While COVID-19 occupied much of our bandwidth in 2020, new medical literature on other important topics still descended upon us faster than it could be consumed. We’ve already covered some of this in previous ACEP Now updates touching on critical care, tranexamic acid, and spontaneous pneumothorax. But those barely scratched the surface of the year in research.
Here’s a quick tour of more of the most talked-about articles from the past year.
High-sensitivity troponin assays have continued to become more commonly used, and the HIGH-US study is one of the most thorough large-scale validations of the rapid rule-out algorithms demonstrated in Europe.1 This study evaluated two pathways for diagnosis of acute myocardial infarction (AMI), generating consistently mixed results. The most important result from this study is the continued demonstration that a single high-sensitivity troponin below the limit of detection can be sufficient for ruling out AMI. Also, using these new assays for rapid repeat testing is safe, with good sensitivity for AMI. Unfortunately, these assays and algorithms still fail to fully provide clarity, as nearly a third of the patients evaluated still required “continued evaluations” despite the additional precision offered in these tests.
Much has been written about using computed tomography coronary angiography (CTCA) to exclude acute coronary syndrome (ACS) in the initial evaluation of chest pain in the emergency department. Interestingly, there may yet be a role for CTCA even following the diagnosis of ACS. In a study in which CTCA was performed prior to invasive coronary angiography in patients with a non-ST segment elevation ACS, nearly a quarter of patients were shown to have coronary stenosis under 50 percent.2 The implication for downstream management is that resource-intensive and costly procedures might be avoided in a large cohort of patients.
Speaking of avoiding low-value procedures, another study took a population-level look at noninvasive cardiac testing.3 This study, performed in the Kaiser Permanente Southern California population, tried to tease out an association between receipt of (primarily) early stress testing on subsequent myocardial infarction and mortality. Based on these data, the authors concluded there may be a benefit to such testing, but between 200 and 500 tests would need to be performed to inform management to improve the outcome of one additional patient. These data may provide some of the first insights into beneficial effects of follow-up noninvasive testing but clearly demonstrate the need for further studies to elucidate the highest-yield population.
Finally, the last point of curiosity involved physician interpretations of the electrocardiogram (ECG). Many physicians poke fun at the erroneous interpretations of the computer embedded in the ECG machine, but a study collating the accuracy of physician ECG reading was humbling.4 In a meta-analysis of ECG interpretation skills, after discarding medical students and trainees, pooled performance for physician accuracy sat squarely between 60 and 80 percent. Much depends on the specifics of each included study, but it should be clear there is always work to be done on improving ECG reading skills—and the computers may be better than we thought.