Absence Of Chest Pain Research Articles

Differential diagnosis of the association of gastrointestinal symptoms and ST segment elevation, in the absence of chest pain.

This is a review of the underlying causes of the association of ST segment elevation and gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and anorexia, in patients who do not have chest pain. The review was based on anecdotal reports in Googlescholar and Pubmed using the search terms, abdominal pain, nausea, vomiting, anorexia, ST elevation, myocardial infarction, and Takotsubo cardiomyopathy. Those patients who did not have acute myocardial infarction as the cause of the association of ST segment elevation and gastrointestinal symptoms were compared with counterparts with similar symptoms who had well authenticated acute myocardial infarction or Takotsubo cardiomyopathy as the underlying cause of ST segment elevation. The underlying causes of gastrointestinal symptoms which could be associated with ST segment elevation in the absence of either acute myocardial infarction or Takotsubo cardiomyopathy comprised pneumonia, pulmonary embolism, perforated gastric ulcer, intestinal obstruction, acute appendicitis, acute pancreatitis, acute cholecystitis, pheochromocytoma, bacterial meningitis, diabetic keto acidosis, and cannabis abuse. However, each of those disorders could also coexist either with acute myocardial infarction or with Takotsubo cardiomyopathy. The coexistence of ST segment elevation and gastrointestinal symptoms(without chest pain) was also documented in patients with esophageal perforation, mesenteric ischaemia, aortic dissection, Kounis syndrome, and in electrolyte disorders. In the context of presentation with gastroenterological symptoms but without concurrent chest pain, echocardiography appeared to be useful in distinguishing between "pseudo" myocardial infarction characterised by ST segment elevation in the absence of cardiac disease vs ST segment elevation attributable either to acute myocardial infarction or to Takotsubo cardiomyopathy.

Cardiac manifestations of fabry disease in female patients: a single centre experience

Abstract Introduction Fabry disease is a lysosomal storage disorder resulting in multisystemic effects due to deposition and accumulation of glycosphingolipids. Although an X linked disorder, it is recognised that female heterozygotes can express clinical manifestations. Cardiac expression in the female Fabry population remains incompletely understood. Data from the Fabry Outcome Survey suggests that up to a quarter of female patients demonstrate left ventricular hypertrophy (LVH) on echocardiography. Although LVH is the most commonly cited cardiac finding, other abnormalities from clinical surveillance can include electrocardiographic abnormalities, fibrosis and elevated troponin levels. Purpose To establish the prevalence and extent of cardiac involvement amongst our cohort of female Fabry patients. Methods Heterozygous females, confirmed by genetic testing, were identified in our single centre Fabry database. Data was collected retrospectively on their 12 lead ECG, high sensitivity troponin I level and echocardiography performed at their most recent cardiac Fabry clinic visit, along with the most recent cardiac magnetic resonance imaging (CMR). Values are expressed as mean ± SD. Results 51 female heterozygotes were identified, ranging from 23 to 83 years (mean age 49.3±15.4). 28 (54.9%) were established on enzyme replacement therapy. On echocardiography LVH of ≥13mm was identified in 14 (27.5%) patients (mean 14.6±1.9 mm). 44 patients had CMR and of these, 17 (38.6%) had findings in keeping with a Fabry cardiomyopathy (34.1% had fibrosis, 15.9% hypertrophy, 13.6% both). Of the 17 patients with abnormalities on CMR, 8 had normal left ventricular wall thickness on echocardiography. All patients had a high sensitivity troponin I measurement and this was above upper reference limits (>40ng/L) in 21 (41.1%) patients in the absence of chest pain. Of 21 patients with abnormal troponin I levels, 9 had normal left ventricular wall thickness on echocardiography. Abnormalities identified on 12 lead ECG are summarised in Table 1. All patients with ECG abnormalities listed in Table 1 had an abnormal troponin and/or abnormal imaging, except for 5 patients who had an isolated short PR interval. 6 patients had a permanent pacemaker and 1 had a primary prevention implantable cardioverter defibrillator. 25 (49%) of the 51 patients were classed as having cardiac involvement based on raised troponin levels and/or abnormal imaging findings. Conclusion Although Fabry disease is traditionally thought to be a male predominant disease, in our cohort nearly half of our female heterozygotes showed evidence of cardiac involvement. The use of CMR, cardiac biomarkers and 12 lead ECG are helpful adjuncts to identify cardiac involvement, which could otherwise be missed if stand-alone echocardiography was used. Timely identification and monitoring of cardiac involvement has clinical implication, especially with regards to prognosis and treatment. Funding Acknowledgement Type of funding sources: None.

Chest Radiograph Utility in Children With Asthma and Chest Pain

Research Article| October 01 2021 Chest Radiograph Utility in Children With Asthma and Chest Pain AAP Grand Rounds (2021) 46 (4): 43. https://doi.org/10.1542/gr.46-4-43 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Chest Radiograph Utility in Children With Asthma and Chest Pain. AAP Grand Rounds October 2021; 46 (4): 43. https://doi.org/10.1542/gr.46-4-43 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: asthma, childhood, chest pain, chest x-ray, rales Source: Majerus CR, Tredway TL, Yun NK, et al Utility of chest radiographs in children presenting to a pediatric emergency department with acute asthma exacerbation and chest pain. Pediatr Emerg Care. 2021;37(7):e372-e375; doi:10.1097/PEC.0000000000001615Google Scholar Investigators from Saint Louis University, St Louis, MO, conducted a retrospective study to assess the association between a complaint of chest pain in children with acute asthma presenting to an ED and having a chest radiograph (CXR) obtained during the visit. The researchers also assessed whether chest pain was a predictor of a “positive” CXR. Study participants were children between the ages of 2 and 18 years presenting to the ED of a tertiary care children’s hospital with acute asthma from August 2014 through March 2016 and were identified by review of ICD-9 codes for asthma, pneumothorax, and pneumomediastinum. The medical records of these patients were reviewed, and information on demographics, history of fever (temperature ≥101.0° F), oxygen saturation, breath sounds (eg, “crackles”), presence or absence of chest pain, whether a CXR was obtained and, if so, radiographic findings, provider type, and medications prescribed were abstracted. Patients for whom the presence or absence of chest pain was not noted in the medical record were excluded. When a CXR was obtained, the radiologist’s report was reviewed; the CXR was classified as positive if infiltrates, consolidations, or opacities were noted, if the CXR findings led to a clinical diagnosis of pneumonia and prescription for antibiotics, or if pneumothorax or pneumomediastinum was present. Variables, including chest pain associated with obtaining a CXR and/or a positive CXR on bivariate analyses (P <0.1) were included in multivariate regression models to identify independent predictors of these outcomes. Data were analyzed on 793 children with a mean age of 8.5 years. Overall, 77.7% of study participants were African American, and 60.4% were male. Chest pain was present in 231 children (29.1%), and a CXR was obtained in 184 (23.2%). Positive findings were present on 21 (11.4%) CXRs, including pneumonia (N = 16), pneumomediastinum (3), and pneumothorax (2). Among patients for whom a CXR was obtained, 74 (40%) had chest pain. In the multivariate model, chest pain was associated with an increased chance for having a CXR obtained (OR, 2.2; 95% CI, 1.5, 3.2); other variables statistically associated with an order for CXR included white race, fever, “crackles” on lung examination, oxygen saturation <93%, and provider type. The only variable that was independently associated with a positive CXR was the presence of “crackles” on examination (OR, 4.0; 95% CI, 1.2, 13.0). Chest pain was not statistically associated with a positive CXR (OR, 2.0; 95% CI, 0.7, 5.6). The authors conclude that providers are more likely to obtain a CXR in children with acute asthma who are complaining of chest pain, but that the yield of CXR among these patients is low. Dr Bechtel has disclosed no financial relationship relevant to this commentary. This commentary does not... You do not currently have access to this content.

COVID-19 in young and middle-aged adults: predictors of poor outcome and clinical differences.

IntroductionYoung and middle-aged adults are the largest group of patients infected with SARS-CoV-2 and some of them develop severe disease.ObjectiveTo investigate clinical manifestations in adults aged 18–65 years hospitalized for COVID-19 and identify predictors of poor outcome. Secondary objectives: to explore differences compared to the disease in elderly patients and the suitability of the commonly used community-acquired pneumonia prognostic scales in younger populations.MethodsMulticenter prospective registry of consecutive patients hospitalized for COVID-19 pneumonia aged 18–65 years between March and May 2020. We considered a composite outcome of “poor outcome” including intensive care unit admission and/or use of noninvasive ventilation, continuous positive airway pressure or high flow nasal cannula oxygen and/or death.ResultsWe identified 513 patients < 65 years of age, from a cohort of 993 patients. 102 had poor outcomes (19.8%) and 3.9% died. 78% and 55% of patients with poor outcomes were classified as low risk based on CURB and PSI scores, respectively.A multivariate Cox regression model identified six independent factors associated with poor outcome: heart disease, absence of chest pain or anosmia, low oxygen saturation, high LDH and lymphocyte count < 800/mL.ConclusionsCOVID-19 in younger patients carries significant morbidity and differs in some respects from this disease in the elderly. Baseline heart disease is a relevant risk factor, while anosmia and pleuritic pain are associated to better prognosis. Hypoxemia, LDH and lymphocyte count are predictors of poor outcome. We consider that CURB and PSI scores are not suitable criteria for deciding admission in this population.

Assessment of the CHA2DS2-VASc score in predicting ischemic stroke and death in patients with acute myocardial infarction without atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. onbehalf on behalf of the investigators of the Portuguese Registry of Acute Coronary Syndromes Introduction The CHA2DS2-VASc score is used in clinical practice to stratify the risk of stroke in patients (pts) with atrial fibrillation (AF). Its usefulness in the population of pts with acute myocardial infarction without AF is not well known. Objectives To investigate whether CHA2DS2-VASc predicts ischemic stroke and death during hospital stay in pts with acute myocardial infarction without known AF. To determine independent predictors of ischemic stroke in this population. Methods A multicentre, retrospective study was performed during 01/10/2010-04/09/2019 period, and included all pts admitted due to acute myocardial infarction. Pts with previous AF, AF rhythm in the electrocardiogram at admission or AF during hospital stay were excluded. Statistical analysis with Kaplan-Mayer and Cox regression was applied. Results Of 29851 pts admitted with acute myocardial infarction, were included in our study 19218 pts (74% male, mean age of 65 ± 14 years). During hospital stay, 78 (0.4%) pts had an ischemic stroke and 462 (2.4%) pts died. The event-free survival analysis showed significant differences according to the CHA2DS2-VASc score at admission (log rank test p = 0.015 for ischemic stroke; log rank test p &amp;lt; 0.001 for in-hospital mortality). (Figure) The CHA2DS2-VASc score demonstrated a good predictive accuracy for in-hospital mortality (area under the ROC curve 0.69; 95% CI 0.67-0.72; p &amp;lt; 0.001). The area under the ROC curve indicates that the CHA2DS2-VASc score performed modestly for ischemic stroke (0.62; 95% CI 0.56-0.68; p &amp;lt; 0.001). In univariate analysis, the factors that were positively associated with ischemic stroke during hospital stay were CHA2DS2-VASc, absence of previous therapy with statin, time between cardiac symptoms and hospital admission, absence of chest pain, Killip-Kimball class, cardiorespiratory arrest, complete left ventricular block and left ventricle ejection fraction &amp;lt;50% (p &amp;lt; 0.05). After multivariate analysis, CHA2DS2-VASc≥3 (HR 2.25; 95% CI 1.37-3.71; p = 0.001), absence of chest pain (HR 3.17; CI 1.44-6.14, p &amp;lt; 0.001) and previous therapy with statin (HR 0.39; 95% CI 0.22-0.67; p = 0.001) were independent predictors of ischemic stroke. Conclusion Among patients with acute myocardial infarction without known atrial fibrillation, the CHA2DS2-VASc score was associated with risk of ischemic stroke and death during hospital stay. This score may be useful for estimating the risk of stroke and in-hospital mortality in these population without known atrial fibrillation. Abstract Figure.

Treatment and Prognosis of Myocardial Infarction Outside Cardiology Departments.

Aim: Our aim was to investigate the characteristics, treatment and prognosis of patients with myocardial infarction (MI) treated outside a cardiology department (CD), compared with MI patients treated at a CD. Methods: A cohort of 1310 patients diagnosed with MI at eight Swedish hospitals in 2011 were included in this observational study. Patients were followed regarding all-cause mortality until 2018. Results: A total of 235 patients, exclusively treated outside CDs, were identified. These patients had more non-cardiac comorbidities, were older (mean age 83.7 vs. 73.1 years) and had less often type 1 MIs (33.2% vs. 74.2%), in comparison with the CD patients. Advanced age and an absence of chest pain were the strongest predictors of non-CD care. Only 3.8% of non-CD patients were investigated with coronary angiography and they were also prescribed secondary preventive pharmacological treatments to a lesser degree, with only 32.3% having statin therapy at discharge. The all-cause mortality was higher in non-CD patients, also after adjustment for baseline parameters, both at 30 days (hazard ratio (HR) 2.28; 95% confidence interval (CI) 1.62–3.22), one year (HR 1.82; 95% CI 1.39–2.36) and five years (HR 1.62; 95% CI 1.32–1.98). Conclusions: MI treatment outside CDs is associated with an adverse short- and long-term prognosis. An improved use of percutaneous coronary intervention (PCI) and secondary preventive pharmacological treatment might improve the long-term prognosis in these patients.

Investigation of Chest X-Ray Use in the Emergency Department in Pediatric Patients with Sickle Cell Disease Presenting with Fever Compared to Age Matched Controls

Background In sickle cell disease (SCD), acute chest syndrome (ACS) is associated with prolonged hospitalization, increased risk of respiratory failure, future lung disease and 25% mortality in hospitalized patients(Bakshi, &amp; Krishnamurti, 2017; Vinchinsky et al. 1997). Pediatric patients with SCD frequently present to the Pediatric Emergency Department (PED) with complaints of fever, chest pain, and cough, all of which may or may not be related to ACS. It is challenging for PED providers to determine which patients are at highest risk of ACS, so chest X-Rays (CXR) are frequently ordered which increases radiation exposure and healthcare costs. The objective of this study was to identify incidence of CXR performance, as well as ACS diagnosis, in SCD patients presenting to our PED with or without fever. Our goal was to identify significant clinical predictors of ACS in this population in order to implement a diagnostic algorithm for PED providers. Methods This was an IRB-approved retrospective medical record review of subjects diagnosed with SCD with inclusion criteria: ages 2-12 years, who presented to the University of Maryland PED between 2016-2018. We performed bivariate analyses comparing these variables between subjects who were febrile vs. afebrile on presentation to the PED, as well as those who were ultimately diagnosed with ACS compared to those who were not. Analysis of categorical variables was performed using Chi-square or Fischer exact test as appropriate. We performed a multivariable logistic regression model to identify significant predictors of ACS diagnosis. Analyses performed using SAS 9.4. Results We identified 424 SCD subjects who presented to our PED meeting inclusion criteria, with 25% (n=108) presenting with fever. Of these, 69% received a CXR on presentation vs. 42% of afebrile subjects (p=&amp;lt;0.0001). In our febrile group 21% (n=23) patients had more than 2 febrile episodes and 100% received CXRs. There were no significant differences between the febrile and afebrile subjects when it came to sex, asthma diagnosis/comorbidity, hydroxyurea use, folic acid supplementation, or pneumococcal prophylaxis. Overall, 10% of patients presenting to the PED were diagnosed with ACS (n=42), made up of 13% of those presenting with fever vs. 9% of those presenting without fever. Those subjects ultimately diagnosed with ACS were significantly more likely to present with chest pain (p=0.003), tachypnea (p=0.001), and hypoxia (p&amp;lt;0.0001), and were more likely to have a past history of asthma (p=0.0085). Sickle cell variant, home medications, and history of splenectomy were not significantly associated with ACS diagnosis. Upon multivariable modeling, when adjusting for fever and pre-existing asthma diagnosis, the only significant predictors of ACS diagnosis were chest pain and hypoxia. Patients without chest pain had an odds ratio (OR) =0.3 of ACS diagnosis [95% Confidence Interval, CI 0.14-0.67], indicating they had 70% lower odds of ACS compared to patients with chest paint. Patients without hypoxia had OR=0.12 of ACS compared to those with hypoxia [CI 0.06-0.25], indicating an 88% reduced odds of ACS diagnosis. Conversely, those with chest pain had 3.3x the odds of ACS diagnosis [CI 1.5-7.4] and those with hypoxia had 8.4x the odds of ACS diagnosis [CI 4-17.9] compared to those without these symptoms. Conclusion In ACS, current guidelines recommend that patients presenting with fever, hypoxia, tachypnea, tachycardia and abnormal respiratory exam findings should be treated empirically as well as receive a CXR. However radiological signs can be delayed compared to physical signs so a normal CXR does not preclude the diagnosis of ACS if there is clinical suspicion(Howard et al. 2015). Our data demonstrate that clinical findings such as chest pain, tachypnea and hypoxia were most likely to correlate to a diagnosis of ACS. While 69% of our febrile patients received a CXR in the PED, only 13% were ultimately diagnosed with ACS, indicating that more CXRs and radiation exposure occurred in the febrile population than may have been necessary. When adjusting for fever and asthma, the most notable predictors of ACS were hypoxia and chest pain. When present, these findings are significant predictors of ACS; when absent, subjects had significantly decreased odds of ACS. Incorporating the presence or absence of chest pain and hypoxia may help focus the use of CXR on the appropriate patient population. Disclosures No relevant conflicts of interest to declare.

High-sensitivity troponin T use in non-chest pain presentations in the emergency department.

To explore troponin testing yield in patients who present to the ED without chest pain. A retrospective medical record audit of all patients who presented to ED in November 2018 and had troponin measured. A total of 1124 troponin assays were performed in 763 patients, 48.7% had no documented chest pain; 8.8% of these met high-risk criteria and 1.1% were diagnosed with acute coronary syndrome. Despite ED troponin testing in the absence of chest pain being common practice, it rarely assisted in a meaningful diagnosis. Consequences of testing may include delays to patient discharge and additional downstream testing.

Factors associated with emergency medical service delays in suspected ST-elevation myocardial infarction in Victoria, Australia: A retrospective study.

To assess the effect of patient and system characteristics on emergency medical service (EMS) delays prior to arrival at hospital in suspected ST-elevation myocardial infarction (STEMI). This was a retrospective observational study of 1739 patients who presented with suspected STEMI to the EMS in Melbourne, Australia between October 2011 and January 2014. Our primary outcome measure was call-to-hospital time, defined as the time in minutes from emergency call to hospital arrival. We examined the association of patient and system characteristics on call-to-hospital time using multivariable linear regression. The mean call-to-hospital time was 60.1 min (standard deviation 20.5) and the median travel distance was 13.0 km (interquartile range 7.2-23.1). In the multivariable model, patient characteristics associated with longer call-to-hospital time were age ≥75 years (2.3 min; 95% confidence interval [CI] 0.6-4.0), female sex (1.9 min; 95% CI 0.3-3.4), pre-existing mental health disorder (4.0 min; 95% CI 1.9-6.1) or musculoskeletal disease (2.7 min; 95% CI 1.0-4.4), absence of chest pain (3.0 min; 95% CI 1.1-4.8), and presentation with clinical complications. System factors associated with call-to-hospital time include lower dispatch priority (12.7 min; 95% CI 9.0-16.5) and non-12-lead electrocardiography (ECG) capable ambulance first on scene (4.5 min; 95% CI 3.1-5.8). Patients who were not initially attended by a 12-lead capable ambulance were less likely to receive a 12-lead ECG within 10 min (18.5% vs 71.0%, P < 0.001). A range of patient and system factors may influence EMS delays in STEMI. However, optimising dispatch prioritisation and widespread availability of prehospital 12-lead ECG could lead to substantial reduction in time to treatment.

Prevalence of pulmonary embolism in emergency department patients with isolated syncope: a prospective cohort study.

Paramount to guide the diagnostic strategy, the prevalence of pulmonary embolism in patients with syncope and no other symptoms is uncertain. We aimed to assess the pulmonary embolism prevalence in patients that present to the emergency department (ED) with syncope and no chest pain nor dyspnea. Multicenter prospective cohort study in seven EDs in France. Adult patients who presented to the ED with syncope (transient loss of consciousness) were included. Patients with chest pain or dyspnea were excluded. Included patients underwent formal work-up for pulmonary embolism, including D-dimer testing and further imaging if positive. Cases of pulmonary embolism were adjudicated by two independent expert radiologists with the review of imaging studies. Secondary objectives included the pulmonary embolism prevalence in the subgroup of patients with cancer, in patients with negative Pulmonary Embolism Rule Out criteria (PERC) score, and according to the clinical probability assessed either by Wells or revised Geneva score. We analyzed 411 patients, in whom 128 (31%) underwent a computed tomographic pulmonary angiogram and 9 (2%) a ventilation-perfusion scan. A pulmonary embolism was confirmed in nine patients (prevalence of 2.2%, 95% confidence interval, 1.1-4.3%), including one subsegmental pulmonary embolism. This prevalence was of 18% (3-52%) in patients with cancer and 0.7% (0.1-4%) in PERC negative patients. In our sample of patients with isolated syncope, the prevalence of pulmonary embolism was 2.2%. This value is not sufficiently low to negate the requirement for a formal work up in the ED, even in the absence of chest pain or dyspnea. However, the large confidence interval precludes any strong conclusion.

P3594Transition from 4th to 5th generation cardiac troponin T: testing patterns, myocardial infarction incident rates, and resource utilization across a multicenter United States regional healthcare system

Abstract Background Several high-sensitivity cardiac troponin (cTn) assays have been cleared by the United States (US) Food and Drug Administration (FDA) for clinical use. Although some of them have been used outside the US for some time, there is limited experience thus far across US sites. Following FDA clearance of the Roche 5th Gen cTnT assay in January 2017, a multicenter US regional healthcare system introduced this more sensitive cTnT assay into clinical practice in September 2018. Purpose To examine cTn testing patterns, incidence of acute myocardial infarction (MI), and resource utilization before and after implementation of the 5th Gen cTnT assay across a large US healthcare system. Methods Using electronic-health records reporting software (Cogito SlicerDicer, EPIC), administrative data was examined to evaluate the transition (4-months before and after implementation) from the 4th to 5th Gen cTnT assays across 16 hospitals but not the major hub hospital of the system that transitioned at a separate time. Adult patient visits (emergency and hospital encounters), cTnT testing, incidence of chest discomfort and acute MI, and resource utilization, including hospital admissions, were examined during the transition period. Results 98,558 adult ED patient visits occurred during an 8-month period across 16 hospitals, including 50,485 and 48,073 patient visits before (5/12/18 – 9/11/18) and after (9/12/18 – 1/11/19) implementation of the 5th Gen cTnT assay respectively. cTnT testing occurred in 20% (range 8.9–34.8%) of all ED visits, with testing performed in the absence of chest pain in 54% (range 37–67%) of cases. Acute MI was diagnosed in 5.6% (n=561) of cases using the 4th Gen cTnT assay as compared to 6.6% (n=608) of cases using the 5th Gen cTnT assay (absolute difference 1.0%, 95% CI: 0.32–1.68, p=0.004). Much of the increase in MI diagnoses were in women (2.2% vs. 2.8%, p=0.008). The proportion of ED patients requiring hospital admission did not differ between pre- and post-implementation periods (24.1% vs. 23.6%, p=0.4); however, among the subset of patients with chest pain, fewer admissions occurred post-implementation (17.9% vs. 15.8%, p=0.006). There was no increase in echocardiography (9.3% vs. 8.4%), coronary angiography (2.9% vs. 3.1%), or cardiac consultations (7.3% vs. 7.3%) utilization post-implementation. Conclusions Cardiac troponin testing occurs in nearly 20% of ED visits in a large multicenter regional healthcare system. About half of all tests are ordered in the absence of chest pain, with a low MI rate observed among the patients undergoing testing. Following implementation of the 5th Gen cTnT assay, testing rates/patterns remained unchanged, with a small but significant increase in MI diagnoses, primarily due to more women being diagnosed with MI. Fewer ED patients with chest pain required admission. Despite using a more sensitive cTn assay, hospital admissions and resource utilization did not increase post-implementation.

ST-segment elevation myocardial infarction with non-chest pain presentation at the Emergency Department: Insights from the Singapore Myocardial Infarction Registry.

ST-segment elevation myocardial infarction (STEMI) often presents acutely at the Emergency Department (ED). Although chest pain is a classical symptom, a significant proportion of patients do not present with chest pain. The impact of a non-chest pain (NCP) presentation on ED processes-of-care and outcomes is not fully understood. We utilised a national registry to characterise predictors, processes-of-care, and outcomes of NCP STEMI presentations. Retrospective data for all STEMI cases occurring between 2010 and 2012 were analysed from the Singapore Myocardial Infarction Registry. Cases of inpatient onset, inter-facility transfers, and out-of-hospital cardiac arrests were excluded. Univariable analysis of demographic, clinical, processes-of-care, and outcome variables was conducted. Multivariable logistic regression ascertained independent predictors of a NCP presentation and 28-day mortality. Of 4667 STEMI cases, 12.9% presented without chest pain. Patients with NCP presentation were older (median, years = 74 vs. 58; p < 0.001), more likely to be female (39.1% vs. 15.7%; p < 0.001), of the Chinese race (72.5% vs. 62.7%; p < 0.001), and with diabetes (48.6% vs. 36.7%; p < 0.001). These patients were more likely to present with syncope (6.0% vs. 1.9%; p < 0.001) or epigastric pain (10.6% vs. 4.9%; p < 0.001). Patients with NCP presentation were less likely to receive percutaneous coronary intervention (27.0% vs. 75.6%; p < 0.001), had longer door-to-balloon time (median, minutes = 83 vs. 63; p < 0.001), and experienced greater mortality at 28days (31.2% vs. 4.5%; p < 0.001). On multivariable logistic regression, independent predictors of a NCP presentation included age (adjusted odds ratio [aOR] = 1.05, 95% confidence interval [CI] 1.04-1.07), diabetes (aOR = 1.76, 95% CI 1.40-2.19), BMI (aOR = 0.93, 95% CI 0.91-0.96), and dyslipidemia (aOR = 0.73, 95% CI 0.58-0.91). Absence of chest pain was an independent predictor for 28-day mortality (aOR = 3.46, 95% CI 2.64-4.52). Patients who presented with a NCP STEMI had a distinct clinical profile and experienced poorer outcomes. Routine triage ECG could be considered for patients with high-risk factors and non-classical symptoms.

Atteinte coronarienne et syndrome néphrotique au cours du lupus systémique : à propos d’une observation

IntroductionHeart failure during systemic lupus erythematosus has various causes. Case reportA 29-year-old female presented with a systemic lupus flare and a nephrotic syndrome, followed by cardiogenic shock requiring extra-corporeal membranous oxygenation. Ventricular dysfunction was related to massive myocardial infarction due to an anterior interventricular artery thrombosis and an underlying atheroma. The young age and the absence of chest pain were not suggestive of coronary artery disease initially. Coronary thrombosis was probably favored by the nephrotic syndrome, in which the arterial thrombotic risk is increased. ConclusionCoronary artery disease should be systematically evoked in the presence of ventricular dysfunction in patients with systemic lupus, including when they are young and in the absence of chest pain. Nephrotic syndrome should be identified as a risk factor for arterial thrombosis.

Very late presentation in ST elevation myocardial infarction: Predictors and long-term mortality

BackgroundDespite improvements in ST elevation myocardial infarction (STEMI) care, total ischemic time remains long in patients who present late. Our goal was to identify predictors of very late presentation (≥12 h) of STEMI and determine long-term mortality. MethodsWe retrospectively examined consecutive patients admitted with STEMI to our institution using the ACTION Registry™. Time of symptom onset to first medical contact (FMC) was calculated and categorized as <12 h or ≥12 h. Predictors of very late presentation were determined. ResultsCompared to patients who presented <12 h (n = 365), those who presented ≥12 h (n = 49) after symptom onset were more likely women, diabetics, and those with prior coronary revascularization. In addition, patients who presented ≥12 h had worse ventricular function, were less likely to report chest pain, and were less likely to be transported by ambulance and to undergo coronary angiography. Late presenters had higher rates of heart failure, longer hospitalizations, and were less likely to be discharged home. Diabetes, female sex, and absence of chest pain were strong predictors of late presentation. Long-term survival was significantly lower in late presenters (73% vs. 93%, p = 0.007). ConclusionsFemale sex, diabetes, and absence of chest pain are strong predictors of presentation delay, and long-term mortality is significantly increased in those presenting very late.

Risk Estimation in Type 2 Myocardial Infarction and Myocardial Injury: The TARRACO Risk Score

Despite adverse prognoses of type 2 myocardial infarction and myocardial injury, an effective, practical risk stratification method remains an unmet clinical need. We sought to develop an efficient clinical bedside tool for estimating the risk of major adverse cardiovascular events at 180 days for this patient population. The derivation cohort included patients with type 2 myocardial infarction or myocardial injury admitted to a tertiary hospital between 2012 and 2013 (n = 611). The primary outcome was a major adverse cardiovascular event (death or readmission for heart failure or myocardial infarction). The score included clinical variables significantly associated with the outcome. External validation was conducted using the UTROPIA cohort (n = 401). The TARRACO Score included cardiac troponin (cTn) concentrations and 5 independent clinical predictors of adverse cardiovascular events: age, hypertension, absence of chest pain, dyspnea, and anemia. The score exhibited good discriminative accuracy (area under the curve = 0.74; 95% CI, 0.70-0.79). Patients were classified into low-risk (score 0-6) and high-risk (score ≥7) categories. Major adverse cardiovascular events rates were 5 times more likely in high-risk patients compared with those at low risk (78.9 vs 15.4 events/100 patient-years, respectively; logrank P < .001). The external validation showed equivalent prognostic capacity (area under the curve=0.71, 0.65-0.78). A novel risk score based on bedside clinical variables and cTn concentrations allows risk stratification for death and cardiac-related rehospitalizations in patients with type 2 myocardial infarctions and myocardial injury. This score identifies patients at the highest risk of adverse events, a subset of patients who may benefit from close observation, medical intensification, or both.

AN UNUSUAL CASE OF A RARE DIAGNOSIS MIMICKING ASTHMA.

Introduction A patient with decreased airflow on chest auscultation, with progressive shortness of breath, dry cough, even in the absence of chest pain, may mimic asthma. A diagnosis of pneumothorax might be delayed if a chest X-ray is not done. Case Description An 18-year-old female presented to us with shortness of breath worsening over 7 days, a dry cough and tightness of the chest. No past medical history of trauma, or surgical procedures. Her primary care 7 days ago diagnosed her with asthma and prescribed an inhaled bronchodilator and corticosteroid. The patient came to our clinic due to the worsening of her symptoms. On physical examination, blood pressure: 110/69, temperature 36.7 C, heart rate 83 per minute, oxygen saturation 97 % at room air, weight 55kg (121lb 4.1 oz.), height 155 cm. Chest examination revealed decreased airflow at the right upper lobe. The trachea was not even displaced. The chest X-ray revealed our impression of right-sided apical pneumothorax. She was transported to the emergency department where a right chest tube was placed on water seal and followed until a complete resolution of the pneumothorax. Discussion Various medical conditions may mimic asthma. Patients unresponsive to asthma treatment should be evaluated for the presence of an asthma mimic, in this case a pneumothorax. A chest X-ray should be performed immediately on the patient as described in this report to aid identifies a rare diagnosis of pneumothorax. This case highlights the importance of ordering a chest X-ray in uncontrolled asthma patients.

Absence of chest pain and long-term mortality in patients with acute myocardial infarction

ObjectiveChest pain is the predominant symptom in patients with acute myocardial infarction (AMI). A lack of chest pain in patients with AMI is associated with higher in-hospital mortality, but whether...

195 Screening Electrocardiograms in Cocaine-Positive Chest-Pain-Free Psychiatric Patients Requiring Medical Clearance

Current practice at our large, public, urban academic emergency department (ED) is to obtain a screening electrocardiogram (ECG) as part of the medical clearance process on all patients who require transfer to an inpatient psychiatric facility and test positive for cocaine on a urine toxicology screen regardless of the presence or absence of chest pain. The purpose of this retrospective quality improvement study is to examine the utility and impact of a screening ECG for patients with urine toxicology screening positive for cocaine who are chest-pain-free and require medical clearance prior to transfer to an inpatient psychiatric facility. An institutional review board-approved, retrospective chart review between January 2014 - December 2015 was performed of all ED patients (1) over 18 years of age, (2) without chest pain documented in the medical record, (3) who required medical clearance in the ED prior to transfer to an inpatient psychiatric facility, (4) who tested positive for cocaine on a screening urine toxicology test, and (5) for whom a screening ECG was obtained. All ECGs were interpreted by an attending physician. Abnormal ECGs were defined as: nonspecific ST changes, T wave inversions, sinus tachycardia, ST elevation, or ST depression. All abnormal ECGs were compared to prior ECGs if available, and if no change noted then these were categorized as normal. Primary outcome was disposition of the patient to an inpatient psychiatric facility versus inpatient medical admission. Secondary outcomes were rates of a subsequent cardiac workup, including inpatient medical admission, cardiac enzymes, stress testing, cardiology consultation, and cardiac catheterization. During the study period, 1968 ED patients tested positive for cocaine on a urine toxicology screen and 853 met inclusion criteria. ECGs were normal in 809 (95%, 95% CI [93%, 96%]) patients, and abnormal in 44 (5%, 95% CI [4%, 7%]) patients. Of the 44 patients with abnormal ECGs, 4 were admitted for a cardiac workup. Two patients had positive troponins in the ED. Two patients had cardiology consultations and 3 had further cardiac stress testing performed, all of which were negative or non-diagnostic. No cardiac catheterizations were performed on any patients. Based on the results of our study, the majority of ED patients with recent cocaine use but without chest pain have a normal ECG. Of the minority of patients with an abnormal ECG, there were no cases of acute myocardial ischemia or infarction identified in the absence of chest pain. Therefore, a screening ECG in patients without chest pain simply because of a cocaine-positive urine toxicology test does not appear to identify any cases of myocardial ischemia or infarction and may, in fact, lead to over-testing, increased admission, misuse of resources, and increased cost. Limitations of this study include its retrospective, chart review design. Additionally, there is the possibility of a patient not being forthcoming regarding the presence or absence of chest pain and being categorized incorrectly.

Early Repolarization with a Constant ST-segment Elevation in Leads II, III, and AVF

Background: A recent scientific statement from the American Heart Association included ST-segment elevation in the absence of chest pain in the definition of early repolarization (ER). ST-elevation at J-point termination (Jt)-point was not taken into account in previous heritability studies. The relevance of ST-elevation at Jt point (especially in inferior leads) is not evident enough. Our aim was to assess the heritability of ER with ST-elevation in inferior leads among offspring of such patients and patients' follow-up results. Materials and Methods: A prospective study of 16 consecutive patients with inferior ST-elevation at Jt ≥0.1 mV, who have arrived to outpatient department most often due to chest pain not associated with coronary stenosis according to multislice computed tomography angiography, started in 2013. Repeated cardiologist evaluation included their 12 children in 2017. Comparisons were made with 16 age- and gender-matched control patients' rest 12-lead electrocardiograms (ECGs) from the outpatient department of year 2018. Impact of ST-elevation's localization and sex on heritability were assessed by odds ratio (OR) with 95% confidence interval (CI). Results: There were no significant changes of patients' (all men) health and ECGs during follow-up. Eight (66.7%) of their children were ECG-positive versus 1 (6.2%) control patient,P = 0.001. All siblings (from the same father) of 5 (62.5%) ECG-positive children were ECG-positive. Two of the 5 (male and female) underwent detailed evaluation, including cardiac magnetic resonance, without abnormalities. In cases of only inferior father's ST-elevation, OR, 3.00; 95%CI, 0.24-37.7, and for male children, OR, 7.00; 95%CI, 0.400-23, for presenting with this pattern. Conclusions: Constant inferior ST-elevation, even in cases of chest pain, maybe ER, heritable without structural abnormalities. Heritability may be greater for male offspring and in cases of only inferior father's ST-elevation. Longer studies are necessary to confirm that it is benign. We suggest the term “a constant ST-segment elevation (at Jt)” instead of “ST-segment elevation in the absence of chest pain,” with adding that it is possible latent, depending on the heart rate.

Utilisation and Prognostic Value of Cardiac Magnetic Resonance Imaging in Myocarditis

Aim: To explore the cardiac magnetic resonance imaging (CMR) features of myocarditis and its prognostic implications in New Zealand. Method: Retrospective study of all patients >15 years of age admitted with suspected myocarditis who had a CMR at Waitemata District Health Board (WDHB) between 2007-2016. Results: Of the 178 patients admitted during this period with myocarditis, 94 (53%) had a CMR. The median number of days from admission to CMR was 9.5 (IQR 4-51). 22 patients had a reduced left ventricular ejection fraction (LVEF) <50%, which was associated with presence of dyspnoea on presentation (38% vs 17%, p = 0.03) and an absence of chest pain (46% vs 16%, p = 0.003). Late gadolinium enhancement (LGE) was found in 71 patients (76%), but its presence was not associated with major adverse cardiac events (MACE) (p = ns). Of those who had LGE, 55% was mid-myocardial and 34% was epicardial. When indexed for body surface area (BSA), 41% and 24% of patients had an increased left ventricular end systolic volume (LVESV) and end diastolic volume (LVEDV) respectively. LVEF<50% on CMR was associated with MACE (HR 3.7, 95% CI 1.2-11.4, p = 0.03), while increased BSA indexed LVESV tended towards significance for MACE (HR 3.2, 95% CI 0.96-10.5, p = 0.06). Conclusion: Reduced LVEF<50% and dilated LV volumes appear to be more significant than tissue enhancement patterns in predicting MACE in patients with myocarditis. Larger studies are warranted to investigate whether CMR findings can be combined with clinical factors to risk stratify myocarditis patients.