Meier MA, Al-Badr WH, Cooper JV, et al. Diagnostic and prognostic implications in patients with acute coronary syndromes. Arch Intern Med 2002; 162:1,585-1,589.

The new definition of acute myocardial infarction (AMI) results in a significant increase in diagnosis of this condition, says this study from the University of Michigan in Ann Arbor. The new definition, which was jointly published in 2000 by the France-based European Society of Cardiology and the Bethesda, MD-based American College of Cardiology, officially included troponins for the first time. Elevated levels of enzymes with either symptoms or electrocardiographic changes suggesting ischemia now constitute an AMI.

The researchers studied 493 patients with suspected acute coronary syndromes. They divided the 275 patients who had positive cardiac enzymes and symptoms suggesting of coronary ischemia into two groups: a group that would have been diagnosed as AMI with the old criteria, and a group of additional patients that were diagnosed based on the new criteria.

The second group consisted of 51 patients, who tended to be older women with increased comorbidities such as previous stroke or aortic stenosis. All of them would have been missed by the old criteria.

The researchers say that the study has the following clinical implications for patients with symptoms of acute coronary syndromes:

  • More AMI patients will be identified. The study found that 10.8% of patients with suspected acute coronary syndrome were not missed or wrongly classified as having unstable angina, as a result of the new criteria.
  • Patients at risk for adverse outcomes can be given tailored treatment strategies to decrease mortality, such as glycoprotein IIb/IIa receptor antagonists, low-molecular-weight heparin, or clopidogrel. The additional patients diagnosed with the new definition had more comorbid conditions and were at greater risk of adverse events.

"Missed diagnosis of such a high-risk cohort has been shown to be associated with worse outcomes," the researchers wrote.

Coyle YM, Hynan LS, Gruchalla RS, et al. Predictors of short-term clinical response to acute asthma care in adults. International Journal for Quality in Health Care 2002; 14:69-75.

Interventions are needed in the ED to improve patients’ asthma knowledge, according to this study from University of Texas Southwestern Medical Center at Dallas. The researchers looked at 309 adult patients who presented to EDs with acute asthma from 1997 to 1999 and checked peak expiratory flow rates several weeks later. They found that patients most likely to have a worsened condition had two major risk factors: lower general knowledge of asthma and exposure to indoor allergens.

The researchers say the study’s findings have important implications for clinical practice in the ED. They suggest the following steps be taken to improve short-term clinical response to acute asthma care in adult ED patients:

  • Refer adult asthma patients of all severity levels for asthma education.
  • Provide patients with education on use of inhalers, spacers, symptom monitoring, peak flow monitoring, and early signs of deterioration.
  • Reinforce the importance of following the prescribed asthma management plan.
  • Target interventions to groups at high risk for asthma morbidity, such as economically disadvantaged inner-city residents.

"High-risk patients consume a disproportionate amount of health care resources, and therefore reducing asthma morbidity in this group should lead to significant savings in acute asthma care," the researchers conclude.