Welcome, everyone, and thank you for joining this Quality Summit Hot Topic session focused on chest pain management. My name is Keri Morris, and I am the Accreditation Clinical Product Manager with ACC Accreditation Services. I will serve as the moderator for today's discussion, beginning with an introduction of our guest speaker. Dr. Phil Levy is a professor of emergency medicine and assistant vice president for research at Wayne State University. He also serves as the chief innovation officer for Wayne Health. Dr. Levy has been an active member of the American College of Cardiology for many years, serving in such roles as the immediate past chair for the ACC Accreditation Oversight Committee, current member of the ACC NCDR Oversight Committee, and current member of the NCDR Chest Pain in My Registry Publications Committee. He is very passionate about ensuring quality care. I hope you take a minute to read his bio to learn more about him. Dr. Levy, thank you for being with us today and preparing this content. Now let's get started. Thank you very much, Keri, for that kind introduction. It's a pleasure to present to the audience today and a pleasure to be here with you. You and I have worked together for many years, as you noted, as part of accreditation in general and specific to chest pain itself, and I'm delighted to be talking about this topic today. You mentioned some of this before, but by way of relevant disclosures, I am the immediate past chair of the ACC Accreditation Oversight Committee and a member of the NCDR committees that was mentioned. I also serve as the vice chair for the ACC AHA 2021 Guideline for the Evaluation and Diagnosis of Chest Pain, which we'll touch upon a little bit here, more so in a prelude to what's going to be coming because it hasn't been published yet. We're not going to get too deep into what the guidelines will contain, but we will dance around the edges a little bit so everyone gets an idea of where this might be going and how it might help us find direction with our chest pain care. I wanted to start off with a little historical context. This is really about death and case fatalities related to acute myocardial infarction. In the 70s and 80s, 1980s, the rates of mortality and the case fatality rates were unacceptably high. A lot of things started to happen to try to improve upon that, perhaps most important of which is the general concept that we can do better in hospital-based care and we should strive to do better in hospital-based care. Some of this coincided, if you will, with changes in technology and advancements in medical practice, but in general, there was a broader understanding and acceptance of the fact that we need to do better. A pioneer in all of this and somebody that we know quite well is Dr. Ray Barr. Ray Barr started the Society of Chest Pain Centers back in the 90s in response to this unacceptable outcome related to acute myocardial infarction. As this was published in Reader's Digest, for those of you that remember that publication, Ray Barr declared war on heart attacks. He really was a pioneer in the concept of team-based care, this idea that it's not just one group of physicians taking care of a patient with chest pain, it's a lot of groups of physicians, but not just physicians, nurses, ancillary personnel. All of that need to come together under at least a more formalized approach to how we deliver care so that we can do the best by our patients. An important part of all of this was the work that Ray and the group did out of St. Agnes, a hospital in Baltimore, and basically created the first coronary care system in the country in that location. The new level of care they were providing was care where we tried or they tried to do the same thing for a patient every time when they entered the door. We couldn't have some people getting electrocardiograms done within two hours and some people getting them done within 10 minutes if we wanted to get everybody to the ideal goals of reduced cardiac mortality and best outcomes. One of the things that Dr. Barr and the system that he put in place really, really promulgated was this concept of time is muscle. The idea that we can't wait to initiate care for people because every minute, every hour that we're waiting, people are developing worse outcomes because the myocardial injury that's sustained from acute coronary artery conclusion is going to decrease the likelihood that that cardiac muscle can be recovered. If we let this go too long, we're going to have the outcomes that we witnessed in that early slide. This idea of a golden hour and that time is myocardium and that we can save more heart muscle by acting expeditiously was all begun during this paradigm shift. That has enabled us to get to better outcomes where we are today. We're at a time right now where we've done much better. We've gotten much lower mortality rates related to heart attacks. The in-hospital mortality rate and the 30-day mortality rate related to heart attacks are at a point they've been relatively stable, somewhere between 8% and 10% potentially depending on where you practice and where you look. That's also come at a little bit of an expense. That expense is that because we directed so much attention to improving outcomes for patients who present to the emergency department with suspected heart attacks, we've also started taking a much lower threshold for where we start to initiate care, initiate more advanced care perhaps to look for that underlying coronary artery disease. We have a crossover inflection point. We improved outcomes related to heart attacks, myocardial infarction because of more attentiveness and team-based care to how we get things done expeditiously, but at the same time, we also reduced the threshold for the additional testing needed to make sure that that patient who's coming through the door with suspected myocardial infarction, chest pain, however you want to think about terming it, doesn't indeed have underlying coronary artery disease. What we see in this graphic right here, which many of you might have seen before, is this idea that we have increased the amount of testing that we're doing over the past few decades. I think anybody who's been involved in the care of chest pain patients knows this. We have a low threshold for diagnostic imaging, but what that does is it actually decreases the amount of positive tests that we're doing. These are data that all coincide. The more testing we do, the less likely we're going to find positive tests. That is a good thing if you're in a world where resources are unlimited, but we're unfortunately not in this world. A lot of the emphasis now is trying to take this movement, everything we can do to improve heart attack and myocardial infarction outcomes, and right-size the care that we're delivering so that we can still achieve optimal outcomes, but not do unnecessary or potentially avoidable testing. Again, a lot of this is because the threshold for what we do next after that initial assessment of a chest pain patient hasn't really been standardized. Some of it is protocol-based in a given institution. Some of it is what's been talked about through expert lectures and presentations like these, but we haven't had a guideline necessarily to hang our hat on for chest pain. I'm not talking about NSTEMI or STEMI guidelines, which are very clear what should happen next when a person does indeed have a heart attack. We're really talking about what happens to the patient who we suspect has a heart attack, has chest pain or chest pain equivalents, and we want to figure out how to get them the right care at the right time. It's really important to notice and to understand that more testing doesn't mean better outcomes. This is a graphic that really shows that if you look at hospitals ranked by their percentage receiving some kind of myocardial imaging, non-invasive imaging for chest pain, you can see there's very big differences. Some institutions are at the low end and don't do testing on anybody. Some institutions do it on 40%, 50%, 60% of their patients that come through. In the next figure here, you can see that there are differences. You have in the lowest quartile, and this is several hundred thousands of patients in multiple different hospital systems using claims-based data, but looking at low versus high utilizer hospitals, places where they image maybe 6% overall versus 35% or more, you see a difference in inpatient admissions. You see a difference in who gets coronary angiograms, and you see a slight difference in who gets a revascularization, but you see a decline in revascularizations per imaging study. You see a decline in revascularizations per angiogram, and you see no difference at all in readmissions with subsequent acute myocardial infarction. What this tells you is that more testing isn't always tied to better outcomes, and more testing isn't always needed to make sure that that person that we're seeing can go home safely and can do well without having to fear coming back to the hospital with an untoward outcome like an acute myocardial infarction. The reason that we do this, though, is because the symptoms that people present with are relatively similar. It's hard when I first walk in the room as an emergency physician and start to talk to a chest pain patient. When we think about typical and atypical symptoms and try to align, this is more or less attributable, if you will, to acute coronary syndrome, acute coronary conclusion, myocardial infarction. What this graphic shows is that patients on the left who presented with myocardial infarction and patients on the right who presented without myocardial infarction have basically the same types of symptoms. You may see typical symptoms amongst those who don't end up with a myocardial infarction diagnosis, and you'll see atypical symptoms amongst those who do. Again, you can see the quality and the descriptives that people use for this just overlap and it makes it much harder to discern off the get-go from the initial assessment that I'm doing. The history, the physical, whatever it is I'm doing doesn't point me in one direction or another very often. We have a very low threshold for at least initially thinking about a chest pain patient potentially being a myocardial infarction patient. The time-honored and still the best initial test that we can do to determine who's having that MI right now is the electrocardiogram. We all know door-to-ECG times have been targeted at 10 minutes or less. We know that's a performance metric that we all strive to achieve. Carrie, I know in the world that we live in, the world you currently live in, the world I lived in a lot for the past years, we target door-to-ECG time as a metric in accreditation and it's an important thing that we strive to achieve. But where we've gone now is that we don't see that many STEMIs perhaps like we used to, but overall, even though we set up outstanding systems of care, targeted door-to-balloon times, less than 45 minutes in some institutions, I know that's what we strive for in mine, at least less than 90 minutes overall. We know that very few of the people who present with chest pain actually have a STEMI. I work in Detroit. We have a five hospital system that sees upwards of 300,000 plus emergency department visits a year. And if on average we do 10 to 15 STEMIs a month, that's going to be a high-value month. So the electrocardiogram most often is going to give us some indication that the person has a myocardial infarction, a STEMI if it's there. But for the vast majority of people, it's either going to be normal or have some irregularity that doesn't give us the key indication that this is coronary artery disease as the etiology for chest pain versus not. So what have we arrived at? We've arrived at this idea that in order to make more effective triage decisions, if we want to determine who rules out, who rules in, and who are we uncertain and should get observed whether that observation occurs in an observation unit or an inpatient ward, we need something else. And so what we need are cardiac biomarkers. And in the era that we're in now, we've gotten to the point where those biomarkers that we use, high-sensitivity troponins, are really darn good. And they can do a very good job of helping us determine who doesn't have a cardiac etiology for their presentation. And it can help us determine who does have a cardiac etiology, but not necessarily who has a coronary etiology of what they're presenting with. And so that's kind of been the big movement right now to try to sort all this out. How do we make those triage decisions incorporating the diagnostic tools we have to go ahead and determine is this an MI, is this somebody we need to worry about, or is this someone with non-cardiac chest pain who we can safely send home? And the Europeans have done a really, really good job of getting ahead of this. So high-sensitivity troponins, only recently approved here in the United States, have been used in Europe for probably almost a decade at this point, a little bit under that. And they have put forth guidelines and created pathways around the care of chest pain patients that, again, begins with the electrocardiogram, always begins with history before the electrocardiogram. Some of that history may just be age and whatnot, because in order to achieve 10-minute and under ECG times, you may need to do those in triage, right? You may need to say, you have chest pain, I don't really care much about anything else beyond those two words, and we're going to get your electrocardiogram. But the next step is, what do you do after that? Who should get a troponin? How do we use the troponin to help us determine what the next step are? And again, the Europeans have done a great job of this. In fact, the Europeans have created pathways that allow for rapid determination of rule-in, rule-out for chest pain patients based on the troponin, and really have kind of led the way for a lot of the stuff that we are beginning to look at and implementing here in the United States. And one of the key things to kind of keep in mind with all of this is that when you move to high-sensitivity troponins, it's not just the initial, we know this, right? You have to look at changes over time. But because the high-sensitivity troponins are such a good indicator of underlying myocardial injury, acute injury, when there's dynamic changes, you can see these changes early. And the European Society of Cardiology has really supported zero- and one-hour and zero- and two-hour algorithms to help us accelerate that process of identifying injury when present so we can get people to the next level of care as appropriate and indicated, and to discharge patients, or at least feel more comfortable that it's non-cardiac in patients who we can rule out quickly. But what we see here is in the European literature published on this, a lot of people fall into this rule-out category. They come in, they're suspected here. It says NSTEMI, but they have chest pain, and you're suspecting a heart attack, right? It's an NSTEMI because the ECG didn't show anything that would require immediate intervention. And the Europeans, again, have broken it down into this idea that we can rule out people with very low initial values or very low initial values and no change over zero from baseline to one hour or two hours. On the right side over here, we can rule people in with very high values or a high or relevant one-hour or two-hour change. We're not going to go over those numbers right now because they're assay specific. It's a moving target. These things change as we learn more about troponins and about what they indicate. The one key thing for everyone to remember on this is that you got to know your assay that you're using at your institution. You have to know what the cut point is for abnormal versus normal. Abnormal is still at least for diagnosing myocardial injury set at the 99th percentile. That doesn't mean that people who have values below that don't have underlying coronary artery disease. And that's why they break these things down as they do. But the Europeans, when they publish data on this, they talk about 60-plus percent people falling into the rule-out category and maybe 15 or 20 percent falling into the rule-in and everybody else falling into the observed. When we see this here in the United States, we have a different patient population. We often have individuals with things like long-standing uncontrolled hypertension, especially in the urban African-American population, the population I work with in Detroit. And so you have people who have big, thick hearts, left ventricular hypertrophy. There's more myocardium around. And so it's harder for us to completely rule people out based on troponin sometimes. It's hard for us to always rule people in because of the uncertainty whether some changes are acute or chronic. And a lot of people fall, a lot more people than you would expect looking at the European literature, fall into this observed observation category. And the reason behind this is when you look at conventional assays, which are basically anything that's not a high-sensitivity assay. We used to use terms like contemporary versus conventional, but now that high-sensitivity troponins are contemporary, the phrase isn't really appropriate. And so conventional assays, you can see that we can get a good sense of who's likely normal, who's likely pathological, and who's pathological. But once you get into high-sensitivity assays, we can determine with much greater precision who's normal and thus very unlikely to have a 30-day MACE event or a risk of myocardial infarction in that short-term period that we all fear as ER docs and as cardiologists. we never want to send someone home who has an untoward outcome 30 days later. After 30 days, it may be less attributable to that initial event. That's why we always use 30 days. But what you can see with the high-sensitivity troponins is more of them are going to fall into the pathological group above that 99th percentile, which is actually a good thing, right? If I were to come to the hospital with chest pain, I'd like to know, even if it was a small bump, that I had a bump in my troponin because it probably means something. And we're able to tell more people who have normal. And not more people who have normal, excuse me. We're able to be a little bit more definitive of who's normal and thus can rule out. So the high-sensitivity troponins have done a lot of things for us, but, you know, it's true, they have created some confusion. They have created some uncertainty in terms of how we go forward. And it's really important that we have guidance to help us get to that, you know, that next level of understanding. And here you can see how obviously we must think about high-sensitivity troponin values that exceed the 99th percentile. Are they stable? Is it chronic myocardial injury? Is it rising and falling? Is there evidence of ischemia? Do they have a type one or a type two MI where it's a coronary artery occlusion or potentially, you know, severe hypotension or something that causes a perfusion mismatch, oxygen supply and demand imbalance, or is it something that is not ischemic but could be acute injury related to heart failure and micro circulatory compression from increased left ventricular and diastolic pressure, or could it be acute myocarditis? And so, you know, this is part of the, you know, the piece that guidelines will include, but most of the guidelines have really been focused or most of the effort in the guidelines have really been focused on guiding people to understand when someone is low risk and doesn't need more workup or testing, and when someone is, you know, not high risk, but not low risk and falls into that intermediate or observation zone. And so this is part of the stuff, again, that we wanna stop spinning and really understand what's our true north, how are we gonna put in place practice protocols, policies that allow us to think about approaching chest pain in this type of manner. And so, as mentioned, this thinking, this thought process is a big component of what we put into the evaluation and diagnosis of chest pain guidelines, which as indicated on this slide here, downloaded last week, but indicating that, you know, it was updated on May 7th, 2021. The chest pain guidelines will be coming out in Q3, 2021. We're looking towards the AHA meeting for the AHA annual meeting for that. And, you know, and hopefully that holds true. We're very optimistic about that. And the chest pain guidelines will be addressing a lot of this type of stuff, understanding how do we identify low risk patients? How do we identify high risk patients? And who do we put in the middle that can't fall into one of those two categories? Again, without getting too much into the detail on it, because I can't, unfortunately, I promise you that these guidelines were written with the idea of making it easier to be a good clinician as it relates to the evaluation management of chest pain patients. And a key component of this guideline and all guidelines is how do you get risk stratification right? How do you do this? And so the low risk patient, like I said, is a big component of the emphasis. It's a large group of people. It's people that we've had a lot of discomfort with prior to high sensitivity troponins and even after high sensitivity troponins and putting something in a guideline that gives clinicians the comfort to know that they're backed in their decision-making by the weight of the AHA, ACC guidelines is really, really important. And as with any risk stratification, our goal is to figure out who can go home, who doesn't need outpatient testing, who needs further risk modification, who may need outpatient testing and who should we bring to the hospital either under observation status or on full admission for further care. And so, again, without getting into any of the details on this and divulging any of the secrets of the guideline, this is consistent with what's been out there for other guidelines and you can anticipate more of the same in these guidelines. Again, giving us the comfort that we need to help practice at our best. At the same time, there are some other guidelines that have come out in the interim. The Society for Academic Emergency Medicine put forth guidelines to look at recurrent low-risk chest pain patients. And this is something that is touched upon in the new AHA, ACC guidelines, but it's different. Here, you're talking about something that we see frequently in the emergency department, which is somebody comes back over and over again with chest pain. And somebody who's been worked up and fully vetted, what do you do with that individual? Do you continue to get testing on people when you're pretty certain that there's no coronary artery disease present? These guidelines are written specific for that. And it's basically looking at patients who have presented to the emergency department two or more times in the last 12-month period who've had a sufficient workup and there's no demonstration of flow-limiting coronary stenosis. You can define low risk as they do here using the HEART score. One of the things in the new guidelines, talking about risk stratification, we'll address things like HEART score and other scores and the ESC guidelines, which don't include score-based risk stratification. They don't include clinical decision rules like the HEART score. They base it all on troponin, as high-sensitivity troponin is the indicator. But bottom line is that for patients who present with recurrent low-risk chest pain, there's not much value in doing further testing beyond an electrocardiogram or perhaps a troponin to determine if they have myocardial injury, which may not be ischemic-based and not coronary artery-based. And so we're in this timeframe, this era right now, where guidelines are starting to creep up and come into play that can really help us manage patients well. But a key for guidelines is gonna be, how do you implement them? How does the rubber meet the road to do this? And I wanted to touch upon ACC Accreditation Services because in a lot of ways, the ACC Accreditation Services, especially chest pain accreditation, we're a driver of the need for the AHA-ACC guidelines around chest pain. Why is that? Well, it's hard to come up with accreditation criteria that speak to the best practices and evidence-based care around chest pain if you don't have the guidelines to back it up. And so we at the ACC, Society of Chest Pain Centers, before that, had been pushing for a while for this idea that we don't need guidelines around the MIA, well, we do, excuse me. We don't need another guideline necessarily around the MI patients to tell us how to manage chest pain. We need a full-on dedicated guideline to chest pain. And so the reason that I bring up the accreditation services here is to show what's offered, chest pain center accreditation, chest pain center accreditation with cath lab capabilities and with resuscitation measures in place. And there are different ways to think about the capabilities of a hospital and what they can do. And accreditation is a way to help get streamlined, standardized protocols in place for care of patients. And I won't say this anymore, but having guidelines in place really makes the implementation of these accreditation programs have more teeth and more weight to them, if you will. But it's the programs themselves that provide a lot of value around guidelines. So you have guidelines that support accreditation. Accreditation can support guidelines by ensuring that hospital systems implement the structure that's needed to be in place in order to implement or enact the processes that drive better patient outcomes. And so I wanted to touch a little bit more on this. The essential components of the ACC chest pain center accreditation, first and foremost, start with the patient at the middle of all of this. The patient comes in with chest pain. And then we're thinking about things like the quality metrics that we wanna talk about. But community outreach is critical. I'm gonna show a slide in a little bit that really brings home the understanding that we can have everything in place at the hospital system to be perfect. But if we don't have people that recognize when they should enact the hospital system, we can't fix that. We can't, if you think back to the time as myocardium, we can't make up the four or eight or 10 hours that a person delayed going to the hospital with a 30 minute door to balloon time, right? Because you're still looking at 10 and a half hours since the onset of symptoms. So community outreach, optimized pre-hospital care are key components, early stabilization. What do we do with these folks when they hit the door? What happens to them after we stabilize them and they're in this acute care phase, transitions of care? How do we ensure that patients who have chest pain, but also hypertension and diabetes get optimized on their guideline directed preventative therapy, as well as guideline directed medical therapy for things like coronary artery disease if a stent gets placed and whatnot. And again, clinical quality and quality overall are key pillars of accreditation. And governance is an important component because behind all of this, you have to get everyone into the sandbox who wants to play first and then they got to play nice in the sandbox. And I think everyone again on this call has had that interaction either as an emergency physician, as a cardiologist where there's incongruity in the language we're speaking. And oftentimes that is to the detriment of the patient. And if you can get ahead of the game by ensuring that you have a governance structure, you have agreements ahead of time as to who does what and who can initiate what, it changes everything. One of the key ones from our world as emergency physicians is ER docs being able to activate the STEMI pager. Back when I started practicing 20 years ago, we had to consult cardiology to come downstairs and tell us if EKG really was, ECG really was a STEMI. And now we've gotten rid of that because we realized it's not helpful to the patient, but governance and structures around that are key to making that type of stuff happen. And marrying this up then, if you wanna track quality, clinical quality, marrying it up with the other quality offerings such as the chest pain MI registry from the ACC is critical. There are other ways to collect chest pain data for accreditation. There's an accreditation confirmation database that was developed initially for this, but aligning with the chest pain MI registry allows standardized data collection, not just for what we had formerly thought of with the action MI registry, which was really based on MI, but really to understand the chest pain side of it. And what do you do with chest pain patients when they present? And it's critical that we understand that. And I think the real, the nice thing, the reason why the organizations came together, the ACC and the Society of Chest Pain Centers, which was later known as the Society for Cardiovascular Patient Care, was to realize these economies of scale and overlap that exists within the ACC's quality offerings, right? Getting the registries aligned with accreditation makes inherent sense. And we really strongly believe that this is gonna be an important component of getting guidelines implemented and making sure guidelines are adhered to. One of the things that I often like to say is accreditation helps hospitals practice at their best, but it doesn't ensure that every time best practices will be used. And so we have to make sure that there's oversight and there's tracking of that. And one of the things that we do know about chest pain care in an accredited facility is that it takes things that hadn't been done before and forces them to be done. So those essential components that I mentioned, there are a number of elements, critical data elements that fall under each one of those. And some of them have to be met in order to achieve accreditation. And sometimes for chest pain, for example, you know, there's several hundred of these things that have to be met. And they're not all about things like, you know, door to ECD times, although we know that's critical. Here you could see things like employees receiving early heart attack care and, sorry, EHAC, early heart attack care training, which is basically how do you get people to recognize early on when they have chest pain or any symptom that they think may be related to the heart that they activate the health system, that they don't sit at home and say, it's just indigestion, it's just whatever. And how do we ensure that people who they may reach out to to say, what do you think, what should I do? Say, every time go get checked out, don't sit on it, don't wait at home. And so what these numbers on the right here show the percentages of the percentages of facilities. And this is, you know, during chest pain accreditation five and six that we were looking at this almost 650 different facilities. These were the percentages of facilities that were doing things that were essential elements to get accredited for accreditation. So one of the key things that occurs during accreditation is the accreditation specialist team under Carrie's leadership goes to a facility or does it virtually, you know, whatever's possible in a changing healthcare environment like COVID now, but goes there and looks over what's happening, the facility reports these things out and every facility to get accredited needs to be 100% for every one of these elements. And so when you see things like facility specific STEMI plan reflecting guidelines, non 24 hour PCI and only 14% or so of facilities doing that, you know that they're falling short. And if we can get these things in place, you set the stage for structure process to lead to outcomes. You can look at other things like patient experience here, you know, reducing differences and disparities in the way we approach sex and age, you know, related patients, you know, not patients, but sex and age as variables in patients who present to the hospital. Simple things like signage, telling where people go to the emergency department that was only being done in 72% of facilities, you know, communications with the community, making sure that internal and external community assessments happen, you know, not done in, you know, up to 60% of facilities, which is really gonna hamper the ability to get optimal care. You look at things like the improved clinician experience, having partners, emergency physicians, cardiologists championing together that they wanna go down this road is critical, having EMS involved, having laboratory staff involved. It's very hard to get goals of turnaround time or troponins if your lab staff is not integrated into the meeting, if they're not part of it, if they don't feel ownership over the process. And then, you know, finally things like, you know, cost. We think about sort of the quadruple aspect of healthcare as we're doing this, patient experience, cost and quality and provider experience. And, you know, how do you identify low risk patients who can be discharged without stress testing? This goes back to that slide that, you know, I was showing early on, more testing doesn't mean better outcomes, but only 33% of facilities were doing this beforehand, identifying who's gonna take responsibility for outpatient follow-up, right? Only 30% of facilities doing that. So if you want the system to work, you have to put in place the pieces for the system to be set up for success. And that's what accreditation really does and strives to achieve. And I can't think of a better time for accreditation than in the era of a brand new guideline around chest pain care being, you know, being put forth and released. And, you know, while we didn't report in our publication that I just showed you about critical gaps being closed through chest pain center accreditation, chest pain center accreditation has taken off in other countries, Germany, and especially in China. And China has some fantastic data on looking at outcomes related to chest pain accreditation. And essentially what they found is that in accredited facilities, the risk of MACE, 30-day MACE events, all-cause death, cardiac death, everything, was, you know, moving in the right direction under accreditation, a lot of it achieving statistical significance, especially things like all-cause mortality. So, you know, while we always sort of think in that Donabedian framework, right? I got my MPH from U of M and I, you know, have to mention Donabedian, structure, process, outcome. Our data show structure and process being changed. The Chinese data show outcome being a change, but it all points in the same direction, which is standardization of implementation of best practices is what we need going forward for healthcare. And again, this is just a graphic representation showing that, you know, things improve after accreditation. You do see a little bit of a waning of effect over time, which, you know, is really important to ensure that the dose, if you will, the dose effect that's achieved from accreditation is something that's lasting. And I know this is something that Carrie and the accreditation team are really keen on understanding going forward. In the past, accreditation had been in three-year cycles and that's moving away from that. So we can, you know, revisit this, continue to support centers, and especially in light of new guidelines coming out, make sure that whatever's learned and taught and implemented initially sustains throughout, you know, the future and ongoing perpetuity. And, you know, I mentioned this before, but one of the key things, again, that Dr. Barr first promulgated and that we all understand is the chain of survival when it comes to, you know, chest pain, heart attack care, right? For those who are suffering from cardiac arrest, early access, CPR, defibrillation, advanced care, but the only way we're going to prevent that from occurring is early response. And that's where this early heart attack program, the EHAC program that ACC has as part of the accreditation process is critical. It's all about the community understanding what they need to do. It's all about people being taught and understanding that they should not ignore these symptoms. And I think this is perhaps one of my favorite studies that that I've seen come out in the last few years. This really gets at that issue of is it symptom to intervention or symptom to balloon time that matters or door to balloon time. Everything we've been talking about, you know, in in the last decade or so, and more around acute myocardial infarction, STEMI in this case, right has been about door to balloon time. But what this article shows right here is that symptom to balloon time is more important in pretty much all the circumstances than door to balloon time. And why is that because if people take more and here the cut point between a short, intermediate and long symptom onset versus door to balloon time was set at about four to six hours. And so people who are waiting past that period, right, that four to six hour period are going to have worse outcomes if you end up with really long times, right, you have an average, you know, adjusted difference of more than four and a half percent or so in terms of the infarct size. And if we can avoid that by teaching people, first sign come back to the hospital will be a lot better off. And so per 60 minute increase, you have an 11% chance, greater chance of death or heart failure, you know, 9% greater chance of death alone and a 14% greater chance of heart failure. And, you know, we've talked always about about death because it's obviously the most important outcome and endpoint we can have. But preventing somebody from having heart failure, which we know is a recurrent, you know, chronic condition that leads to decompensation periodically makes people's lives miserable, very hard to control for a lot of folks. If we can avoid doing that by getting people to recognize symptoms early and coming to the hospital, everyone, especially the patient is going to be much better off. So really just thinking about this, I think it's very important. So again, we can set the perfect circumstance up in a hospital to implement guidelines. But if we're not thinking about what happens before that person reaches our door, then we're not going to be able to do the best we can for our patients. And so with that, I wanted to open it up to questions. I know, Carrie, you have a couple that that have come up that that I'd love to take an answer. So wow, that was an amazing presentations. You're always such a wealth of knowledge. And so I'm just thoroughly impressed and so grateful for you today. The rich history with the pictures that you had of Dr. Barr was just mind blowing for me. So I'd like to start off with a couple of questions here. So high sensitivity troponins, that's certainly a game changer for us in the U.S. In working with hundreds of hospitals and seeing chest pain accreditations, we're often asked about the process of moving from contemporary or those conventional troponins now to high sensitivity troponins. So can you share with us a couple of key tactics for successful implementation? Yeah, absolutely. So first of all, thanks for the kind words, Carrie, you know, I always love, again, presenting with you and working with you. And not because you say nice things about me. So, but, you know, I led our rollout of high sensitivity troponin at the Detroit Medical Center, and it was tough, honestly, first and foremost, the way we're all supposed to do this is understand what is the 99th percentile for our population, not what does the manufacturer say is the 99th percentile, but that's inherently difficult, right? And so we all use what's been derived from the manufacturer as their 99th percentile. But as I said, it may be different in different populations. And that's one of the things that some centers may want to consider, right? There's no rule that says you need to use the manufacturer's 99th percentile if it's different for your population. But by default, most of us do that because it's easier, and it's a path of least resistance. So I would say that the most important thing is, first of all, to understand your assay and what you want to do with it. A second thing is, you really have to spend some time habituating your clinicians to what this means for them. Foremost, is just even understanding the reporting. These all high sensitivity proponents are reported out in whole integers, there's no decimals, right? It's nanograms per liter, rather than nanograms per deciliter. And so it changes what we think. And so initially, when people see high sensitivity proponents, they say, oh my god, it's a proponent of 10. That's the biggest proponent I've ever seen. It's the same number, we just shifted the decimal places. And what that allows us to do is to have a more standard frame of reference across different proponent assays. Understanding that each assay is going to have its own 99th percentile cut point, and each assay is going to have its own zero, one or two hour, you know, excuse me, one or two hour delta, you know, that's going to help us understand what the difference is. And an important thing also with the high sensitivity assays is, it is a number that's going to determine that delta, it's not a percentage. So a lot of people may be used to the idea of a 20% rise or fall, which was you know, embedded in the third and fourth universal definition of MI for conventional assays, that goes away here. And you have to understand what is the number, the absolute number of a difference that is going to matter. And what this means basically is that number determines just how much myocardial injury may be ongoing. And that gives an indication of whether this person has something that's, you know, acute and dynamic or something that may be subacute or even chronic. And so while we think about threshold for diagnosing myocardial injury as a 99th percentile, the threshold for concern about underlying coronary artery disease falls below the 99th percentile in some, but it's dependent on the difference between the measurements. And that difference, you know, has implications for our treatment pathways. So I think all of that is really important for clinicians to know what's what, you know, they have to understand, though, is that it's not like a sodium or creatinine or something that every lab is the same. People have to know what is their assay? And what are the values mean? I think beyond that, they have to whether they go through accreditation or not, right? They have to have protocols in place that guide clinicians as to what to do with this. And the protocols have to be agreed upon by everybody. You can't reinvent the wheel every time. You know, the European Society of Cardiology, rule out, rule in, observation has really become the standard in how we think about this. Green, go home. Red, don't go home. Yellow or orange, whatever color it ends up being, you know, we keep around to get a little more information. And that type of paradigm needs to be in place at every institution with these assays, so that I as an ER doc, I'm not calling the cardiologist, you know, and we're speaking different languages, we're speaking the exact same language, according to the protocol, this is going to happen. Not only does this require that on the low end, you know, the low risk end, it requires it on the high risk end. High risk, unfortunately, is a lot harder to identify the low risk, believe it or not, not every positive troponin patient needs to go to the cath lab. Right. But what we need to figure out is what number should prompt that? Is there a number, you know, for a given assay that should say, yes, send this patient to the cath lab. For some, it's 50 or 100, right? You know, the patient should go to the ICU, and should go to the cath lab, what delta, what difference over time matters, 15 or greater has evolved for some, but you know, that's troponin I's, and then there's troponin T's. And so it really a lot of it is assay dependent. So I think the best thing to start with is the champions coming together, emergency physicians, laboratory champions, cardiologists, internists as well, maybe even your OBS team, because they're all going to be involved in this. Everybody has to agree upon what the interpretation of the troponins mean, you can then go out there, habituate your clinical practice group, you know, your clinicians, your physicians and nurse practitioners, PAs around what they're going to do with these numbers, and then have the protocols in place as to how you deal with it. I'd say one thing that troponins, high sensitivity troponins are good at, but it's not the best use of is a general prognostic marker of badness. As my good friend and colleague Judd Hollander is very fond of saying, more troponin is always worse than less troponin. Right. And, you know, that's important, but we don't need to know in sepsis, that the person has a positive troponin, per se, right, because the person who has a lactate of five, and has a blood pressure of 70 is already in a world of trouble. Getting the troponin may only cloud the picture, because you then introduce something that probably doesn't need to get introduced, which is, let me whisk this patient to the cath lab when in actually, you know, in actuality, what they need is something completely different. So I think all of those nuances have to be talked about. And if you don't talk about them ahead of time, you get into a lot of trouble. Right? It's like they say in marriage, if you don't discuss finances before you get married, you're in trouble. Very true. Very true. All right. Excellent. All right. So next question, moving patients through the ED is certainly essential to the overall efficiency and patient satisfaction. And so now more than ever, given our current state of pandemic, so once the chest pain guidelines are released, how best can this guideline impact ED practices? What do they first, what do hospitals first need to focus on when those come out? Perhaps the most important thing that the guidelines will help people understand is who can go home, and who can go home with comfort, right? So a lot of what we've been doing a lot of what you've been doing, you know, through accreditation, is adhering to what was put forth in the 2014 NSTEMI guidelines, which basically said that if you present to the emergency department with chest pain, and you don't rule in, you should have some type of testing done within 72 hours, right? So a lot of us have felt locked in to get testing done, whether it's done in hospital or out of hospital, the easiest way to do it is in the hospital, right? Because the person's there, so they can go from the ER to, you know, the CT angiogram, or they can go to, you know, the nuclear medicine suite to get, you know, to get whatever study they're going to get done. Hopefully they're not going right to the cath lab. But you know, that does happen in certain cases. But what I'm, you know, what I think a lot of people will come to understand is the chest pain guidelines will help us help us, you know, discern, be more discerning, if you will, about utilization of resources, and be more specific about as the SAM guidelines did understanding what's happened before this presentation, we often think of each presentation with chest pain in the ER as isolated. But if the person's been there before, and they've had a workup before, and we've already determined they don't have coronary artery disease, sending them for another test to reconfirm that is not going to be useful. Right. And so a lot of what we're trying to really think about is, how do you take this holistic approach to evaluation of the chest pain patient? And how do you feel comfortable saying it's not cardiac? And if it's not cardiac, do I need to continue to dig and look for what it might be? Or, you know, are there other things that we need to consider in the SAM guidelines, you know, they talk about getting, you know, potentially, you know, psychiatric evaluation on patients who definitively have no coronary artery disease, and continue to come back with chest pain, or definitively have no other explainable cause of what's going on, because they've been worked up many, many times. You know, when I first started out as a physician here at Detroit Receiving, we had a series of patients that would come in with quote, unquote, sticky platelet syndrome. And every time those patients came in, they would get a CT scan of their chest, we literally had some people who were getting 150 CT scans a year, right? And, and how can we continue to practice that way? And you know, Carrie, when you see these sites, there are hospitals that are going to do a stress test every time when someone comes in despite a stress test that was negative three months ago, or whatever it might be. And so, you know, I think that's a lot of what the guidelines will help systems do is risk stratify appropriately, and then not just stop there, but say, this is what should happen next. Or this is what shouldn't happen next. And I think those are very powerful statements to include. Absolutely. And resource utilization is, should be just paramount on our radar for our program sustainability and viability. So and absolutely, you know, as you were saying, I didn't mean to cut you off, I apologize. But you know, in the era of COVID, we're dealing with a very different ballgame, right? So at my facility and facilities across the country, there are nursing shortages, there's a lack of inpatient beds, patients are being boarded in the emergency department for 2448, sometimes 96 hours sitting there, who the heck would ever want to sit on a stretcher in the ER for that long, if we continue to do what's not needed for people, we're going to create more problems than good. And so the person who doesn't need to be there 96 hours waiting for a stress test, get them out of there. Right, let's do the right thing for the patient. And I think that's one of the other key features, you know, that comes into this in the guidelines, the guidelines are inherently patient centered. And a lot of what we've done in care has been physician centered. Yeah, I totally agree. I'm with you. Thank you. Okay, so last question. So it was so impressive to see the benefits of chest pain accreditation had on hospitals for treatment of MI both in the US and other countries like China. So I think one of the big takeaways for me was the impact of reducing myocardial damage in those STEMI patients, decreasing not only that door to reperfusion time, but the focus on the symptom onset to reperfusion time. And I imagine the EHAC message has had a big role to play in this. So what were your thoughts? Yeah, I agree. We've always wanted to assess what has been the impact of EHAC. But effectively, what EHAC does is it gets on people's radar or their compass, if you will, that they need to think about this, what we really need to do is not have people not go to the ER, because they have chest pain, especially during COVID. We have seen a dramatic rise in people succumbing to myocardial infarction, or, you know, sudden cardiac death during COVID, because people didn't go to the ER, they were more scared of going to the ER and what might happen to them there than they were of what would happen if they stay at home. And so, as you said, I highlighted, you know, that particular point, because preventing morbidity, and long term repeat episodes is equally important as preventing death, they kind of go hand in hand, right, as we saw, but it's really, really important. And one of the things again, not giving anything away in the chest pain guidelines that I'm not allowed to, but you know, the patient centric perspective and the patient's, you know, thoughts on this are really important. And, you know, some of the work that that colleague and friend Eric Hess had done around chest pain choice, where you actually talk to patients, believe it or not, right, talk to patients about their risk profile, and have them be party to the decision making that occurs, you know, is an important portion of the future of chest pain care. So talking to them while they're there, yeah, you're ruled out, but don't be afraid to come back next time, because we're here for you. That's the message they need to get, you know, it's sort of tough when people come back over and over again, we don't want that. But we want people to feel comfortable coming to the emergency department, understanding that sooner is better when they have these types of things. And then also feeling that, you know, they have control over what happens to them. I think a lot of people really look at hospitals, healthcare systems, emergency departments as the as the sort of source of truth for them. But what's happened in COVID is, is the whole thing's been turned on its head, right? You couldn't go to your doctor or your hospital to get a COVID test. Sometimes you couldn't go there to get a vaccination, you had to fend for yourself. And I hope that the lesson that people take away from this is that they have to do the best for themselves. And the best thing they can do is go to the hospital when you have chest pain, don't try to diagnose, go in there, let's let's work with you to figure out what's going on the worst that happens. Absolutely, absolutely. And I love the direction of the shared decision making and, and powering patients to take ownership of their own health, and doing a self inventory of what are my personal risk factors? What can I do to implement and improve my own health and not set me up for a cardiac event potentially down the road? So absolutely. Just one final comment on that. And that's why I emphasize, you know, the patients that rule out that have hypertension and diabetes, we as providers are responsible for being involved in that equation. The conversation isn't just you're ruled out, you don't have a problem. It's you're ruled out, but you might not be so lucky next time until you get your hypertension, your diabetes and your cholesterol under control. So you know, it's really important that we think of all of that, that our goal in chest pain care is not just you're good to go, or you're good to go to the cath lab. It's we need to do everything else now that we've determined that you're okay. Right. Absolutely. Great. 100%. All right. So we certainly look forward to the chest pain guidelines upcoming release. It's exciting to have a standardized pathway for an efficient workout process that presents with chest pain and angina equivalent to the emergency department. And on that note, it's time for us to end this session. So thank you, Dr. Levy for the wealth of information you've shared with us. And for everyone who's joined us today. If you have additional inquiries, please email us at accreditationinfo at acc.org. And thank you guys so much. Talk to you soon. Thanks, Kerry. And thanks, everybody for tuning in.

chest pain management

standardized protocols

high-sensitivity troponins

European guidelines

AHA-ACC guidelines

risk stratification

healthcare professionals

chest pain accreditation

patient outcomes