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The BEACON RegistryThe BEACON Registry
BEACONBEACON
• Principal Investigators:
–W. Frank Peacock, MD, FACEP
–Deepak L. Bhatt, MD, FACC
• Sponsor:
–Heartscape Technologies, Inc.
• Clinical Trial Management:
–C5Research
• Data/database & Web Site Management:
–PharmalinkFHI
BEACON – Executive CommitteeBEACON – Executive Committee
• W. Frank Peacock, MD (Chairman), Cleveland Clinic
• Deepak L. Bhatt, MD, Cleveland Clinic
• Christopher P. Cannon, MD, Brigham & Women’s Hospital
• James Hoekstra, MD, Wake Forest University
• Arthur Hiller (Non-voting) CEO, Heartscape Technologies, Inc.
BEACON – Steering CommitteeBEACON – Steering Committee
• W. Frank Peacock, MD (Chairman), Cleveland Clinic
• Deepak L. Bhatt, MD, Cleveland Clinic
• Christopher P. Cannon, MD, Brigham & Women’s Hospital
• James Hoekstra, MD, Wake Forest University
• Arthur Hiller, CEO, Heartscape Technologies, Inc.
• Deborah B. Diercks, MD, UC Davis Health System
• Cindy L. Grines, MD, William Beaumont Hospital
• Charles V. Pollack, Jr., MD, Pennsylvania Hospital
• Robert L. Jesse, MD, Virginia Commonwealth University
• E. Magnus Ohman, MD, Duke University Medical Center
BEACON – C5ResearchBEACON – C5Research
• Susan Jasper, RN, Project Manager
• Marilyn Borgman, RN, Project Manager
• Karen Mrazeck, Project Specialist
• Danielle Brennan, MS, Senior Statistician
• Alex Fu, PhD, Assistant Professor
BEACON - RationaleBEACON - Rationale
• 2% of patients seen for chest pain are quickly identified as STEMI from a standard 12-lead ECG
• Remaining 98% of patients undergo a battery of tests
• Of these, 10-15% will eventually be diagnosed as acute coronary syndrome (ACS) and admitted to the hospital
• The remainder will be sent home after several hours in the ED
ED Visits - USED Visits - US
130,000,000annually
6.24 Msuspected or actual
cardiac4.1 M
sent home non-cardiac
50,000 MIs3.1 M
non-cardiac(50%)
10.4 M chest pain (8.0%)
1.2 MAMI
(20%)
1.5 MUA
(24%)
374,400sudden death
(6%)
Myocardial PainMyocardial Pain
PneumoniaPneumoniaPneumothoraxPneumothorax
Sickle cellSickle cellAnemiaAnemia
Pulmonary EmbolusPulmonary Embolus
Musculoskeletal PainMusculoskeletal Pain
Aortic DissectionAortic Dissection
Mondor’sMondor’sSyndromeSyndromeTietze’sTietze’s
diseasedisease
Herpes Herpes ZosterZoster
Blunt Chest TraumaBlunt Chest Trauma
BreastBreastCancerCancer
Breast AbcessBreast Abcess
ContactContactDermatitisDermatitis
GERDGERD
Boerhave’sBoerhave’s
Mallory-Mallory-WeissWeiss
MediastinitisMediastinitis
LungLungCancerCancer
AnxietyAnxiety Panic AttackPanic Attack
Breast ImplantBreast Implant
ThoracicThoracicSpine DsSpine Ds
SubdiaphragSubdiaphragAbcessAbcess
EmpyemaEmpyema
Amniotic FluidAmniotic FluidEmbolusEmbolus
IVDA Pulm InfarctionIVDA Pulm Infarction
AsthmaAsthma
Of all the Chest Pain coming to the ER, what do we Of all the Chest Pain coming to the ER, what do we know…..know…..
NRMI 2%NRMI 2%
CRUSADE 16%CRUSADE 16%
82%
Pre-test odds defined:Pre-test odds defined: N= 10,869N= 10,8698% MI rate8% MI rate 17% ACS rate17% ACS rate
Pope JH, et al. Missed Diagnosis of Acute Cardiac Ischemia in the Pope JH, et al. Missed Diagnosis of Acute Cardiac Ischemia in the Emergency Department. N Engl J Med 2000;342:1163-70Emergency Department. N Engl J Med 2000;342:1163-70
12 lead ECG errors12 lead ECG errors
• False PositivesFalse Positives– BERBER
– LBBBLBBB
– LV aneurysmLV aneurysm
– Pre-excitationPre-excitation
– Brugada syndromeBrugada syndrome
– Peri/myocarditisPeri/myocarditis
– Pulmonary embolismPulmonary embolism
– J wave of OsborneJ wave of Osborne
– MimicsMimics– Subarachnoid hemorrhageSubarachnoid hemorrhage
– CholecystitisCholecystitis
– PancreatitisPancreatitis
– Metabolic disturbances (e.g. Metabolic disturbances (e.g. ↑K+)↑K+)
– ErrorError– Failure to recognize nl J point limitsFailure to recognize nl J point limits
– Lead transpositionLead transposition
• False NegativesFalse Negatives– Prior Q wavesPrior Q waves
– ErrorError– Ventricular aneurysmVentricular aneurysm
– Paced rhythmPaced rhythm
– LBBBLBBB
BEACON – RationaleBEACON – Rationale
• The use of additional testing on patients may improve:
– Hospital performance and efficiency measures, and
–Provide earlier identification of the patients who would ultimately be admitted for ACS
• This Registry will provide an opportunity to demonstrate which diagnostic methods facilitate earlier treatment of patients
BEACON – Primary ObjectiveBEACON – Primary Objective
• The primary objective is to:
–assess and ultimately improve the process of care and health outcomes of patients presenting with chest pain suspected to be of cardiac origin
–This will include identifying which methods facilitate the diagnosis and risk stratification of STEMI or non-STEMI patients, including patients with occult myocardial infarction (MI) and result in a shorter time to definitive diagnosis and treatment
BEACON BEACON Secondary ObjectivesSecondary Objectives
• The secondary objective is to determine the impact of:
–new technologies
–practice patterns
– initiatives on:
–patient time to diagnosis
–patient time to treatment
–patient survival and overall economics
-METHYL-P-[123I]-IODOPHENYLPENTADECANOIC
ACID (IODOFILTIC ACID I 123
PROCESSPOC, 24/7 rest mibiD2B
Coronary CTA
BEACON – Secondary ObjectivesBEACON – Secondary Objectives
Including:
• Testing/evaluation with cardiac imaging versus standard 12-lead ECG alone versus enhanced lead ECG, including 80-lead PRIME ECG®
• STEMI outcomes diagnosed by various technologies
• Impact of various marker strategies
– Point of care testing vs. lab based strategies
– High sensitivity vs. standard assay platforms
HsTnIMAMPOST-2
Scube 1MMX
BEACON – Study DesignBEACON – Study Design
• Multi-center Data Collection & Follow-up Registry
• Participating centers will complete a survey regarding their current cardiac marker strategies, lab platforms, accessibility to nuclear and other innovative diagnostic technology.
• Participating centers will have enhanced lead ECG (PRIME ECG®) technology available. A work station, training and 30 vests will be provided to each Site at no cost by Heartscape Technologies. Usage of the PRIME ECG® is not required, but when it is used its impact as a new modality will be assessed.
• All data collected will be standard of care at each institution.
BEACON – Study DesignBEACON – Study Design
• Electronic Data Collection (EDC) technology will be used to assign unique patient identifiers and collect data on patients.
• Sites will receive quarterly reports indicating their
–enrollment
–outcomes
–key quality indicators
– rates of compliance with AHA/ACC 1A recommendations for the care of ACS patients.
BEACON – Study DesignBEACON – Study Design
• 30 Clinical Sites
• Each site will enroll at least 60 STEMI and high risk patients in Part 1a and 1b (n=1800) and
• Each site will enroll approximately 64 patients per month (all patients presenting with chest pain suspected to be of cardiac origin) in Part 2 (n=68,200)
• Total of 70,000 patients in the Registry
• Part 1a – 30 patients without PRIME ECG® available
• Part 1b – patients with PRIME ECG® available; sites will collect data on this group of patients until they have used PRIME ECG® on 30 patients. This group will include patients with 12-lead identified STEMI
• Part 2 – All patients presenting with chest pain suspected to be of cardiac origin with PRIME ECG® available
BEACON – Study DesignBEACON – Study Design
1) Positive Troponin defined by institutional standard
OR
2) At least 10 minutes of chest pain within 24 hours of presentation AND any one of the following:
a) ST elevation >1mm on 12 lead ECG, in any 2 anatomically contiguous leads
b) New LBBB
c) ST depression of at least 0.5mm on 12 lead ECG, in any 2 anatomically contiguous leads
d) Age ≥ 55
BEACON – Inclusion CriteriaBEACON – Inclusion Criteria
e) History of PTCA, PCI, CABG, MI or myocardial ischemia by stress test
f) Receiving treatment for diabetes or hyperlipidemia
g) More than 20 pack years of cigarette smoking
h) Admits to cocaine usage ever
THERE ARE NO EXCLUSION CRITERIATHERE ARE NO EXCLUSION CRITERIA
BEACON – Inclusion Criteria cont.BEACON – Inclusion Criteria cont.
• InSpire System, password protected
• Access via BEACON Web Site: www.beaconregistry.com
• Data collected via chart review
–List of ICD chest pain codes
–Print out from PRIME ECG®
• All information from current ED visit
• 30 day follow up if any information available
• 1 year mortality status via Social Security Death Index – date of inquiry to be 18 months after ED presentation to allow for 6 month delay in SSDI system
• Source document – patient’s medical record
BEACON – Electronic Data Collection (EDC)BEACON – Electronic Data Collection (EDC)
• HIPKey – a random, secure 32 digit patient identifier
• Patient information used is not saved in any form, it is consumed
• HIPKey generated from:–Last name–First name–Gender–Date of Birth–Last 4 digits of SSN–Country
BEACON – EDC HIPKeyBEACON – EDC HIPKey
• Patient demographics
• Emergency Department arrival date & time
• Hospital discharge date
• Number of hospital days – ICU or Telemetry–Non-ICU Telemetry– “Day” defined as where patient is at midnight
BEACON – Electronic Data CollectionBEACON – Electronic Data Collection
BEACON – EDC DemographicsBEACON – EDC Demographics
BEACON – EDC Arrival/DischargeBEACON – EDC Arrival/Discharge
• Signs & symptoms
• Vital Signs
• Cardiopulmonary Exam
• Medical History
• ED Laboratory Assessments (whatever is available)– Troponin Hct– CK-MB INR– BNP Lipids– Creatinine HgbA1c
BEACON – Electronic Data CollectionBEACON – Electronic Data Collection
BEACON – EDC Signs & SymptomsBEACON – EDC Signs & Symptoms
BEACON – EDC Cardiopulmonary ExamBEACON – EDC Cardiopulmonary Exam
BEACON – EDC Medical HistoryBEACON – EDC Medical History
BEACON – EDC Laboratory TestsBEACON – EDC Laboratory Tests
• 12-Lead ECG
• Augmented 15-18 Lead ECG
• Right side ECG
• PRIME ECG®
• Concurrent Medications
BEACON – Electronic Data CollectionsBEACON – Electronic Data Collections
• 12-Lead ECG
–Data from routine report
• PRIME ECG®
–Data from routine report
BEACON – ECG dataBEACON – ECG data
BEACON – EDC ECG BEACON – EDC ECG
BEACON – EDC ECG cont.BEACON – EDC ECG cont.
BEACON – EDC PRIME ECG BEACON – EDC PRIME ECG ®®
BEACON – EDC PRIME ECG BEACON – EDC PRIME ECG ®® cont. cont.
BEACON – EDC Concurrent MedicationsBEACON – EDC Concurrent Medications
• Emergency Department Disposition Decision
–Date & Time
–Location
–Definition of Disposition Time:
– the time that the decision is made about what to do with the patient:
–the time physician writes order for cardiac cath OR when the cardiac cath lab is called OR
–The time physician writes order for admission OR when admitting office is called OR
–the time the patient is discharged from the ED
BEACON – Electronic Data CollectionBEACON – Electronic Data Collection
• Emergency Department Discharge Diagnosis
–Date & Time
• Observation Unit Discharge Diagnosis
• Final Hospital Discharge Diagnosis
BEACON – Electronic Data CollectionBEACON – Electronic Data Collection
BEACON – EDC ED Disposition DecisionBEACON – EDC ED Disposition Decision
BEACON – EDC ED Discharge DiagnosisBEACON – EDC ED Discharge Diagnosis
• Echocardiogram
• SPECT
• Coronary CT
• Cardiac Catheterization
• Mortality Status – 1 year from ED presentation
BEACON – Electronic Data CollectionBEACON – Electronic Data Collection
BEACON – EDC ImagingBEACON – EDC Imaging
BEACON – EDC Coronary CTBEACON – EDC Coronary CT
BEACON – EDC Cardiac CatheterizationBEACON – EDC Cardiac Catheterization
BEACON – EDC Mortality StatusBEACON – EDC Mortality Status
BEACON – Primary EndpointBEACON – Primary Endpoint
• Time to definitive diagnosis of:
–STEMI
–UA/NSTEMI
–Non-cardiac chest pain
• Time to disposition decision will be used as an objective measure of time to definitive diagnosis.
BEACON – Primary EndpointBEACON – Primary Endpoint
Time to disposition decision:
• STEMI - the time of ED admission to the time physician writes order for cardiac cath OR when the cardiac cath lab is called
• UA/NSTEMI – the time of ED admission to the time the physician writes order for admission or when admitting office is called
• Non-cardiac chest pain – the time of ED admission to the time the patient is discharged from the ED
BEACON – Secondary EndpointsBEACON – Secondary Endpoints
• Quality indicators (time to treatment)
• Economic outcomes (LOS, cost of diagnosis, cost of treatment)
• Survival outcomes (during hospitalization, 30 day, 1 year)
BEACON – Statistical AnalysisBEACON – Statistical Analysis
• Endpoints will be described by:
–Type of diagnosis (STEMI, UA/NSTEMI, and non-cardiac chest pain)
–Diagnostic device utilized and testing procedures performed within each group
–A cost will be assigned to each test, procedure and treatment so a total relative cost can be calculated for each type of diagnosis
BEACON – Web PageBEACON – Web Page
• www.beaconregistry.com
–Access EDC
–Protocol Training
–Contacts
–Chat Room
–Links
–Resources
BEACON – Benchmark ReportsBEACON – Benchmark Reports
• Quarterly reports
• Each site will receive CD containing their data
–Enrollment
–Key BEACON variables
–Outcomes
–JCAHO Quality measurements
–Rates of compliance with AHA/ACC 1A recommendations for the care of ACS patients
BEACON BEACON
• Please sign the Certificate of Training and
–Keep for your files
–Fax copy to Karen Mrazeck @ 216 444 9732
–Protocol Questions?
–Call Sue Jasper @ 216 445 3484 or email: [email protected]
Thank youThank you
