines, successful implementation of and compliance with guidelines may be an alternative to major organizational change.

Adult↗
PubMed2000

Health and economic benefits of increased beta-blocker use following myocardial infarction.

CONTEXT: beta-blockers are underused in patients who have myocardial infarction (MI), despite the proven efficacy of these agents. New evidence indicates that beta-blockers can have benefit in patients with conditions that have been considered relative contraindications. Understanding the consequences of underuse of beta-blockers is important because of the implications for current policy debates over quality-of-care measures and Medicare prescription drug coverage. OBJECTIVE: To examine the potential health and economic impact of increased use of beta-blockers in patients who have had MI. DESIGN AND SETTING: We used the Coronary Heart Disease (CHD) Policy Model, a computer-simulation Markov model of CHD in the US population, to estimate the epidemiological impact and cost-effectiveness of increased beta-blocker use from current to target levels among survivors of MI aged 35 to 84 years. Simulations included 1 cohort of MI survivors in 2000 followed up for 20 years and 20 successive annual cohorts of all first-MI survivors in 2000-2020. Mortality and morbidity from CHD were derived from published meta-analyses and recent studies. This analysis used a societal perspective. MAIN OUTCOME MEASURES: Prevented MIs, CHD mortality, life-years gained, and cost per quality-adjusted life-year (QALY) gained in 2000-2020. RESULTS: Initiating beta-blocker use for all MI survivors except those with absolute contraindications in 2000 and continuing treatment for 20 years would result in 4300 fewer CHD deaths, 3500 MIs prevented, and 45,000 life-years gained compared with current use. The incremental cost per QALY gained would be $4500. If this increase in beta-blocker use were implemented in all first-MI survivors annually over 20 years, beta-blockers would save $18 million and result in 72,000 fewer CHD deaths, 62,000 MIs prevented, and 447,000 life-years gained. Sensitivity analyses demonstrated that the cost-effectiveness of beta-blocker therapy would always be less than $11,000 per QALY gained, even under unfavorable assumptions, and may even be cost saving. Restricting beta-blockers only to ideal patients (those without absolute or relative contraindications) would reduce the epidemiological impact of beta-blocker therapy by about 60%. CONCLUSIONS: Our simulation indicates that increased use of beta-blockers after MI would lead to impressive gains in health and would be potentially cost saving. JAMA. 2000;284:2748-2754.

Adrenergic beta-Antagonists↗
PubMed2000

Technical appendix

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Journal Article↗
PubMed2000

Clinical characteristics of patients intolerant to VVIR pacing.

The incidence and clinical predictors of the development of intolerance to VVIR pacing have not been extensively studied in prospective long-term randomized trials comparing different pacing modes. The frequency and clinical factors predicting intolerance to ventricular pacing are controversial. The Pacemaker Selection in the Elderly (PASE) Trial enrolled 407 patients aged >/=65 years in a 30-month, single-blind, randomized, controlled comparison of quality of life and clinical outcomes with ventricular pacing and dual-chamber pacing in patients undergoing dual-chamber pacemaker implantation for standard clinically accepted indications. We reviewed the clinical, hemodynamic, and electrophysiologic variables at the time of pacemaker implantation in 204 patients enrolled in the PASE trial and randomized to the VVIR mode, some of whom subsequently required crossover (reprogramming) to DDDR pacing. During a median follow-up of 555 days, 53 patients (26%) crossed over from VVIR to DDDR pacing. A decrease in systolic blood pressure during ventricular pacing at the time of pacemaker implantation (p = 0.001), use of beta blockers at the time of randomization (p = 0.01), and nonischemic cardiomyopathy (p = 0.04) were the only variables that predicted crossover in the Cox multivariate regression model. After reprogramming to the dual-chamber mode, patients showed improvement in all aspects of quality of life, with significant improvements in physical and emotional role. The high incidence of crossover from VVIR to DDDR pacing along with significant improvements in quality of life after crossover to DDDR pacing strongly favors dual-chamber pacing compared with single-chamber ventricular pacing in elderly patients requiring permanent pacing.

Aged↗
PubMed2000

Cost-effectiveness of cholesterol-lowering therapies according to selected patient characteristics.

BACKGROUND: The National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II) recommends treatment guidelines based on cholesterol level and number of risk factors. OBJECTIVE: To evaluate how the cost-effectiveness ratios of cholesterol-lowering therapies vary according to different risk factors. DESIGN: Cost-effectiveness analysis. DATA SOURCES: Published data. TARGET POPULATION: Women and men 35 to 84 years of age with low-density lipoprotein cholesterol levels of 4.1 mmol/L or greater (> or =160 mg/dL), divided into 240 risk subgroups according to age, sex, and the presence or absence of four coronary heart disease risk factors (smoking status, blood pressure, low-density lipoprotein cholesterol level, and high-density lipoprotein cholesterol level). TIME HORIZON: 30 years. PERSPECTIVE: Societal. INTERVENTIONS: Step I diet, statin therapy, and no preventive treatment for primary and secondary prevention. OUTCOME MEASURES: Incremental cost-effectiveness ratios. RESULTS OF BASE-CASE ANALYSIS: Incremental cost-effectiveness ratios for primary prevention with step I diet ranged from $1900 per quality-adjusted life-year (QALY) gained to $500000 per QALY depending on risk subgroup characteristics. Primary prevention with a statin compared with diet therapy was $54000 per QALY to $1400000 per QALY. Secondary prevention with a statin cost less than $50000 per QALY for all risk subgroups. RESULTS OF SENSITIVITY ANALYSIS: The inclusion of niacin as a primary prevention option resulted in much less favorable incremental cost-effectiveness ratios for primary prevention with a statin (>$500000 per QALY). CONCLUSIONS: Cost-effectiveness of treatment strategies varies significantly when adjusted for age, sex, and the presence or absence of additional risk factors. Primary prevention with a step I diet seems to be cost-effective for most risk subgroups but may not be cost-effective for otherwise healthy young women. Primary prevention with a statin may not be cost-effective for younger men and women with few risk factors, given the option of secondary prevention and of primary prevention in older age ranges. Secondary prevention with a statin seems to be cost-effective for all risk subgroups and is cost-saving in some high-risk subgroups.

Adult↗
PubMed2000

Resource use and survival of patients hospitalized with congestive heart failure: differences in care by specialty of the attending physician. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

BACKGROUND: Previous studies suggest that specialty care is more costly but may produce improved outcomes for patients with acute cardiac illnesses. OBJECTIVE: To determine whether patients with congestive heart failure who are cared for by cardiologists experienced differences in costs, care patterns, and survival compared with patients of generalists. DESIGN: Prospective cohort study. SETTING: 5 U.S. teaching hospitals between 1989 and 1994. PATIENTS: 1298 patients hospitalized with an exacerbation of congestive heart failure. MEASUREMENTS: Hospital costs; average daily Therapeutic Intervention Scoring System (TISS) score; and survival censored at 30, 180, and 365 days and 31 December 1994. RESULTS: Compared with patients of generalists, patients of cardiologists were younger (mean age, 63.3 and 71.4 years; P < 0.001) and had lower Acute Physiology Scores at the time of admission (35.1 and 36.7; P < 0.001) but were more likely to have a history of ventricular arrhythmias (21.0% and 10.2%; P < 0.001). At 6 months, 201 (27%) patients of cardiologists and 149 (27%) patients of generalists had died. After adjustment for sociodemographic characteristics and severity of illness, patients of cardiologists incurred costs that were 42.9% (95% CI, 27.8% to 59.8%) higher and average daily TISS scores that were 2.83 points (CI, 1.96 to 3.68 points) higher than those of patients of generalists. Patients of cardiologists were more likely to undergo right-heart catheterization (adjusted odds ratio, 2.9 [CI, 1.7 to 4.9]) or cardiac catheterization (adjusted odds ratio, 3.9 [CI, 2.4 to 6.2]) and had higher odds for transfer to an intensive care unit and electrocardiographic monitoring. Adjusted survival did not differ significantly between groups at 30 days; however, there was a trend toward improved survival among patients of cardiologists at 1 year (adjusted relative hazard, 0.82 [CI, 0.65 to 1.04]) and at maximum follow-up (adjusted relative hazard, 0.80 [CI, 0.66 to 0.96]). CONCLUSIONS: In this observational study of patients hospitalized with congestive heart failure, cardiologist care was associated with greater costs and resource use and no difference in survival at 30 days of follow-up. Whether the trend toward better survival at longer follow-up represents differences in care or unadjusted illness severity is uncertain.

Adult↗
PubMed2000

Patient race and decisions to withhold or withdraw life-sustaining treatments for seriously ill hospitalized adults. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

PURPOSE: Patient race is associated with decreased resource use for seriously ill hospitalized adults. We studied whether this difference in resource use can be attributed to more frequent or earlier decisions to withhold or withdraw life-sustaining therapies. SUBJECTS AND METHODS: We studied adults with one of nine illnesses that are associated with an average 6-month mortality of 50% who were hospitalized at five geographically diverse teaching hospitals participating in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). We examined the presence and timing of decisions to withhold or withdraw ventilator support and dialysis, and decisions to withhold surgery. Analyses were adjusted for demographic characteristics, prognosis, severity of illness, function, and patients' preferences for life-extending care. RESULTS: The mean (+/- SD) age of the patients was 63 +/- 16 years; 16% were African-American, 44% were women, and 53% survived for 6 months or longer. Of the 9,076 patients, 5,349 (59%) had chart documentation that ventilator support had been considered in the event the patient's condition required such a treatment to sustain life, 2,975 charts (33%) had documentation regarding major surgery, and 1,293 (14%) had documentation of discussions about dialysis. There were no significant differences in the unadjusted rates of decisions to withhold or withdraw treatment among African-Americans compared with non-African-Americans: among African-Americans, 33% had a decision made to withhold or withdraw ventilator support compared with 35% among other patients, 14% had a decision made to withhold major surgery compared with 12% among other patients, and 25% had a decision made to withhold or withdraw dialysis compared with 30% among other patients (P >0.05 for all comparisons). After adjustment for demographic characteristics, prognosis, illness severity, function, and preferences for care, there were no differences in the timing or rate of decisions to withhold or withdraw treatments among African-Americans compared with non-African-American patients. CONCLUSION: Patient race does not appear to be associated with decisions to withhold or withdraw ventilator support or dialysis, or to withhold major surgery, in seriously ill hospitalized adults.

Adult↗
PubMed2000

Patient characteristics associated with care by a cardiologist among adults hospitalized with severe congestive heart failure. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

OBJECTIVES: The goal of this study was to determine factors associated with receiving cardiologist care among patients with an acute exacerbation of congestive heart failure. BACKGROUND: Because cardiologist care for acute cardiovascular illness may improve care, barriers to specialty care could impact patient outcomes. METHODS: We studied 1,298 patients hospitalized with acute exacerbation of congestive heart failure who were cared for by cardiologists or generalist physicians. Using multivariable logistic models we determined factors independently associated with attending cardiologist care. RESULTS: Patients were less likely to receive care from a cardiologist if they were black (adjusted odds ratio [AOR] 0.53, 95% confidence interval [CI] 0.35, 0.80), had an income of less than $11,000 (AOR 0.65, 95% CI 0.45, 0.93) or were older than 80 years of age (AOR 0.23, 95% CI 0.12, 0.46). Patients were more likely to receive cardiologist care if they had college level education (AOR 1.89, 95% CI 1.02, 3.51), a history of myocardial infarction (AOR 1.59, 95% CI 1.17, 2.16), a serum sodium less than 133 on admission (AOR 1.96, 95% CI 1.30, 2.95) or a systolic blood pressure less than 90 on admission (AOR 1.97, 95% CI 1.20, 3.24). Patients who stated a desire for life extending care were also more likely to receive care from a cardiologist (AOR 1.40, 95% CI 1.04, 1.90). CONCLUSIONS: After adjusting for severity of illness and patient preferences for care, patient sociodemographic factors were strongly associated with receiving care from a cardiologist. Future investigations are required to determine whether these associations represent unmeasured preferences for care or inequities in our health care system.

Adult↗
PubMed2000

The mode selection trial (MOST) in sinus node dysfunction: design, rationale, and baseline characteristics of the first 1000 patients.

BACKGROUND: More than 200,000 permanent pacemakers will be implanted in the United States in 2000 at a cost of more than $2 billion. Sick sinus syndrome (SSS) will likely account for approximately half of all cases necessitating implantation. Pacemaker technology permits the selection of ventricular (single-chamber) or dual-chamber devices. However, clinical and outcomes data are inadequate to support a clear recommendation that one or the other type of device be used. METHODS: The Mode Selection Trial (MOST) is a single-blind study supported by the National Heart, Lung, and Blood Institute designed to enroll 2000 patients with SSS. All patients will receive a DDDR pacemaker programmed to VVIR or DDDR before implantation. The average time of follow-up will be 3 years. MOST has a >90% power to detect a 25% reduction in the primary end point-nonfatal stroke or total (all cause) mortality-in the DDDR-treated group. Secondary end points will include health-related quality of life and cost effectiveness, atrial fibrillation, and development of pacemaker syndrome. Prespecified subgroups for analysis will include women and the elderly. Enrollment was completed in October 1999, with a total of 2010 patients. RESULTS: The median age of the first 1000 enrolled patients is 74 years, with 25% of patients 80 years or older. Women comprise 49%, and 17% are nonwhite, predominantly black (13%). Before pacemaker implantation, 22% of patients reported a history of congestive heart failure, 11% coronary angioplasty, and 25% coronary bypass surgery. Supraventricular tachycardia including atrial fibrillation was present in 53% of patients. A prior stroke was reported by 12%. Antiarrhythmic therapy was in use in 18% of patients. CONCLUSIONS: MOST will fill the clinical need for carefully designed prospective studies to define the benefits of dual-chamber versus single-chamber ventricular pacing in patients with SSS. The MOST population is typical of the overall pacemaker population in the United States. Thus the final results of MOST should be clinically generalizable.

Aged↗
PubMed1999

Expert panel vs decision-analysis recommendations for postdischarge coronary angiography after myocardial infarction.

CONTEXT: Expert panels and decision-analytic techniques are increasingly used to determine the appropriateness of medical interventions, but these 2 approaches use different methods to process evidence. OBJECTIVE: To compare expert panel appropriateness ratings of coronary angiography after myocardial infarction (from the time of hospital discharge to 12 weeks after infarction) with the health gains and cost-effectiveness predicted by a decision-analytic model. DESIGN: Comparison of the degree of importance of the clinical variables considered in expert panel appropriateness ratings vs a previously published decision-analytic model. Identification of 36 clinical scenarios from the expert panel that could be simulated by the decision-analytic model. MAIN OUTCOME MEASURES: Appropriateness score and appropriateness classification (expert panel) vs gain in quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (decision-analytic model). RESULTS: The most important clinical variables were similar in the 2 approaches, with the exercise tolerance test result exerting the greatest leverage on strength of recommendation for angiography. Among the expert panel clinical scenarios considered to be appropriate for coronary angiography that could be simulated in the decision-analysis model, the median (interquartile range) health gain and incremental cost-effectiveness ratio were 0.59 (0.41-0.76) QALYs and $27000 ($23000-$35000) per QALY gained, respectively. Among the clinical scenarios that expert panels considered inappropriate, the corresponding medians (interquartile ranges) were 0.24 (0.19-0.34) QALYs and $54000 ($36000-$58000) per QALY gained. The Spearman rank correlation between appropriateness score and QALY gain was 0.58 (P<.001) and between appropriateness score and estimated incremental cost-effectiveness ratios was -0.66 (P<.001). CONCLUSIONS: For the 36 expert panel scenarios that could be simulated by the decision-analytic model, there was moderate to good agreement between the appropriateness score and both the health gain and the incremental cost-effectiveness ratio of coronary angiography compared with no angiography in the convalescent phase of acute myocardial infarction, but several scenarios judged as inappropriate by the expert panel approach had cost-effectiveness ratios comparable with many generally recommended medical interventions. Formal synthesis of expert judgment and decision modeling is warranted in future efforts at guideline development.

Adult↗
PubMed1999

Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.

BACKGROUND: Cardiac complications are important causes of morbidity after noncardiac surgery. The purpose of this prospective cohort study was to develop and validate an index for risk of cardiac complications. METHODS AND RESULTS: We studied 4315 patients aged > or = 50 years undergoing elective major noncardiac procedures in a tertiary-care teaching hospital. The main outcome measures were major cardiac complications. Major cardiac complications occurred in 56 (2%) of 2893 patients assigned to the derivation cohort. Six independent predictors of complications were identified and included in a Revised Cardiac Risk Index: high-risk type of surgery, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and preoperative serum creatinine >2.0 mg/dL. Rates of major cardiac complication with 0, 1, 2, or > or = 3 of these factors were 0.5%, 1.3%, 4%, and 9%, respectively, in the derivation cohort and 0.4%, 0.9%, 7%, and 11%, respectively, among 1422 patients in the validation cohort. Receiver operating characteristic curve analysis in the validation cohort indicated that the diagnostic performance of the Revised Cardiac Risk Index was superior to other published risk-prediction indexes. CONCLUSIONS: In stable patients undergoing nonurgent major noncardiac surgery, this index can identify patients at higher risk for complications. This index may be useful for identification of candidates for further risk stratification with noninvasive technologies or other management strategies, as well as low-risk patients in whom additional evaluation is unlikely to be helpful.

Aged↗
PubMed1999

The impact of hospitalists on medical education and the academic health system.

Hospitalism as a career option is likely to reinforce the emphasis of traditional medical residency programs on inpatient care; may become an alternative area of emphasis in many subspecialty fellowship programs; and may even generate its own specific types of advanced training and certification. In the academic setting, subspecialists and their trainees are concerned that hospitalists may request fewer consultations, which could adversely affect subspecialists and the education of both fellows and residents. However, the focus and expertise of hospitalists is likely to improve inpatient education for students and residents and is appealing because it has the potential to improve the quality of inpatient care. Perhaps the major effect of the hospitalist movement on academic centers will be the creation of a cadre of physicians committed to critical pathways; clinical guidelines; quality assurance; risk management; clinical re-engineering; and the use of the inpatient service as a laboratory for developing, evaluating, and implementing initiatives to improve patient care. Although any fundamental change in the organization of clinical services brings with it the risk that essential components of the current system will be jeopardized, the hospitalist movement may have great benefits if it can develop safeguards to ensure seamless patient care and the appropriate use of subspecialty expertise.

Academic Medical Centers↗
PubMed1999

Patient age and decisions to withhold life-sustaining treatments from seriously ill, hospitalized adults. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

BACKGROUND: Patient age may influence decisions to withhold life-sustaining treatments, independent of patients' preferences for or ability to benefit from such treatments. Controversy exists about the appropriateness of using age as a criterion for making treatment decisions. OBJECTIVE: To determine the effect of age on decisions to withhold life-sustaining therapies. DESIGN: Prospective cohort study. SETTING: Five medical centers participating in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). PATIENTS: 9105 hospitalized adults who had one of nine illnesses associated with an average 6-month mortality rate of 50%. MEASUREMENTS: Outcomes were the presence and timing of decisions to withhold ventilator support, surgery, and dialysis. Adjustment was made for sociodemographic characteristics, prognoses, baseline function, patients' preferences for life-extending care, and physicians' understanding of patients' preferences for life-extending care. RESULTS: The median patient age was 63 years; 44% of patients were women, and 53% survived to 180 days. In adjusted analyses, older age was associated with higher rates of withholding each of the three life-sustaining treatments studied. For ventilator support, the rate of decisions to withhold therapy increased 15% with each decade of age (hazard ratio, 1.15 [95% CI, 1.12 to 1.19]); for surgery, the increase per decade was 19% (hazard ratio, 1.19 [CI, 1.12 to 1.27]); and for dialysis, the increase per decade was 12% (hazard ratio, 1.12 [CI, 1.06 to 1.19]). Physicians underestimated older patients' preferences for life-extending care; adjustment for this underestimation resulted in an attenuation of the association between age and decisions to withhold treatments. CONCLUSION: Even after adjustment for differences in patients' prognoses and preferences, older age was associated with higher rates of decisions to withhold ventilator support, surgery, and dialysis.

Activities of Daily Living↗
PubMed1999

Cardiac troponin T as a marker for myocardial ischemia in patients seen at the emergency department for acute chest pain.

BACKGROUND: Identification of patients with acute chest pain at high risk for cardiovascular complications is a common and difficult challenge for clinicians and must be based initially on data from the history, physical examination, electrocardiogram, and chest radiograph. Some data suggest that elevations in cardiac troponin T (cTnT) may be useful for detection of less severe degrees of myocardial injury that may occur in some patients with unstable angina. Therefore we designed a prospective follow-up study to assess the diagnostic performance and prognostic value of cTnT in a population of patients presenting to the emergency department with acute chest pain. METHODS: The patient population included all 1477 admitted patients aged 30 years or more who presented to the emergency department of an urban teaching hospital from October 1992, through February 1994, with a chief symptom of acute chest pain not explained by trauma or chest radiograph abnormalities. The 1303 patients (88%) who had 2 or more measurements of cTnT during the first 24 hours after presentation comprised the final study population. Sensitivity, specificity, positive predictive value, negative predictive value, and receiver operator characteristics curve (ROC) were determined for cTnT and creatine kinase-MB (CK-MB) (measured using activity and mass assays) data from the first 24 hours after admission for the outcomes of acute myocardial infarction (AMI) and major cardiac events during the first 72 hours of hospitalization. RESULTS: The sensitivity and specificity of cTnT (threshold of 0.1 ng/mL) for detecting AMI during the first 24 hours after presentation were 99% and 86%, respectively. The CK-MB activity and mass assays had diagnostic performance for detecting AMI similar to cTnT. Among patients who did not meet study criteria for AMI, cTnT was elevated during the first 24 hours in 31% of patients who had major complications, compared with a 17% rate for the CK-MB activity assay and a 3% rate for the CK-MB mass assay. In these patients, the cTnT assay had superior diagnostic performance compared with the CK-MB mass assay as a marker for cardiac complications as assessed with ROC analysis (P <.0004). CONCLUSIONS: In a heterogeneous population of patients seen in the emergency department with acute chest pain, cTnT was similar to CK-MB (activity and mass assays) for detection of AMI and superior to the CK-MB mass assay as a marker for major cardiac events early in the hospital course among those who were ruled out for an AMI. Further study is required to determine how this assay can be used to provide more appropriate, cost-effective care.

Acute Disease↗