Detection Of Acute Coronary Syndrome Research Articles

Abstract 15702: Leveraging Advanced AI Algorithms for Predicting Outcomes in Non-Acute Coronary Syndrome Chest Pain Patients

Introduction: Chest pain is often encountered in emergency rooms and the detection of acute coronary syndrome (ACS) is a major focus. However, a notable percentage of patients present with a diverse range of nonACS conditions. Accurately identifying the causes and outcomes of these cases can prevent unnecessary interventions, reduce healthcare costs, and optimize resource allocation. This study aims to explore how advanced AI algorithms can enhance risk assessment, refine classification, and predict outcomes in nonACS chest pain patients using conventional ECG analysis. Methods: We studied 3458 nonACS patients referred to the Emergency Room at Instituto Dante Pazzanese de Cardiologia with chest pain. A total of 185 features, including sex, height, ECG diagnostic statements, and measures, were used. The predicted outcome was defined as hospitalization within 14 days and/or death (1 or 0). We employed the AutoGluon framework for feature engineering and early model selection. XGBoost, a tree-based model, was chosen as the architecture. Training and k-fold stratified cross-validation were performed using an oversampled balanced dataset, and evaluation metrics such as AUROC, specificity, and sensitivity were measured using the original data. Results: In this study, 18.2% (630 patients) had a positive outcome. The sex distribution was comparable between outcome groups, with men accounting for 57-58% and women for 42-43%. Significant differences (p<0.01) were observed in ECG intervals (QRS, corrected QT, RR interval, PSP) between the groups. The AI model identified important diagnostic statements, including normal ECG (19.4), atrial fibrillation (7.4), left ventricular hypertrophy (7.1), Ischemic T-wave inversion in inferior leads (6.7), T-wave changes in inferior leads (5.9), and first-degree atrioventricular block (5.8). The AI model performed exceptionally well, with a sensitivity of 97.93%, specificity of 96.08%, and an AUROC of 0.97. Conclusions: The AI model demonstrated its ability to predict outcomes in patients with acute chest pain without ACS, making it an appealing tool for effective risk stratification. The early identification provided by the AI model presents an opportunity for timely intervention to mitigate adverse outcomes.

114 High-Sensitivity Troponin Velocity for the Detection of Acute Coronary Syndrome

114 High-Sensitivity Troponin Velocity for the Detection of Acute Coronary Syndrome

A hybrid machine learning and natural language processing model for early detection of acute coronary syndrome

Acute coronary syndrome (ACS) is a leading cause of mortality and morbidity. Predicting the associated risks of patients with chest pain using electronic health record data can help identify those needing more tailored care. This study proposes the development of a reliable prediction framework to serve as a diagnostic support tool for preventing misdiagnoses among patients with clinical concerns for ACS. Data were collected from an urban, demographically diverse hospital in Detroit, Michigan, for patients presenting to the emergency department (ED) with primary chief complaints of chest pain from January 2017 to August 2020. This study incorporated term frequency-inverse document frequency features from free-text summaries, which contain anecdotal symptom descriptions and are among the first data points provided upon entering the ED. The analysis included 16,096 patients with clinical concerns for ACS and trained three machine learning models, logistic regression, AdaBoost, and linear discriminant analysis, across different data processing stages to predict patients with ACS from non-ACS etiology. The AdaBoost model outperformed the other two models with an accuracy of 94% and an F1-score of 0.943 in predicting ACS on the testing data. This study identified key independent factors from patient demographics, comorbidities, and clinical narrative data that predicted ACS in patients. The prediction framework can serve as a decision-support tool to classify ACS and inform physicians about better ACS risk factors.

Focused Chest Pain Assessment for Early Detection of Acute Coronary Syndrome: Development of a Cardiovascular Digital Health Intervention.

Chest pain misinterpretation is the leading cause of pre-hospital delay in acute coronary syndrome (ACS). This study aims to identify and differentiate the chest pain characteristics associated with ACS. A total of 164 patients with a primary complaint of chest pain in the ER were included in the study. ACS diagnosis was made by a cardiologist based on the WHO criteria, and the patients were interviewed 48 hours after their admission. Furthermore, every question was analysed using the crosstabs method to obtain the odds ratio, and logistic regression analysis was applied to identify the model of focused questions on chest pain assessment. Among the samples, 50% of them had an ACS. Four questions fitted the final model of ACS chest pain focused questions: 1) Did the chest pain occur at the left/middle chest? 2) Did the chest pain radiate to the back? 3) Was the chest pain provoked by activity and relieved by rest? 4) Was the chest pain provoked by food ingestion, positional changes, or breathing? This model has 92.7% sensitivity, 84.1% specificity, 85% positive predictive value (PPV), 86% negative predictive value (NPV), and 86% accuracy. After adjusting for gender and diabetes mellitus (DM), the final model has a significant increase in Nagelkerke R-square to 0.737 and Hosmer and Lemeshow test statistic of 0.639. Focused questions on 1) left/middle chest pain, 2) retrosternal chest pain, 3) exertional chest pain that is relieved by rest, and 4) chest pain from food ingestion, positional changes, or breathing triggering can be used to rule out ACS with high predictive value. The findings from this study can be used in health promotion materials and campaigns to improve public awareness regarding ACS symptoms. Additionally, digital health interventions to triage patients' suffering with chest pain can also be developed.

The Value of Troponin as a Biomarker of Chemotherapy-Induced Cardiotoxicity.

In cancer survivors, cardiac dysfunction is the main cause of mortality. Cardiotoxicity represents a decline in cardiac function associated with cancer therapy, and the risk factors include smoking, dyslipidemia, an age of over 60 years, obesity, and a history of coronary artery disease, diabetes, atrial fibrillation, or heart failure. Troponin is a biomarker that is widely used in the detection of acute coronary syndromes. It has a high specificity, although it is not exclusively associated with myocardial ischemia. The aim of this paper is to summarize published studies and to establish the role of troponin assays in the diagnosis of cardiotoxicity associated with various chemotherapeutic agents. Troponin has been shown to be a significant biomarker in the diagnosis of the cardiac dysfunction associated with several types of chemotherapeutic drugs: anthracyclines, anti-human epidermal growth factor receptor 2 treatment, and anti-vascular endothelial growth factor therapy. Based on the data available at this moment, troponin is useful for baseline risk assessment, the diagnosis of cardiotoxicity, and as a guide for the initiation of cardioprotective treatment. There are currently clear regulations regarding the timing of troponin surveillance depending on the patient’s risk of cardiotoxicity and the type of medication administered, but data on the cut-off values of this biomarker are still under investigation.

The importance of clinical risk assessment in reducing the pathway of acute coronary syndrome

Introduction: Early diagnosis of acute coronary syndrome is emergency providers' task. In the last decade, vast amounts of clinical risk stratification scores were developed to decrease the hospital load of patients by selecting them properly. Objective: Together with the diagnostic and therapeutic challenges, decreasing treatment duration is essential for the improvement of acute coronary syndrome prognosis. Our aim was to assess the HEART score's time-and therapy -related effects on acute coronary syndrome detection as a decision support system. Method: We conducted a retrospective, quantitative study at a county state emergency department amongst patients with the myocardial infarction ICD codes. We assessed their admission time, the way they were delivered to the hos-pital, their presenting symptoms, vital parameters, chronic medical conditions, laboratory and imaging results and the time of their admission to the percutan intervention center. We calculated the HEART score retrospectively from the collected data. Results: Our sample size consisted of 360 people. Coronary artery disease (80%) and hypertension (73.3%) were the most common risk factors, while chest pain (80%) and shortness of breath (48.6%) were the most common com-plaints. Coronary artery disease, hypertension and diabetes are not related to percutan coronary intervention admis-sion times (p = 0.110; p = 0.173; p = 0.507). We found a correlation between the presence of chest pain and mortal-ity (p = 0.009). The calculated HEART score had a correlation with the fact of coronary intervention admission (p = 0.005). Conclusion: We conclude that the retrospectively calculated HEART score correlates with percutan coronary inter-vention admission. Choosing the proper risk stratification can increase the lifespan of the patients and hospital cost-efficiency.

Early detection of acute coronary syndrome through prothrombin time measurement using flexible UWB antenna for cardiac patient

Acute coronary syndrome (ACS) is the disease occurs due to clot formation in heart arteries. The prothrombin time (PT) of the blood measures various health disorders such as liver dysfunction, cardiac function, internal bleeding and internal blood clots. The PT measurement through optical and mechanical coagulation analyzers is influenced by plasma turbidity, reagent sensitivity and vitamin K levels. In this paper a novel method for early detection of ACS through PT measurement using flexible ultra-wide band (UWB) antenna is proposed. This study is carried on 200 persons with and without ACS. In the proposed method the electromagnetic radiations absorbed from the plasma sample using flexible ultra-wide band antenna is processed further to determine the prothrombin time. The plasma concentration is proportional to electromagnetic energy density and based on the voltage clotting duration is acquired. The clotting frequency ranges of human blood varies from 2 GHz to 3 GHz and voltage from 0.55 mV to 0.85 mV in the observed electromagnetic radiation. The clot concentration is measured from the observed electromagnetic emitted voltage which is converted into frequency during clotting. The prothrombin time is measured from the acquired clotting concentrated voltage through regression modelling and validated through laboratory standards. The proposed UWB antenna based prothrombin time measurement achieves 96.48% accuracy in detecting ACS at the early stage The variations in PT values, need for reagents, vitamin-K impacts, and plasma turbidity impacts were eradicated in the proposed method and ACS is detected early from the measured PT values.

Determination of 97.5th and 99th percentile upper reference limits for heart-type fatty acid-binding protein (H-FABP) in a US population

BackgroundHeart-type fatty acid binding protein (H-FABP), a low molecular weight protein found primarily in myocardial tissue, has been identified as a potential biomarker in the detection of acute coronary syndrome and acute kidney injury. To further investigate clinical utility, we sought to establish an upper reference limit (URL) of H-FABP within a healthy U.S. population. MethodsSerum samples of healthy donors were acquired from the AACC Universal Sample Bank. We analyzed 355 samples for H-FABP concentration using the Randox Laboratories immunoturbidimetric assay on the Roche Cobas 8000 series analyzer. ResultsThe final sample population consisted of individuals aged 18–74 y, with 170 males and 185 females. The distribution of the population exhibited a strong positive skew, affecting outlier analysis and URL determination. The 97.5th-percentile URL was found to be 7.4 ng/ml (95% CI: 6.3–9.2), while the 99th-percentile URL was 12.1 ng/ml (8.6–14.9). ConclusionAs the URL for H-FABP is highly affected by population distribution and outlier removal, final determination for an assay cutoff should be made in the context of clinical utility, either as a standalone assay or in conjunction with other biomarkers, and the desired clinical sensitivity and specificity.

Copeptin, miRNA-208, and miRNA-499 as New Biomarkers for Early Detection of Acute Coronary Syndrome.

cTn and CK-MB are gold standard biomarkers for acute coronary syndrome (ACS) but are less sensitive in the first 3h after onset of symptoms. A need thus exists for novel biomarkers for early detection of ACS. We evaluated circulating copeptin, miRNA-208, and miRNA-499 as possible biomarkers for early detection of unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI). Sixty-five patients with probable ACS that presented within 4h of the onset of chest pain (23 UA and 42 NSTEMI) and 25 apparently healthy individuals were studied. Two sets of blood samples collected in the first 3h and at 6h after onset were analyzed for copeptin levels via ELISA and miRNA-208 and miRNA-499 expression via real-time PCR. Copeptin, miRNA-208, and miRNA-499 expression levels were significantly increased in UA and NSTEMI patients compared with controls (p < 0.001) and in NSTEMT compared with UA patients (p < 0.001). Levels were also significantly elevated in UA and NSTEMI patients with negative cardiac troponin in the first 3h (p < 0.001). ROC curves displayed AUC for prediction of ACS of 0.96 for copeptin, 0.97 for miRNA-208, and 0.97 for miRNA-499. Their combination improved AUC to 0.98. Copeptin and miRNA-208 and miRNA-499 expression are promising biomarkers for UA and NSTEMI that present in the first 3h of pain onset. A combination of these markers with cTn may increase the accuracy of diagnosis by avoiding the gray zone of cTn as a biomarker.

Premature atherosclerosis and acute coronary syndrome in a child with end-stage renal disease

BackgroundAlthough acute coronary syndrome is rare in children, it is the most important cause of mortality in children with end-stage renal disease.Case presentationHere, a 16-year-old pediatric patient, who has been on dialysis since the age of 3, and who was diagnosed with acute coronary syndrome and placed an emergency percutaneous transcatheter stent in the left anterior descending branch of the left coronary artery is presented. It is important that the present patient does not have any electrocardiography findings in favor of cardiovascular disease and that he cannot fully explain the complaint of chest pain due to his mental retardation.ConclusionsEarly detection of acute coronary syndrome is life-saving, especially in children with chronic kidney disease.

102 Detection of Acute Coronary Syndrome by Magnetocardiography

To evaluate the use of magnetocardiography (MCG) for early identification or rule out of acute coronary syndromes (ACS) in emergency department (ED) patients with chest pain. Magnetocardiography is a noninvasive imaging method that measures the electromagnetic fields generated by the heart’s activity. MCG is rapid, easy to perform, and provides a radiation-free imaging assessment for patients with suspected ACS. This is a prospective, observational, multicenter trial comparing the accuracy and time to disposition of ED standard of care (SOC) vs. MCG. Patients were enrolled at 3 sites from January to May 2021. Inclusion criteria were ED patients with chest pain, age ≥ 18 years, modified heart score > 2, and signs/symptoms of ACS in the ED. Exclusion criteria were STEMI, unable to fit into the device, non-ambulatory, hemodynamically unstable, and unable to lie supine for up to 5 minutes. Additional exclusion criteria were patients with pacemakers, AICD, other active devices, or any ferromagnetic metal above the costal margins. Patients underwent a MCG scan in addition to ED SOC. MCG was performed within 4 hours of ED triage. We hypothesize that the use of MCG will lead to shorter ED length of stay (LOS), with equal or improved diagnosis of suspected ACS patients. Of 58 scans, 32 were available for evaluation. 26 were unevaluable due to either insufficient data or uninterpretable. Patients with any artifacts were considered unevaluable. With technical improvements, the arttifact on current scans may be decreased which will result in fewer unevaluable scans. Mean age was 51.3 (SD± 1 .9) years, 50% female, 59.4% Black, 37.5% White, 3.1% other. Mean HEART score was 4.2 (SD± 1.1). Mean number of cardiovascular risk factors was 3.0 (SD± 1.6). Mean LOS (minutes) for MCG was 187 (SD ± 122) vs. SOC 812 (SD ± 73) (P < 0.0001 by paired t-test) (95% CI difference: -882.0, - 368.1). Thus, when compared with standard of care evaluation alone, the mean length-of-stay could have been reduced by 10.6 hours without any significant change in diagnostic accuracy. MCG and SOC based on troponins were both negative in 28 patients.There were 2 false positives by SOC (6.2%, 2/32). In these two patients presumed to have ACS by SOC, both went to cardiac catheterization, which revealed no ACS. MCG correctly identified the patients to have no ACS. There were two false negatives by MCG. In these two patients, MCG was positive and SOC rule out by troponins was negative. No stress test or cardiac catheterization was done in these two patients. Eleven patients (34%) were placed in the observation unit (OU). The MCG done in the ED and the rule out in the OU were both negative for ACS. Furthermore, early MCG done in the ED as compared with standard of care evaluation alone, would potentially eliminate overnight observation unit stays in 34% of the study population. Magnetocardiography results in a significantly lower LOS for chest pain in the ED which could lead to decreased ED LOS, improved ED turnaround times and better ED efficiency. MCG may avoid an OU stay with resultant cost savings in about one-third of ED chest pain patients. More importantly, MCG detected patients who were false positive by SOC and could have avoided a cardiac catheterization. MCG had two false positives which were negative by troponins but no cardiac catheterization or stress test were done in these two patients.

Prehospital ECG with ST-depression and T-wave inversion are associated with new onset heart failure in individuals transported by ambulance for suspected acute coronary syndrome

BackgroundPrehospital electrocardiogram(s) (ECG) can improve early detection of acute coronary syndrome (ST-segment elevation myocardial infarction [STEMI], non-STEMI, and unstable angina) and inform prehospital activation of cardiac catheterization lab; thus, reducing total ischemic time and improving patient outcomes. Less is known, however, about the association of prehospital ECG ischemic findings and long term adverse clinical events. With this in mind, this study was designed to examine the: 1) frequency of prehospital ECGs for acute myocardial ischemia (ST-elevation, ST-depression, and/or T-wave inversion); and, 2) whether any of these specific ECG features are associated with adverse clinical events within 30 day of initial presentation to the emergency department (ED). MethodsWe included consecutive patients ≥ 21 years during a five-year period (2013–2017), who were transported by ambulance to the ED with non-traumatic chest pain and/or anginal equivalent(s) and had a prehospital 12‑lead ECG. Two cardiologists (LG, EC), blinded to clinical data, interpreted the 12‑lead ECGs applying current guideline based ischemia criteria. Adverse clinical events, return to ED, and rehospitalization evaluated at 30-days. ResultsWe identified 3646 patients (mean age, 59.7 years ±15.7; 45% female) with ECGs, of which N = 3587 had data on the three ischemic markers of interest. Of these, 1762 (49.1%) had ECG evidence of ischemia. In adjusted logistic regression models, those with T-wave inversion had a higher odds (OR = 1.59) of new onset heart failure, while ST-elevation was associated with lower odds (OR = 0.69). Patients with ST-depression had higher odds of new onset heart failure and death within 30 days (OR = 1.29, 1.49 respectively), but this association attenuated after controlling for other ECG features. ConclusionsST-depression and/or T-wave inversion are independent predictors of new onset heart failure, within 30 days of initial ED presentation. Our study in a large cohort of patients, suggests that using ECG ST-elevation alone may not capture patients with ischemia who may benefit from aggressive anti-ischemic therapies to reduce myocardial damage with resultant heart failure.

The Best of Both Worlds: Eliminating Creatine Kinase-Muscle/Brain (CK-MB) Testing in the Emergency Department Leads to Lower Costs Without Missed Clinical Diagnoses.

The 2014 American Heart Association/American College of Cardiology (AHA/ACC) clinical guidelines recommend cardiac troponin as a superior biomarker to creatine kinase (CK) and creatine kinase-muscle/brain (CK-MB) for the detection of acute coronary syndrome (ACS), namely myocardial infarction and unstable angina. In April 2018, our Emergency Department (ED) transitioned from using standard troponin to using high-sensitivity troponin T, and adopted a clinical guideline consistent with the AHA/ACC. The guideline recommended high-sensitivity troponin T without CK/CK-MB testing in the majority of clinical situations, limiting CK/CK-MB testing to two specific clinical cases: 1) estimated glomerular filtration rate (eGFR) value <15 mL/min, or 2) recent acute coronary syndrome (ACS) event. Per our ED’s policy, a “negative” troponin T was defined as being below the limit of detection (LOD) (i.e., <6 ng/L); such a value obtained at least 3 hours after symptom onset “ruled out” an ACS event and did not require a repeat troponin.The goal of this retrospective study was to determine whether the guideline limiting CK-MB testing missed clinically-significant cardiac outcomes (ACS or new diagnosis of coronary artery disease [CAD]) or was associated with mortality. Pre-implementation data (July 1, 2017 - December 31, 2017) was compared with post-implementation data (July 1, 2018 - December 31, 2018). After guideline introduction, CK/CK-MB ordering decreased by nearly 90%, while troponin ordering increased by nearly 20%, likely due to the introduction in June 2018 of high-sensitivity troponin T, which yielded numerous intermediate/indeterminate-range results that prompted repeat testing. Fewer than 1.5% of patients with a “negative” troponin (below the LOD) and a “positive” CK-MB (above the upper limit of normal [ULN]) had ACS or new-diagnosis CAD; patients with either diagnosis did not expire during their hospital stay or within 30 days of their index visit. CK-MB Index, which has a higher specificity than CK, only found ACS or new CAD among 0.8% of positive results. Considering both decreased CK/CK-MB and increased troponin ordering, the net annual direct cost savings in cardiac biomarker testing was extrapolated to $12,700. Had our institution not transitioned to higher cost high-sensitivity troponin ($2.054/unit) from standard troponin ($1.65/unit), and had the rate of troponin ordering increased solely proportionate to the rate of ED visit increase (2% year-over-year) rather than increase nearly 20% (likely due to the transition to high-sensitivity troponin), then the total six-month direct costs on troponin testing would have been $14,632 instead of $21,267.12, and annual direct cost savings would have been $18,945.80 instead of $12,700. The new ED clinical guideline did not result in a significant number of missed ACS or new-diagnosis CAD, and was associated with direct cost savings. These savings probably underestimate total savings, as the reduced number of “false-positive” CK-MB results likely prevented additional costs, such as hospitalization, specialty consultation, coronary calcium CT, echocardiogram, cardiac stress test, and coronary artery catheterization.

Impact of copeptin, miRNA-499 and miRNA-208 as new biomarkers for early detection of acute coronary syndrome

Abstract Introduction Acute coronary syndrome (ACS) is a leading cause of mortality and morbidity worldwide. Despite being the gold standard biomarkers, cTn and CK-MB have a major drawback as they are less sensitive in the first 3 hours of the onset of symptom. So, there is still a need for novel biomarkers, which can reliably rule in or rule out this disease immediately on admission. Aim of the work To evaluate the role of copeptin, miRNA-499 and miRNA-208 as novel biomarkers for early detection of unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI) Patients and Methods: A total of 65 patients presenting within 4 h of onset of chest pain suggestive of ACS were enrolled in the study. They included 23 UA, 42 NSTEMI. Also 25 apparently healthy controls were included. Blood samples (first set within the first 3 hours and second set at 6 hours) were taken for estimation of copeptin by ELISA and miRNA-499 and miRNA-208 expression levels by real time PCR. Results Copeptin, miRNA-499 and miRNA-208 expression levels were significantly increased in UA and NSTEMI patients compared to controls (P&amp;lt;0.001 each). Also these biomarkers were significantly increased in NSTEMT compared to UA (P&amp;lt;0.001 each). They also significantly elevated in UA and NSTEMI patient in the first 3 hours who had negative cardiac troponin (p&amp;lt;0.001 each). ROC curve analysis revealed that the area under curve (AUC) for prediction of ACS was 0.96 for copeptin, 0.97 for miRNA-499 and 0.0.97 for miRNA-208. Interestingly, combining copeptin with miRNA-499 and miRNA-210 significantly improved the diagnostic value by increasing the AUC to 0.98, P&amp;lt;0.001. The sensitivity and specificity within the first 3 hours were 90%, 86% for copeptin, 95%, 94% for miRNA-499 and 93%, 98% for miRNA-208. The sensitivity and specificity were 81% and 86% for cardiac troponin within 6 hours. There was a positive correlation between copeptin and miRNA-499 and miRNA-208 (r=0.75, P&amp;lt;0.001 and r=0.76, P&amp;lt;0.001 respectively) Also, there was a positive correlation between these biomarkers and cTn (r=0.7. P&amp;lt;0.001, r=0.64, P&amp;lt;0.001 and r=0.68, P&amp;lt;0.001 respectively). Conclusions Copeptin, miRNA-499 and miRNA-208 expression might be novel biomarkers as they are associated with UA and NSTEMI presented in the first 3 hours of onset of pain. The combination of copeptin and miRNA with cTn accelerate the diagnosis of ACS and avoiding the gray zone of cTn. Copeptin and miRNAs representing a potential aid in early diagnosis as they have different pathogenesis and site of liberation. Funding Acknowledgement Type of funding source: None

Post renal transplant acute myocardial infarction

Background: Renal transplant recipients (RTR) have a comparatively lower risk of acute myocardial infarction (AMI) than wait-list patients. Cardiovascular diseases especially AMI are the leading cause of morbidity and mortality in post-renal transplant patients.1,4 They account for up to 50% of the deaths in RTR. The incidence of AMI in RTR is about 0.2% but it is on the rise. Meticulous pre-operative assessment of cardiac status, appropriate pre-operative cardiac management, and post-operative cardiac monitoring will prevent mortality.2 Recently it has been emphasized and there is ample evidence to use cardiac troponins from day zero in the post-operative period to diagnose peri-operative cardiac events like AMI.3 We report a case of post-operative myocardial infarction in a live renal donor transplant patient. This case report will serve to increase the awareness of the cardiovascular event in RTR. Case Report: A 62-year-old obese male patient known to have Type II diabetes mellitus, dyslipidemia, hypertension, end-stage renal disease (ESRD) on peritoneal dialysis, presented for live non-related donor renal transplant. In the pre-operative evaluation, his comorbidities were well controlled. His electrocardiogram (ECG) was normal and an echocardiogram revealed left ventricular enlargement and grade 1 diastolic dysfunction. Induction of anesthesia and intra-operative periods were smooth and he remained hemodynamically stable. The patient did not consent for epidural catheter insertion. Intra-operatively his iliac arteries showed multiple plaques, and his renal vessels were anastomosed with difficulty. After a 6-hour surgery, he was admitted to the surgical intensive care unit (SICU) sedated, intubated, and ventilated.In SICU initially, his hemodynamics were stable, passing 20 to 30 ml of urine per hour, and started on 100% renal replacement with IV Ringer's Lactate. The central venous pressure was between 12 to 14 mmHg. He was rapidly weaned from the ventilator and extubated after 8 hours. Post-extubation, he was awake, stable, and resumed his oral medications.On day 2, during physiotherapy, he complained of shortness of breath and developed severe bradycardia (24 beats/minute). Twelve-lead ECG showed ST-segment depression in the anterior-lateral leads. Within a few minutes, he went into cardiac arrest requiring CPR (cardio-pulmonary resuscitation) for 1 minute. Cardiac biomarkers were elevated (Figure 1) and chest x-ray showed pulmonary congestion (Figure 2). An echocardiogram revealed left ventricular ejection fraction of 58% and mild hypokinesia of the anterior wall. CT coronary angioram or conventional coronary angiogram was not done to avoid constrast induced injury to the transplanted kidney.He was started on aspirin and heparin infusion. His newly grafted kidney was functioning well and he was passing 50-100 ml of urine per hour. He was hemodynamically stable and transferred to the ward on day three. From there, he was discharged home and followed in the transplant and cardiac outpatient clinics. After three months of follow-up, his kidney was functioning well and his echocardiogram became normal. Conclusion: RTR are at greater risk of cardiovascular events, particularly AMI though significantly less than the wait-list patients. Cardiac troponins should be monitored in the post-operative period as early detection of acute coronary syndrome improves their outcome.3

Effect of combined testing of ceramides with high-sensitive troponin T on the detection of acute coronary syndrome in patients with chest pain in China: a prospective observational study.

ObjectiveCeramides are associated with coronary plaque vulnerability. We aim to investigate the potential diagnostic value of ceramides for acute coronary syndrome (ACS) in Chinese patients with chest pain.DesignProspective observational survey.SettingShanghai, China, 2016–2017.ParticipantsA total of 2773 patients with chest pain from four hospitals in Shanghai, China, between August 2016 and October 2017.Main outcome measuresPerformance of metabolites model in detection of ACS cases including ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI) and unstable angina.ResultsPlasma levels of 12 ceramide molecules and corresponding ratios were compared between patients diagnosed with ACS and those without. Cer(d18:1/24:1(15Z))/Cer(d18:1/24:0) ratio, Cer(d18:1/14:0) and Cer(d18:1/22:0) were independent predictors of ACS after adjustment of traditional risk factors and high-sensitivecardiac troponin T. Receiver operating characteristic curve analysis showed a significant improvement in detecting ACS in the multivariable model with ceramides compared with that without (0.865 (0.840 to 0.889) vs 0.808 (0.776 to 0.841), p<0.001).ConclusionDistinct plasma ceramides are independent diagnostic predictors of ACS among patients with chest pain. Ceramides together with high-sensitive troponin and traditional factors showed great potential in identifying ACS among patients with chest pain.

Value of Manchester Acute Coronary Syndromes Decision Rule in the Detection of Acute Coronary Syndrome; a Systematic Review and Meta-Analysis.

There is still no consensus on the value of Manchester Acute Coronary Syndromes (MACS) decision rule in detecting acute coronary syndrome (ACS). Therefore, the purpose of the present systematic review and meta-analyzes is to summarize the clinical evidence in the evaluation of the value of MACS in the diagnosis of ACS. A literature search was performed on the Medline, Embase, Scopus, and Web of Science databases. Outcomes included acute myocardial infarction (AMI) and major adverse cardiac event (MACE). Data were analyzed in the STATA 14.0 statistical program and the results were reported as summary receiver operating characteristics (SROC), sensitivity, specificity, positive and negative likelihood ratio, and diagnostic odds ratio with 95% confidence interval (95% CI). Finally, 8 articles included in the meta-analysis. The area under the SROC of MACS was excellent in rule out of AMI (AUC = 0.99, 95% CI: 0.97 to 0.99) and MACE (AUC = 0.97, 95% CI: 0.95 to 0.98). The sensitivity and specificity of the troponin-only MACS/history electrocardiogram alone MACS (HE-MACS) in the rule out of AMI were0.99 (95% CI: 0.98-0.99) and 0.22 (95% CI: 0.11-0.37), respectively, and for the original MACS were in order 0.99 (95% CI: 0.98-0.99) and 0.26 (95% CI: 0.20-0.34),. The sensitivity and specificity of the troponin-only MACS / HE-MACS in the rule out of MACE were 0.94 (95% CI: 0.92-0.96) and 0.22 (95% CI: 0.12-0.39) compared to the 0.99 (95% CI: 0.98-0.99) and 0.27 (95% CI: 0.22-0.33) for the original MACS. The findings of this study showed that original MACS, troponin-only MACS, and HE-MACS are able to rule out AMI and MACE. However, further studies are needed in developing countries to confirm its external validity.

Increased serum nardilysin is associated with worse long-term outcome of ST-elevation myocardial infarction.

Nardilysin (N-arginine dibasic convertase, NRDC) is a kind of metalloendopeptidase associated with several inflammatory diseases. NRDC is reported to be eligible for early detection of acute coronary syndrome. However, the availability and effectiveness of NRDC in predicting the prognosis of patients with ST-elevation myocardial infarction has never been investigated. From January 2010 to January 2012, the prospective observational cohort study enrolled a total of 396 STEMI patients, who were sampled with blood within 24 hours after admission. A long-term follow-up was conducted to record the primary endpoint of all-cause mortality, as well as secondary endpoint of myocardial infarction, stroke, emergent revascularization and admission due to heart failure. Hazard ratio (HR) related to the serum NRDC level was estimated by Cox regression model. The enrolled patients completed the follow-up with an average of 4.6 ± 0.5 years, of whom 24 patients died (primary endpoint, 6.1%), while 89 episodes of secondary endpoints occurred (22.5%). Patients with highest quartile level of NRDC (Q4 level, > 2041 pg/ml) were subjected to higher risk of all-cause death [HR 3.973, 95% CI (1.648-9.575), p = 0.002] compared to patients with lower three quartiles level of NRDC (Q1 to Q3, < 2041 pg/ml), while there was no difference in adverse events (p = 0.403). The increased serum NRDC level at admission is associated with a higher risk of all-cause mortality for ST-elevation myocardial infarction patients.

Utility of the History and Physical Examination in the Detection of Acute Coronary Syndromes in Emergency Department Patients.

Chest pain accounts for approximately 6% of all emergency department (ED) visits and is the most common reason for emergency hospital admission. One of the most serious diagnoses emergency physicians must consider is acute coronary syndrome (ACS). This is both common and serious, as ischemic heart disease remains the single biggest cause of death in the western world. The history and physical examination are cornerstones of our diagnostic approach in this patient group. Their importance is emphasized in guidelines, but there is little evidence to support their supposed association. The purpose of this article was to summarize the findings of recent investigations regarding the ability of various components of the history and physical examination to identify which patients presenting to the ED with chest pain require further investigation for possible ACS.Previous studies have consistently identified a number of factors that increase the probability of ACS. These include radiation of the pain, aggravation of the pain by exertion, vomiting, and diaphoresis. Traditional cardiac risk factors identified by the Framingham Heart Study are of limited diagnostic utility in the ED. Clinician gestalt has very low predictive ability, even in patients with a non-diagnostic electrocardiogram (ECG), and gestalt does not seem to be enhanced appreciably by clinical experience. The history and physical alone are unable to reduce a patient’s risk of ACS to a generally acceptable level (<1%).Ultimately, our review of the evidence clearly demonstrates that “atypical” symptoms cannot rule out ACS, while “typical” symptoms cannot rule it in. Therefore, if a patient has symptoms that are compatible with ACS and an alternative cause cannot be identified, clinicians must strongly consider the need for further investigation with ECG and troponin measurement.

AKTIVITAS CKMB DAN MASA CKMB TERKAIT KARDIAK TROPONIN-I DALAM GEJALA KORONER AKUT

Coronary Heart Disease (CHD) is the leading cause of death recently, including in Indonesia which is raised to 25%. Acute Coronary Syndrome (ACS) is its common clinical manifestation. Therefore, the necessity for a sensitive as well as specific diagnostic biomarker for ACS should be addressed in discriminating the ACS patient and its related risks. The diagnostic sensitivity of characteristic electrocardiography pattern in ACS cases were reported to be variatively between 55–75%. In laboratory diagnostic, ACS markers among others are CKMB activity, CKMB mass as well as Cardiac Troponin-T and Troponin-I (cTnT and cTnI). Currently, cTnI is the gold standard. The present study is to know the analysing of the CKMB activity as well as the mass diagnostic performance in the detectionof ACS in the patient presenting with chest-pain at RSDM, by using cTnI as the standard of reference. As many 30 samples, 18−65 years old, were selected trough incidental sampling method from the subjects presenting with chest-pain no longer than 6 hrs before admission. The blood samples were drawn at admission and 6 hrs afterward. The CKMB activity (immunoinhibition assay), CKMB mass (ELFA) and cTnI (ELFA) measurement were performed on each sample. The analysis showed that cTnI cut-off on 0.1 μg/L (ESC/ACC 2000) was most optimal in the laboratory diagnostic of ACS compared to that of 0.01 μg/L (ESC/ACC 2007 update) and 1.0 μg/L (WHO). Using the cTnI cut-off on 0.1 μg/L, on admission (0 hr) the diagnostic efficiency of CKMB mass was 56.7% while that of CKMB activity was 60.0%. While on the serial measurement (6 hrs), the diagnostic efficiency of CKMB mass was 76.6% while that of CKMB activity was 56.7%. The results showed that by serial measurements, CKMB mass is superior than CKMB activity in the diagnosis of ACS in patient presenting with chest-pain. Further researches are necessary to elaborate the comparison elucidatively. The results of the study considered that in designing the protocol for laboratory examination should carried out in patient presenting with chest pain.