Atraumatic chest pain is a common emergency department (ED) presentation and the American College of Cardiology and American Heart Association recommends stress testing within 72 hours. The HEART score predicts major adverse cardiac events (MACE) in ED populations and does not require universal stress testing. An evaluation based solely on history, electrocardiography, and biomarkers, therefore, is an attractive approach to risk stratification in resource-limited settings. The HEART score has not been previously evaluated in a safety net hospital setting. We therefore implemented an interdisciplinary clinical care guideline utilizing the HEART score to stratify patients presenting to our inner-city hospital. During a 6-month study period, 1170 patients were evaluated (521 before and 649 after implementation). Among the 998 patients with confirmed follow-up 6-weeks after the index ED encounter, the prevalence of MACE (all-cause mortality, acute myocardial infarction, or coronary revascularization) was 0% [95% confidence interval (CI), 0%–1%] for low, 9% (95% CI, 7%–12%) for moderate, and 52% (95% CI, 39%–65%) for high-risk groups. Guideline implementation significantly increased admissions (+12%, 95% CI, 7%–17%) primarily in the moderate risk group (+38%, 95% CI, 29%–47%), but significantly decreased median ED length of stay (−37 minutes, 95% CI, 17–58). It also led to an increase in stress testing among moderate and high-risk patients (+10%, 95% CI, 0%–19%). In conclusion, the HEART score effectively stratified risk of MACE in a safety net population, improved evaluation consistency, and decreased ED length of stay. However, implementation was associated with an increase in hospitalizations and stress testing. Although the American Heart Association/American College of Cardiology guideline regarding atraumatic chest pain in the ED recommends universal noninvasive testing, the value of this approach, particularly in conjunction with the HEART score is uncertain in safety net hospitals. Further evaluation of the costs and clinical advantages of this approach are warranted.

Objectives: To observe change in economy of 9 ultrasound probe movement metrics among internal medicine trainees during a 5-day training course in cardiac point of care ultrasound (POCUS). Methods: We used a novel probe tracking device to record nine features of ultrasound probe movement, while trainees and experts optimized ultrasound clips on the same volunteer patients. These features included translational movements, gyroscopic movements (titling, rocking, and rotation), smoothness, total path length, and scanning time. We determined the adjusted difference between each trainee’s movements and the mean value of the experts’ movements for each patient. We then used a mixed effects model to trend average the adjusted differences between trainees and experts throughout the 5 days of the course. Results: Fifteen trainees were enrolled. Three echocardiographer technicians and the course director served as experts. Across 16 unique patients, 294 ultrasound clips were acquired. For all 9 movements, the adjusted difference between trainees and experts narrowed day-to-day ( p value < 0.05), suggesting ongoing improvement during training. By the last day of the course, there were no statistically significant differences between trainees and experts in translational movement, gyroscopic movement, smoothness, or total path length; yet on average trainees took 28 s (95% CI [14.7–40.3] seconds) more to acquire a clip. Conclusions: We detected improved ultrasound probe motion economy among internal medicine trainees during a 5-day training course in cardiac POCUS using an inexpensive probe tracking device. Objectively quantifying probe motion economy may help assess a trainee’s level of proficiency in this skill and individualize their POCUS training.

Ultrasound-guided pre-procedural planning decreases complications from bedside thoracentesis. Although rare, intercostal artery (ICA) laceration is a serious complication that occurs when vulnerable intercostal arteries (VICA) are no longer protected by the superior rib. We sought to determine if increasing patient age is associated with greater odds of encountering a VICA. Randomly selected in-patients underwent pre-procedural planning for a mock posterior bedside thoracentesis. ICAs were categorized as vulnerable if they were visible within the corresponding intercostal space (ICS). We recorded where the VICA entered and exited the ICS as well as its unshielded length. A total of 40 patients (20 male) were enrolled and 240 ICS (6 ICS per patient) were scanned. Within this cohort, 25% of patients were noted to have at least one VICA. We could not demonstrate any relationship between the patient’s age or location of the ICS, with the odds of encountering a VICA (odds ratio (OR) = 1.0, p = 0.76; OR = 0.85, p = 0.27, respectively). Given the haphazard nature of VICA distribution and poor outcomes associated with inadvertent laceration, we recommend that ICA screening at the site of needle insertion be routinely performed prior to thoracentesis.

The journal retracts the article, ‘Is Increasing Age Associated with Higher Rates of Intercostal Arteries Vulnerable to Laceration