IMPORTANCE Chest pain is among the most common reasons for emergency department (ED) presentations. However, most patients are at low risk for acute coronary syndrome (ACS), with low cardiac adverse outcomes rates. Biomarker testing with troponin levels is key in the initial assessment for ACS. Although serial troponin testing can improve the diagnosis of ACS in clinical practice, some patients deemed to be low risk are discharged after a single negative troponin test result.OBJECTIVE To report the clinical outcomes of patients discharged after a single negative troponin test result compared with patients discharged after serial troponin measurements. DESIGN, SETTING, AND PARTICIPANTSThis is a retrospective cohort study of ED encounters from May 5, 2016, to December 1, 2017, across 15 community EDs within an integrated health care system in southern California. The study cohort includes 27 918 adult ED encounters in which patients were evaluated for suspected ACS with a HEART (history, electrocardiogram, age, risk factors, and troponin) score and an initial conventional troponin-I measurement below the level of detection (<0.02 ng/mL). Statistical analysis was performed from December 1, 2019, to December 1, 2020. EXPOSURE Single troponin test vs multiple troponin tests. MAIN OUTCOMES AND MEASURES The primary outcome was acute myocardial infarction or cardiac mortality; secondary outcomes included coronary artery bypass graft, percutaneous coronary intervention, invasive coronary angiography, and unstable angina within 30 days of discharge. A multivariable logistic regression model was performed to evaluate the association between testing strategies and clinical outcomes. RESULTS A total of 27 918 patient encounters (16 212 women [58.1%]; mean [SD] age, 58.7 [15.2] years) were included in the study. Of patients with an initial troponin measurement below the level of detection, 14 459 (51.8%) were discharged after a single troponin measurement, and 13 459 (48.2%) underwent serial troponin tests. After adjustment for cardiac risk factors and comorbidities, there was no statistically significant difference in the primary outcome of acute myocardial infarction or cardiac mortality within 30 days between the 2 groups (single troponin, 56 [0.4%] vs serial troponin, 52 [0.4%]; adjusted odds ratio, 1.41 [95% CI, 0.96-2.07]). Patients discharged after a single troponin test had lower rates of coronary artery bypass graft (adjusted odds ratio, 0.24 [95% CI, 0.11-0.48]) and invasive coronary angiography (adjusted odds ratio, 0.46 [95% CI, 0.38-0.56]). (continued) Key Points Question Do patients discharged from the emergency department after a single troponin test with negative results have similar outcomes to patients undergoing multiple troponin tests? Findings This cohort study found no significant difference in 30-day acute myocardial infarction or cardiac mortality between patients receiving a single troponin test with negative results and those who underwent serial troponin tests (single troponin test, 0.4% vs serial tr...

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His bundle pacing (HBP) has been shown to be a feasible, beneficial, and safe way to achieve cardiac resynchronization therapy (CRT) with recruitment of the heart's physiological conduction system. HBP should be considered for those with unfavorable coronary sinus (CS) anatomy, and nonresponders to biventricular (BiV) pacing. HBP CRT may also help patients with the nonleft bundle branch block form of conduction delay and heart failure (HF). HBP CRT should be considered strongly in preventing right ventricular (RV) pacing-induced cardiomyopathy, especially after atrioventricular nodal ablation given the discrete nature of the block and the low likelihood of distal block. With increased operator experience and improved lead delivery systems, HBP success rates and safety have improved and are comparable to traditional RV pacing. Battery longevity is also likely comparable to traditional BiV CRT devices. We anticipate the use of HBP CRT growing significantly.

Introduction: Chest pain is among the most common reasons for emergency department (ED) presentations. However, most patients are low risk for acute coronary syndrome (ACS) with low cardiac adverse outcomes. Biomarker testing with troponins is the mainstay of initial assessment for ACS. Although serial troponin testing can improve diagnosis of ACS, in clinical practice, some patients deemed to be low risk are discharged after a single negative troponin measurement. Our study evaluated the safety of single-troponin rule-out strategy using a conventional troponin assay. Hypothesis: We assessed the hypothesis that there is no significant difference in the clinical outcomes of patients deemed low-risk and discharged after a single negative troponin compared to patients discharged after serial troponin measurements. Methods: This is a retrospective study of ED encounters from January 2015 to December 2017 across 13 community emergency departments within an integrated healthcare system in Southern California. The study cohort includes adult ED encounters evaluated for suspected ACS with a HEART score and an initial conventional troponin-I below the level of detection (<0.02). Multivariate logistic regression model was performed to evaluate the association between testing strategies and clinical outcomes. Results: Among 27,918 patients with an initial troponin measurement below the level of detection, 14,459 (51.8%) were discharged after a single measurement, and 13,459 patients (48.2%) had serial troponin orders. After adjusting for cardiac risk factors and comorbidities, there was no statistically significant difference in the primary outcome of AMI or cardiac mortality within 30 days between the two groups (single troponin 0.4% vs. serial troponin 0.4%, OR 1.41, 95% CI (0.96-2.07)). Single troponin was associated with a lower rate of CABG (OR 0.24, 95% CI: 0.11-0.48) and invasive coronary angiogram (OR 0.46, 95% CI: 0.38-0.56). Conclusions: When compared to serial troponin testing, discharge after a single negative troponin is routinely done among ED patients, and appears safe based on current physician decision making with no difference in rates of 30-day cardiac mortality and AMI.