Cardiac Pain Research Articles

Liposomal Bupivacaine Versus Plain Bupivacaine for Pain Control Following Congenital Cardiac Surgery.

Pain control following cardiac surgery can be challenging, and inadequate pain control is associated with postoperative complications. Liposomal bupivacaine can improve postoperative pain control due to its prolonged duration compared with plain bupivacaine. However, there is a paucity of data regarding its efficacy in congenital cardiac surgery. The primary outcome was to compare opioid requirements between liposomal bupivacaine and plain bupivacaine for local infiltration in pediatric patients undergoing cardiac surgical procedures via a median sternotomy approach. Secondary outcomes included antiemetic use, adjunct pain medication use, length of stay, and pain scores. This single center retrospective study analyzed data from 2017 to 2022 involving patients who underwent congenital cardiac surgery via median sternotomy. Sixty-three patients who received liposomal bupivacaine were matched with 33 patients who received plain bupivacaine. Patient data were extracted from the electronic medical record and underwent statistical analysis using Wilcoxon, χ2, and Fisher exact tests. There were no demographic differences between the two groups. Postoperative opioid use did not differ significantly between the liposomal bupivacaine and plain bupivacaine groups. The liposomal bupivacaine group had increased acetaminophen and antiemetic use, while the plain bupivacaine group had increased ketorolac use. Otherwise, there were no significant differences in secondary outcomes, including length of stay. Liposomal bupivacaine may not offer any advantage over plain bupivacaine in congenital cardiac postoperative pain control.

SUMO regulation of ion channels in health and disease.

The Small Ubiquitin-like Modifier (SUMO) protein pathway governs a panoply of vital biological processes ranging from cell death, proliferation, differentiation, metabolism, and signal transduction by diversifying the functions, half-lives, and partnerships of target proteins in situ. More recently, SUMOylation has emerged as a key regulator of ion homeostasis and excitability across multiple tissues due to regulation of a plethora of ion channels expressed in a range of tissues subtypes. Altogether, the balance of SUMOylation states amongst relevant ion channels can result in graded biophysical effects that tune excitability and contribute to a range of disease states including cardiac arrythmia, epilepsy, pain transmission, and inflammation. Here, we consolidate these concepts by focusing on the role of ion channel SUMOylation in the central nervous system, peripheral nervous system and the cardiovascular system. In addition, we review what is known about the enigmatic factors that regulate the SUMO pathway and consider the emerging role of small molecule SUMO-modulators as potential therapeutics in a range of diseases.

Assessing cardiac chest pain in prescribing practice

Assessing cardiac chest pain in prescribing practice

Safety and efficiency of implementation of high-sensitivity troponin T in the assessment of emergency department patients with cardiac chest pain.

For emergency department (ED) patients with cardiac chest pain, introduction of high-sensitivity troponin (hsTnT) pathways has been associated with reductions in length of stay of less than 1h. At two urban Canadian sites, we introduced hsTnT on January 26, 2016. While the prior diagnostic algorithm required troponin testing at 0 and 6h, serial hsTnT serial testing was conducted at 0 and 3h. We identified consecutive patients who presented with cardiac chest pain from January 1, 2015, to March 31, 2017, along with 30-day outcomes. The primary outcome was a missed 30-day major adverse cardiac event, (MACE) defined as death, revascularization, or readmission for myocardial infarction occurring in a patient-discharged home with a minimizing diagnosis and without cardiac-specific follow-up. Secondary outcomes included admission rate, ED length of stay, and MACE. We compared pre- and post- implementation periods using descriptive methods and repeated this analysis in patients with noncardiac chest pain. We collected 5585 patients with cardiac chest pain, (2678 pre- and 2907 post-introduction) and 434 had (7.8%, 95% CI 7.1 to 8.5%) MACE, with 1 missed MACE. (0.2%, 95% CI 0.04 to 1.3%). Admission rate was stable at 24.1% pre- and 23.7% while median length of stay decreased from 464 to 285 min, a difference of 179 min. (95% CI 61 to 228 min). For 11,611 patients with noncardiac chest pain, admission rate (9%) and length of stay (191 versus 193 min) remained constant. Implementation of hsTnT for evaluation of ED chest pain patients was safe and associated with a 3-h decrease in length of stay.

Language barrier as social determinant of health: unmasking the disparities in the emergency department evaluation for patients with chest pain at a community hospital

Abstract Background/Introduction Patients with limited English proficiency (LEP) constitute 8.6% of the United States population. They may have lower health literacy related to cardiovascular disease, reluctance to seek care, and communication difficulties in reporting symptoms, posing challenges to care provision. Throughout medical literature, these barriers reportedly lead to increased utilisation of diagnostic testing, hospital admission rate, and length of stay. Purpose Language barrier appears to negatively impact individuals' healthcare experience. The goal of this study is to examine whether disparities exist in the emergency department (ED) evaluation and management of chest pain in LEP patients by comparing their wait time and admission rate to that of English-proficient (EP) counterparts. Methods This retrospective cohort study included adults age 18 or older that presented to our hospital ED with a chief complaint of chest pain from 1/9/2022 to 30/9/2023. We identified all LEP patients during this period and matched a random sample of EP patients in a 1:2 ratio. We treated each encounter as an independent subject and eliminated those that left prior to disposition. Our primary outcomes were time from arrival to provider evaluation, and admission rate. Covariates were sex, age, race, acuity level, arrival mode, and insurance status to adjust for characteristic difference between cohorts. Descriptive comparisons between cohorts and bivariate outcomes were conducted using independent samples t-tests for continuous variables and chi-squared tests for categorical ones. Multivariable linear and logistic regression models were used to compute adjusted mean wait time for provider and adjusted odds of admission, respectively. All analyses were done on SAS 9.4. Results Our study sample included 690 encounters, with 239 LEP and 451 EP patients. The two cohorts were similar in sex, age, and acuity level, but there were significant disparities in insurance status, arrival mode, and race. A higher proportion of EP patients were admitted to the hospital or observational unit than LEP patients (45.0% vs. 28.0%, respectively, P<0.001). After multivariable adjustment, LEP patients were half as likely to be admitted compared to EP patients (adjusted odds ratio, 0.51 [95% CI, 0.35-0.74], P<0.001). LEP patients waited longer for provider evaluation from the point of ED arrival, though this was not statistically significant when adjusting for acuity and arrival mode (19.6 minutes, [95% CI, 5.9-45.1], P=0.132). Conclusions Whilst we did not observe a significant difference in wait time for provider between LEP and EP patients, LEP patients were less likely to be admitted when presenting with chest pain at the ED. One possibility is that language barrier may limit a patient’s ability to convey cardiac versus non-cardiac chest pain, adversely influencing downstream management and outcomes. To address this, further large-scale investigation is needed.

Dysregulation of sympathoadrenal system activity in patients with microvascular angina

Abstract Introduction Recent studies have highlighted that a significant proportion of patients (up to 47%) undergoing coronary angiography due to clinical indications do not exhibit significant stenosis in epicardial vessels. Among these patients, up to 50% may suffer from microvascular angina (MVA). Despite the absence of intramural coronary artery lesions typically associated with atherosclerosis, the occurrence of transient myocardial ischemia and cardiac pain syndrome raises interest due to the incomplete understanding of their underlying mechanisms. Objective This study aims to comprehensively investigate sympathoadrenal system activity in patients with microvascular angina. Materials and Methods A total of 40 patients diagnosed with MVA, aged 35-76 years, including 11 (27.5%) men and 29 (72.5%) women, were enrolled, along with 20 healthy individuals. Assessment of sympathoadrenal system (SAS) activity involved determining daily urinary excretion levels of free and conjugated catecholamine fractions (CA) using solid-phase enzyme immunoassay: adrenaline (A), noradrenaline (NA), dopamine (DA), and DOFA. Additionally, catecholamine deamination enzyme activity—monoamine oxidase (MAO)—was determined using solid-phase EIA. Results Patients with MVA exhibited a significant increase in the excretion of all CA fractions. Specifically, adrenaline (A) excretion increased by 56.7%, surpassing the control by 1.7 times (p<0.001). Noradrenaline (NA) levels were elevated by 59.5% in MVA patients, which was 1.6 times higher than the control group (p<0.001). Dopamine (DA) levels in MVA patients increased by 31.0%, surpassing control values by 1.36 times (p<0.001). Moderate elevation in DOFA levels by 19.7% was observed, which was 1.23 times higher than the control (p<0.01). Ratios of CA sulfocatecholamine formation processes indicated pronounced deviations from normal. Gender differences revealed marked changes in sympathoadrenal activity, particularly in women (p<0.001). Studies of MAO activity on the first day identified a moderate decrease in its activity in MVA patients—0.03±0.002 units/ext. (p<0.01), while healthy individuals exhibited an activity level of 0.07±0.001 units/ext. Conclusion The findings underscore the crucial pathogenetic role of SAS in the development of MVA. The study demonstrates that the severity of ischemia correlates with disruptions in SAS components. Notably, these disruptions are pronounced in MVA, indicating an overload of the sympathoadrenal system—a critical component of organismal homeostasis. Under conditions of SAS overload, the pivotal enzyme in biogenic amine oxidation, MAO, undergoes significant transformation, leading to reduced activity towards monoamines. These findings were consistent with our clinical investigation.

Bayesian intelligence for medical diagnosis: a pilot study on patient disposition for emergency medicine chest pain.

Clinicians can rapidly and accurately diagnose disease, learn from experience, and explain their reasoning. Computational Bayesian medical decision-making might replicate this expertise. This paper assesses a computer system for diagnosing cardiac chest pain in the emergency department (ED) that decides whether to admit or discharge a patient. The system can learn likelihood functions by counting data frequency. The computer compares patient and disease data profiles using likelihood. It calculates a Bayesian probabilistic diagnosis and explains its reasoning. A utility function applies the probabilistic diagnosis to produce a numerical BAYES score for making a medical decision. We conducted a pilot study to assess BAYES efficacy in ED chest pain patient disposition. Binary BAYES decisions eliminated patient observation. We compared BAYES to the HEART score. On 100 patients, BAYES reduced HEART's false positive rate 18-fold from 58.7 to 3.3 %, and improved ROC AUC accuracy from 0.928 to 1.0. The pilot study results were encouraging. The data-driven BAYES score approach could learn from frequency counting, make fast and accurate decisions, and explain its reasoning. The computer replicated these aspects of diagnostic expertise. More research is needed to reproduce and extend these finding to larger diverse patient populations.

Diagnosis and Management of Thoracolumbar Spinal Disorders Presenting as Cardiac, Gastrointestinal, and Other False Pain Syndromes.

Although pseudoangina is most commonly caused by cervical disc herniation, several cases have been described where thoracic herniation produced symptoms of pseudoangina. If thoracic herniation can produce angina-like pain, then it is important to consider whether pathology of the thoracolumbar spine, in general, can trigger false pain syndromes distinct from pseudoangina. We seek to provide the most comprehensive study regarding the diagnosis and treatment of spinal conditions causing false pain syndromes. Systematic review of the current literature using PRISMA 2020 recommendations. We queried the literature and systematically selected relevant studies according to PRISMA guidelines. Across 22 selected studies, the sample size was 30 patients, and a total of 26 met the criteria for statistical analysis. Seven (26.9%) of these patients presented with a chief complaint of pseudoangina resulting from thoracic disc herniation. 73.1% (19/26) of patients exhibited pain mimicking visceral origin. Overall, 13/19 (68.4%) patients exhibited thoracic spine disease only and 4/19 (21.1%) patients were affected at lumbar levels only, while 2 (10.5%) patients exhibited thoracolumbar herniation. Presentations included abdominal pain (11/19) mimicking appendicitis or pancreatitis, flank pain mimicking renal colic (8/19), and 2 cases of scrotal pain/orchalgia. Symptom durations ranged from acute (<24h) to 7 years. Treatments were reported for 18/19 patients and all treated patients reported alleviated pain. Seven out of 18 patients were managed conservatively while 11/18 were treated surgically. Misdiagnosis resulted in unnecessary surgery (pancreaticojejunostomy) or other invasive procedures. In spinal disorders manifesting with atypical pain syndromes, delay in proper diagnosis and unnecessary treatments can, unfortunately, cause prolonged patient suffering and increased cost of health care. As a result, some have proposed that spinal screening should be incorporated into clinical examinations involving false pain syndromes.

Effectiveness of accelerated diagnostic protocols for reducing emergency department length of stay in patients presenting with chest pain: A systematic review and meta-analysis.

In recent years, there has been an increase in the use of accelerated diagnostic protocols (ADPs) and high-sensitivity troponin assays (hsTn) for the assessment of chest pain in emergency departments (EDs). This study aimed to quantitatively summarize the operational and clinical outcomes of ADPs implemented for patients with suspected cardiac chest pain. To be considered eligible for inclusion, studies must have implemented some form of ADP within the ED for evaluating adult (age ≥18 years) patients presenting with chest pain using Tn assays. The primary outcome was ED length of stay (LOS). Secondary outcomes included the proportion of patients admitted and the proportion with 30-day major adverse cardiac events (MACE). Thirty-seven articles involving 404,566 patients met the inclusion criteria, including five randomized controlled trials (RCTs) and 32 observational studies. A significant reduction in total ED LOS was reported in 22 observational studies and four RCTs. Emergency departments with longer baseline ED LOS showed significantly larger reductions in LOS after ADP implementation. This observed association persisted after adjusting for both the change in serial Tn measurement interval and transition from conventional Tn assay to an hsTn assay (β = -0.26; 95% CI, -0.43 to -0.10). Three studies reported an increase in the proportion of patients admitted after introducing an ADP, one of which was significant while 15 studies reported a significant decrease in admission proportion. There was moderate heterogeneity among the 13 studies that reported MACE proportions, with a non-significant pooled risk ratio of 0.95 (95% CI, 0.86-1.04). Implementation of ADPs for chest pain presentations decreases ED LOS, most noticeably within sites with a high baseline LOS; this decreased LOS is seen even in the absence of any change in troponin assay type. The decrease in LOS occurred alongside reductions in hospital admissions, while not increasing MACE. The observed benefits translated across multiple countries and health regions.

Impact of admission glucose and 30-day major adverse cardiovascular events on patients with chest pain in an emergency setting: insights from the China EMPACT registry.

Although the association between admission glucose (AG) and major adverse cardiac events (MACE) is well-documented, its relationship with 30-day MACE in patients presenting with cardiac chest pain remains unclarified. In light of this, this study aims to examine the correlation between AG levels and the incidence of MACE in patients with chest pain in an emergency setting. We consecutively enrolled patients who presented to the emergency department for chest pain symptoms within 24 h from the EMPACT cohort in Eastern China (clinicaltrials.gov, Identifier: NCT02536677). The primary outcome was 30-day MACE, including all-cause death, recurrent myocardial infarction, urgent target vessel revascularization, stroke, cardiogenic shock, and cardiac arrest (CA). The associations of AG levels with 30-day MACE were analyzed using Kaplan-Meier analysis and Cox regression models. Among 1,705 patients who were included in this study, 154 (9.03%) patients met the primary outcome at 30 days. The average age of the patients was 65.23 ± 12.66 years, with 1,028 (60.29%) being male and 500 (29.33%) having diabetes. The median AG levels were 7.60 mmol/L (interquartile range: 6.30-10.20). Kaplan-Meier survival analysis revealed significant differences in the 30-day MACE risk (P < 0.001 according to the log-rank test). We found that the highest AG level (Q4) was associated with increased MACE risk compared with the lowest AG level [adjusted hazard radio (aHR): 2.14; 95% confidence interval (CI): 1.2-3.815; P = 0.010]. In addition, Q4 level was also associated with increased all-cause death risk (aHR: 3.825; 95% CI: 1.613-9.07; P = 0.002) and increased CA risk (aHR: 3.14; 95% CI: 1.251-7.884; P = 0.015). An elevated AG level significantly correlates with a higher incidence of 30-day MACE in patients with acute chest pain. The findings reveal the importance of managing AG levels to potentially reduce the risk of adverse cardiac events.

Post-Vaccine Myocarditis: Clinical Insights and Epidemiological Trends

Myocarditis is a rare but key adverse event linked to mRNA COVID-19 vaccines, predominantly in young males. Epidemiological data indicate an incidence of approximately 12.6 cases per million doses administered to patients aged 12-39 years, mostly following the second dose of the vaccine. Most patients present with elevated levels of cardiac biomarkers, chest pain, and abnormal ECG findings within a few days of vaccination. Proposed mechanisms for the exact pathophysiology of this include molecular mimicry between the SARS-CoV-2 spike protein and cardiac antigens, activation of immune pathways, and dysregulated cytokine expression. Despite these findings, the overall benefit-risk balance for COVID-19 vaccination remains positive, as the majority of patients recover fully. In contrast, COVID-19-associated myocarditis is more common and more severe, with an estimated incidence of 1,000-1,400 cases per 100,000 infections. Clinical presentation of vaccine-associated myocarditis is usually mild and self-limiting, and most patients do recover without significant long-term effects. Treatment is usually supportive in nature and has an emphasis on ruling out acute coronary syndrome and symptomatic management for heart failure or arrhythmias if present. Given its low incidence and the generally good outcome, vaccination against COVID-19 is recommended from 12 years of age and above, with provision for ongoing surveillance for monitoring and management of rare adverse events like myocarditis.

Optimal triage of patients with acute chest pain.

Acute chest pain (ACP) is one of the most common symptoms in patients admitted to emergency departments (ED). It can be related to several life-threatening cardiovascular conditions such as acute coronary syndrome (ACS), aortic dissection, and pulmonary embolism. The optimal triage of patients with ACP is a clinical and healthcare necessity given the large number of patients daily admitted to ED with this symptom. The first contact with the patient in ED includes the clinical appraisal of the characteristics of ACP and coexisting symptoms, and the assessment of the patient's medical history. Risk scores may help stratify a patient's likelihood of having cardiac chest pain. The ECG examination allows the identification of patients with ST-segment elevation, depression, or T-wave changes, but may be normal in patients with non-ST-segment elevation ACS. Rapid protocols based on serial high-sensitivity cardiac troponin assays within one or two hours are recommended for identifying candidates for early discharge. Due to the bedside feasibility, non-invasiveness, and wide availability, transthoracic echocardiography represents the first-line imaging modality for evaluating patients with ACP. In selected cases, computed tomography angiography may also be performed. A practical approach to ACP in ED should improve patient outcomes and reduce healthcare system costs. This review aimed to provide an overview of the characteristics of patients with ACP of cardiac origin and to describe the state of the art about their management in the ED.

A patient-centric chest pain management approach utilizing a high sensitivity Troponin-I assay

ObjectiveThe purpose of this study was to assess the impact of adoption of a new cardiac chest pain pathway that included hs-cTnI in the emergency department (ED) when evaluating chest pain patients. MethodsA new pathway incorporating both hs-cTnI testing (Seimens Healthineers Atellica) and risk stratification tools was developed. The impact of the new algorithm was assessed through a retrospective observational review of patients admitted to the ED with chest pain before implementation and after implementation. Before implementation, the conventional Seimens troponin Vista assay was utilized without a defined algorithmic approach. Bivariate analyses were performed comparing the time periods to determine differences in patient discharge dispositions, length of stay, outcomes, and rate of diagnostic cardiac catheterization. ResultsThe proportion of patients discharged from the ED increased while the proportion of patients placed in observation or admitted as in-patient decreased. Variation amongst providers regarding patient disposition decreased. The stress testing rate of patients placed in observation decreased over baseline. There was no change in 30-day MACE rate, but there was a decrease in 30-day MI rate. ConclusionsThe new standardized hs-cTnI algorithm approach is safe as demonstrated by no change in 30-day MACE and is also more appropriate and efficient for patients presenting to the ED with chest pain compared to the non-standardized approach with cTnI used previously.

Development of a Quality Evaluation Method for Allii Macrostemonis Bulbus Based on Solid-Phase Extraction–High-Performance Liquid Chromatography–Evaporative Light Scattering Detection Chromatographic Fingerprinting, Chemometrics, and Quantitative Analysis of Multi-Components via a Single-Marker Method

As a traditional Chinese medicine (TCM), Allii Macrostemonis Bulbus (AMB) is a key herb for the treatment of thoracic paralytic cardiac pain, but its quality evaluation method has not yet been fully clarified. In this study, chromatographic fingerprints of AMB were developed using solid-phase extraction–high-performance liquid chromatography–evaporative light scattering detection (SPE-HPLC-ELSD) to evaluate the quality of AMB from various origins and processing methods. This was achieved by employing chemical pattern recognition techniques and verifying the feasibility and applicability of the quality evaluation of AMB through the quantitative analysis of multi-components via a single-marker (QAMS) method. Through the analysis of the fingerprints of 18 batches of AMB, 30 common peaks were screened, and 6 components (adenosine, syringin, macrostemonoside T, macrostemonoside A, macrostemonoside U, and macrostemonoside V) were identified. Moreover, three differential markers (macrostemonoside A, macrostemonoside T, and macrostemonoside U) were screened out using chemometrics techniques, including principal component analysis (PCA), hierarchical cluster analysis (HCA), and orthogonal partial least squares discriminant analysis (OPLS-DA). Subsequently, a QAMS method was established for macrostemonoside T and macrostemonoside U using macrostemonoside A as an internal reference. The results demonstrate the method’s accuracy, reproducibility, and stability, rendering it suitable for the quality evaluation of AMB. This study provides a theoretical basis for drug quality control and the discovery of quality markers for AMB.

Implementation of a High-sensitivity Troponin Assay for Adult Patients Who Present to the Emergency Department: The Role of Clinical Decision Support

BackgroundThe objective of this study was to assess the health outcomes for patients who present to the emergency department (ED) with cardiac chest pain after the implementation of an accelerated diagnostic protocol using a high-sensitivity troponin assay (hs-TnI). MethodsThis prospective before-after cohort study used population-based linked health administrative data for adult patients who presented to a Canadian urban ED with chest pain of suspected cardiac origin over a 2-year study period. The primary outcome was ED length of stay (LOS). Secondary outcomes included operational and clinical outcomes within 30 days of the index ED visit. ResultsDuring the study period, 4339 patients were included, with 2031 in the conventional troponin group and 2308 in the hs-TnI group. Overall, the median age was 56 years and 52% were male. The median ED LOS was reduced from 430 minutes to 400 minutes after protocol implementation (median difference, -30.0; 95% confidence interval, -47.8 to -12.3). For discharged patients who underwent serial troponin tests, the LOS was 89 minutes shorter (95% confidence interval, -110.8 to -67.2). The proportion of patients discharged increased from 73% to 78% after implementation (P = 0.0001). At 30 days, there were no differences in hospital readmission or major adverse event outcomes. ConclusionsUsing clinical decision support, the implementation of a new hs-TnI and accelerated diagnostic protocol was associated with shorter ED LOS and fewer hospitalizations for adult patients with chest pain who were assessed in the ED. These results suggest that the protocol is effective and safe in real-world clinical settings.

Clinical Significance of Platelet Indices (Mean Platelet Volume and Mean Platelet Volume-to-lymphocyte Ratio) in Acute Coronary Syndrome: A Hospital-based Observational Study.

The role of platelet indices, such as mean platelet volume (MPV) and MPV-to-lymphocyte ratio (MPVLR), in diagnosing, and predicting the severity, and fatality in acute coronary syndrome (ACS) has not been extensively studied, particularly in Indian patients. Therefore, the study aimed to investigate the clinical significance of MPV and MPVLR in ACS. This hospital-based observational study was conducted from 2020 to 2022. It included 110 ACS cases and an equal number of age- and sex-matched controls with chest pain of noncardiac origin. The primary objective was to compare MPV and MPVLR in ACS patients and controls. Secondary objectives included examining the associations between MPV, MPVLR, and different ACS types, as well as their correlation with the global registry of acute coronary events (GRACE) risk score and inhospital major adverse cardiovascular events (MACE). Higher MPV and MPVLR were observed in ACS cases compared to controls [(11.1 ± 1.1 fL; 10.6 ± 1.3 fL, p < 0.01), (7.63 ± 4.9 fL/mm3; 4.74 ± 1.6 fL/mm3, p < 0.01) respectively]. Significant associations were found between platelet indices (MPV, MPVLR) and various ACS types (p < 0.01). Both indices positively correlated with the severity of heart failure, GRACE score, and inhospital MACE (p < 0.01). MPVLR showed a positive correlation with the duration of hospital stay [(r: 0.21; p = 0.03), but MPV did not (r: 0.13; p = 0.17)]. The GRACE score demonstrated the highest discriminating capacity in predicting inhospital mortality compared to platelet indices. Additionally, MPV serves as a more effective prognostic marker than MPVLR in predicting inhospital mortality. Both MPV and MPVLR are higher in ACS than in healthy individuals. Therefore, both may be used as discriminating markers for differentiating cardiac and noncardiac chest pain when cardiac biomarkers are not available. Additionally, both have good sensitivity for predicting the severity of the disease, inhospital mortality, and MACE in ACS.

Pain from Internal Organs and Headache: The Challenge of Comorbidity.

Headache and visceral pain are common clinical painful conditions, which often co-exist in the same patients. Numbers relative to their co-occurrence suggest possible common pathophysiological mechanisms. The aim of the present narrative review is to describe the most frequent headache and visceral pain associations and to discuss the possible underlying mechanisms of the associations and their diagnostic and therapeutic implications based on the most recent evidence from the international literature. The conditions addressed are as follows: visceral pain from the cardiovascular, gastrointestinal, and urogenital areas and primary headache conditions such as migraine and tension-type headache. The most frequent comorbidities involve the following: cardiac ischemic pain and migraine (possible shared mechanism of endothelial dysfunction, oxidative stress, and genetic and hormonal factors), functional gastrointestinal disorders, particularly IBS and both migraine and tension-type headache, primary or secondary dysmenorrhea and migraine, and painful bladder syndrome and headache (possible shared mechanisms of peripheral and central sensitization processes). The data also show that the various visceral pain-headache associations are characterized by more than a simple sum of symptoms from each condition but often involve complex interactions with the frequent enhancement of symptoms from both, which is crucial for diagnostic and treatment purposes.

SALT SENSITIVITY AND CHRONIC KIDNEY DISEASE IN PATIENTS WITH ARTERIAL HYPERTENSION: CLINICAL SYMPTOMS

The purpose of the research to assess the frequency of salt sensitivity and chronic kidney disease (CKD) in population of essential arterial hypertension (EAH) patients and some clinical symptoms based on salt sensitivity/salt resistance and CKD appearance.Material and methods. 100 patients with EAH II stage participated in the study. All participant underwent a complex of clinical and laboratory examinations. Salt sensitivity / salt resistance was determined by Weinberger M.H. based method. CKD was defined by glomerular filtration rate (GFR) according to the CKD-EPI equation taking into account creatinine and Cystatin-C blood level (KDIGO, 2024).Results. EAH patients with CKD (GFR ≤60 ml/min/1.73m2, for ≥3 months), as well as salt-sensitive patients, more often complain of breath’ shortness, cardiac pain - by 17.5-18.8% (р≤0.05-0.022), peripheral edema - by 41.7-52.1% (р&lt;0.001), headache and sleep impairment – by 24.2-32.0% (р≤0.016-0.001), rhythm and conduction disturbances – by 28.8- 34.1% (р≤0.004-0.001), show signs of depression – by 17.4-33.7% (р≤0.039-0.001). The risk of cardialgia, arrhythmias/blockades, signs of depression, suffocation, impaired sleep, headaches in EAH patients increases 2.4-4.2 times in salt-sensitive subjects (OR95%CI:1.0-10.33; p≤0.044), for CKD – 2.3-3.8 times (OR95%CI:1.04-8.86; p≤0.031). The probability of peripheral edema increases twice as much in salt-sensitive patients – almost 14 times (OR95%CI:4.73-41.06; p&lt;0.001), than in CKD patients – 6.3 times (OR95%CI:2.60-15.37; p&lt;0.001). The risk of gastrointestinal disorders increases almost three times (p=0.03) in salt-sensitive individuals and the CKD presence elevates the chances of fatigue and general weakness almost 4 times (p=0.001).Conclusion. Salt sensitivity and CKD appearance worsen the EAH clinical course.

Australia's first cardiac emergency department: Patient profile, activity and performance in the initial 6 months.

To profile the initial 6-month experience at the Victorian Heart Hospital (VHH) cardiac emergency (CE). The primary objective was to describe VHH CE patient characteristics, including presenting complaint, final diagnosis and disposition. Secondary objectives were to report on patient numbers, patient source and quality indicator performance including ambulance off-load by 40 min, waiting time and length of stay (LOS). A retrospective review included all patients who presented to the VHH CE from 9 March 2023 to 8 September 2023. Patient reports containing the relevant clinical information were generated from the CE electronic medical record system. Diagnoses of MI were checked for accuracy by full record review. There were 3303 CE presentations in the first 6 months of operation, of which 6% were transferred from other sites. Median age was 65 years (interquartile range [IQR]: 53-77), 56% were males; the most common presenting complaints were presumed cardiac chest pain (67%) and arrhythmia (17%). The admission, discharge and transfer rates were 38%, 54% and 8%, respectively. In total, 15% were diagnosed with MI. The most common diagnoses for discharged and admitted patients were non-specific chest pain (57%) and ST-elevation MI (22%), respectively. Ambulance off-load by 40 min was met for 96%. Median waiting time was 6 min (IQR: 3-10). Median CE LOS for discharged and admitted patients was 3.2 h (IQR: 2.5-4.0) and 3.7 h (IQR: 1.8-6.0), with 75% and 56% being <4 h, respectively. The population predominantly had cardiovascular disease as expected. Some performance indicators, including ED LOS, were identified as requiring intervention.

Effect of Fentanyl Compared to Morphine on Pain Score and Cardiorespiratory Vital Signs in Out-of-Hospital Adult STEMI Patients

Objective: ST-elevation myocardial infarction (STEMI) is a leading cause of mortality in Australia. Paramedics treating adults with STEMI in the out-of-hospital environment can use fentanyl or morphine to manage the patient’s pain, although there is little research comparing the efficacy and safety of these drugs. Therefore, the objective of this study was to compare the effects of fentanyl to morphine on cardiac chest pain and cardiorespiratory vital signs in adult STEMI patients in the out-of-hospital environment. Methods: We conducted a retrospective analysis of records of 1902 STEMI cases attended by Queensland Ambulance Service paramedics during the 4-year interval from 2013 to 2016. We compared pain score, blood pressure, respiratory rate, and pulse rate between patients administered intravenous fentanyl and intravenous morphine. We used a two-way mixed effects model (drug, time) to assess for main and interaction effects, and where the interaction effect was significant, applied Mann-Whitney U tests to further analyze between-group differences at each time point. Results: We observed a significant main effect of time on pain score (p &lt; 0.001), respiratory rate (p &lt; 0.05), and pulse rate (p = 0.025), such that these variables all decreased over time. Additionally, we observed a significant drug-time interaction for systolic and diastolic blood pressures (both p &lt; 0.01), such that blood pressures decreased over time in the morphine, but not fentanyl, group. Conclusion: We compared the effects of fentanyl to morphine on cardiac chest pain and cardiorespiratory vital signs in out-of-hospital adult STEMI patients and observed differences in blood pressures only. Morphine appeared to have a depressive effect on systolic and diastolic blood pressure, whereas fentanyl did not. An unanticipated behavioural finding of this research is that, in the absence of a definitive guideline, paramedics appear to use fentanyl when patients may be at risk of developing hypotension.