Chest Pain In Emergency Department Research Articles

Assessing modified HEART scores with high-sensitivity troponin for low-risk chest pain in the emergency department.

The accuracy of using HEART (history, electrocardiogram, age, risk factors, and troponin) scores with high-sensitivity cardiac troponin (hs-cTn) to risk stratify emergency department (ED) chest pain patients remains uncertain. We aim to compare the performance accuracy of determining major adverse cardiac event (MACE) among three modified HEART (mHEART) scores with the use of hs-cTn to risk stratify ED chest pain patients. This retrospective single-center observational study included ED patients with suspected acute coronary syndrome who had HEAR scores calculated and at least one hs-cTnI result. Various hs-cTnI parameters, including 99th percentile upper reference limit (URL, i.e., positive, ≥ 53ng/l for females and ≥ 78ng/l for males), limit of quantitation (LoQ, i.e., negative: < 20ng/l), and limit of detection (LoD, < 3ng/l), were used to calculate a troponin score (T-score). Patients with a T-score of 0 or mHEART score of 0-3 were considered low risk. The study compared the accuracy of different mHEART scores in predicting 30-day and 180-day MACE outcomes. A total of 10,495 patients were included, with 337 (3.21%) and 647 (6.16%) experiencing 30-day and 180-day MACE. The 30-day MACE rates were 0.53%, 1.37%, and 2.00% for patients whose hs-cTnI was beyond the cutoffs of LoD, LoQ, and URL, respectively. However, when low risk was defined as an mHEART score of 0-3, the 30-day MACE rates ranged from 0.33 to 0.62% across different mHEART scores. The mHEART score for risk stratification of low-risk chest pain patients shows acceptable accuracy in predicting MACE outcomes.

Valency of cystatin C and creatinine on troponin values in chronic kidney disease patients with chest pain in emergency department.

Chronic kidney disease (CKD) patients with chest pain (CP) should receive special attention in the emergency department (ED). Evaluating troponin levels is highly confusing. This study aims to compare Cystatin C (CysC) and creatinine on troponin results in CKD patients with CP in ED. A prospective cross-sectional study was conducted on 174 patients with CKD who were admitted to ED with CP and registered with clinicaltrials.gov (NCT05303441). Patients were risk classified. Blood samples were collected for 0th-hour, 1st-hour, and 3rd-hour troponin levels and admission CysC level. Then they were grouped as they were diagnosed with ACS or not. CKD-EPI formula was used to calculate Glomerular filtration rate (GFR) with creatinine, CysC and cyscrea for each patient (https://www.kidney.org/professionals/kdoqi/gfr_calculator). The overall rate of CKD stage change calculated with creatinine to another stage with CysC was 52.87% in all groups. There was a highly significant correlation between creatinine and CysC levels with 1st-hour and 3rd-hour troponin levels in both ACS and non-ACS groups (r=0.809 and 0.810, respectively; r=0.908 and 0.912, respectively). The prediction equations between creatinine, CysC, and troponin were as 0th-hour troponin=1.553+1.074creatinine and 0th-hour troponin=1.580+0.837cystatin C, respectively. 3rd-hour troponin level had a markedly good predictive power for ACS (AUC=0.813, p<0.001; sensitivity 74.7%, specificity 74.7%) with a cut-off value of 64.50. CysC can be preferable in CKD patients with CP due to the stage change and the decisive effect of CysC on troponin compared to creatinine in patients with and without ACS.

Outcomes of ED chest pain visits: the prognostic value of negative but measurable high-sensitivity cardiac troponin (hs-cTn) levels.

Chest pain is a common condition in the emergency department (ED). High-sensitivity cardiac troponin (hs-cTn) assays are crucial for diagnosing acute coronary syndrome, but the implications of "negative but measurable" hs-cTn levels are not well understood. This study assesses the outcomes of patients with acute chest pain discharged from the ED based on their hs-cTn levels. This retrospective cohort study analyzed medical records of patients aged 18 and older presenting with chest pain to the Tel Aviv Sourasky Medical Center ED from 2017 to 2022. We compared patients with negative but measurable hs-cTn levels (3-50 ng/L) to those with very low hs-cTn levels (< 3 ng/L). Primary outcomes included 90- days coronary angiogram (CAG), and secondary outcomes were 7- days ED revisits, 14-days hospital admissions, and 30- days mortality. Of 32,162 eligible patients, 23,297 had hs-cTn levels ≤ 50 ng/L. Patients with negative but measurable hs-cTn levels had higher rates of 90-days CAG (1.8% vs. 0.5%, p < 0.001), 7-day ED revisits (5.2% vs. 3.3%, p < 0.001), 14-day hospital admissions (3.1% vs. 0.9%, p < 0.001), and 30-day mortality (0.3% vs. 0.01%, p < 0.001) compared to those with very low hs-cTn levels. Independent predictors for 90 days CAG included age ≥ 57 years, male sex, and hs-cTn ≥ 3.5 ng/L. Negative but measurable hs-cTn levels are linked to worse outcomes than very low hs-cTn levels in discharged ED patients. Closer follow-up and further cardiac evaluation may be warranted for these patients.

Coagulation studies are frequently ordered in emergency department chest pain patients and do not change emergency department management

BackgroundDespite research findings, implementation into clinical practice is often delayed. Coagulation panels are still ordered as part of an emergency department (ED) chest pain evaluation, despite multiple studies showing that it is unnecessary and does not change management. ObjectiveOur primary outcome is to determine if the practice of ordering coagulation studies (PT/INR) is still occurring in ED chest pain patients. Our secondary outcome is to determine if abnormal results change management. MethodsWe performed an IRB approved retrospective chart review of patients with chest pain presenting to three rural-community EDs over 49 months. Medical students, blinded to the study intent, performed data abstraction using the approach of Gilbert and Lowenstein to determine if coagulation testing (PT/INR) was ‘indicated’ based on a preexisting condition (ie liver disease) or medication use (warfarin). Next, the data abstractors determined if the abnormal coagulation results prompted a therapeutic intervention or change in the management in the ED. ResultsWe randomly identified 1,200 patients with chest pain before covid-19 and, after exclusions, analyzed 830 patient charts. 440 patients (53.0%) had coagulation panels completed, but they were only indicated in 55 of the 440 patients (12.5%). Of the 385 patients without indications, 378 (98.2%) had an INR level in the normal range and 7 patients (1.8%) had an elevated INR. None of these 7 patients had a change in ED management. ConclusionsIn this multicenter study, 53% of ED patients with chest pain had coagulation studies ordered. Only 12.5% were indicated. None of the abnormal results changed management.

Concordance between cardiological interventions and artificial intelligence recommendations for patients presenting with chest pain, based on consultations from the emergency department to cardiology

Abstract Introduction The management of chest pain in emergency departments is a critical challenge. The integration of advanced artificial intelligence (AI) tools, such as pre-trained generative systems like ChatGPT, may present an opportunity to optimize this diagnostic process. This study investigates the effectiveness of AI in recommending diagnostic tests for patients presenting with chest pain, evaluating its concordance with clinical decisions by experienced cardiologists. Methods Retrospective observational study where 102 cases of patients with chest pain treated in the ED and assessed by Cardiology between January and March 2023 were reviewed. Chest pain was classified into high, medium and low probability. Data from emergency department to cardiology consultations were presented to ChatGPT, asking which diagnostic test it would recommend: conventional ergometry, coronary CT, imaging stress test, coronary angiography, or discharge. Various concordance indices, such as Simple Match and Tanimoto, among others, were used to evaluate the consensus between ChatGPT recommendations and cardiologists' decisions (table 2). Results Out of the 102 cases collected, 54% presented with high, 35% with medium and 11% with low probability chest pain. Table 1 summarizes the different proposals between the cardiologist and the AI. For patients with high probability chest pain, coronary angiography was the most commonly requested test, with a positive concordance of 77% according to the Simple Match index and 72% as per the Tanimoto coefficient. For other tests such as ergometry or imaging stress test, there were a 77% and 74% agreement, respectively, in not performing these tests, and there was an almost unanimous agreement (close to 100%) against discharging patients without conducting tests. Medium probability chest pain was more frequent and complex in its management. The decision to perform a coronary angiography agreed in 70% according to the Simple Match index and 72% with Tanimoto. The decision not to discharge patients directly without conducting tests showed a higher agreement at 89%. Other results were less precise. For low probability chest pain, there was a notable concordance (90%) in the decision not to perform diagnostic tests, such as imaging stress test, according to the Simple Match index. Conclusions - The AI achieves a notable concordance with cardiologists' decisions in the diagnostic approach of chest pain, particularly for patients with high probability chest pain, where the coronary angiography demonstrated good agreement. - Although AI cannot fully replace the clinical judgment of cardiologists in cases based on self-reported information, its utility as a supportive tool underscores the potential for its careful integration with medical expertise to enhance the diagnostic process. This implies the need for the development of specialized AI tools to better assist cardiologists in patient diagnosis.Table 1Table 2

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.

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.

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.

Churg-Strauss Syndrome Presenting with Pericarditis

Background Churg-Strauss syndrome (CSS) is a rare systemic vasculitis, that affects medium-sized vessels, involves multiple organs and in the majority of cases is related to asthma and eosinophilia. We report the case of a young woman with acute pericarditis. Case History A 22-year-old woman with a history of allergic rhinitis, asthma and nasal polyposis was admitted at our emergency department for chest pain and bilateral lower extremity weakness with paresthesia. Laboratory tests showed eosinophilia, elevated C-reactive protein (112 mg/dl) and elevated biochemical markers of myocardial injury (troponin 0.46 ng/ml). The electrocardiogram was negative. Transthoracic echocardiography revealed a small pericardial effusion with no other abnormalities. Hearth magnetic resonance imaging was permormed and confirmed a diagnosis of pericarditis. Immunologic study showed ANA and ANCA positive, in particular ANA 1:100, p-ANCA 134 U/l, and elevated IgE. Electromyography revealed sensory-motor symmetric axonal neuropathy. She had also arthritis of the right wrist. This presentation led to a diagnosis of CSS and appropriate therapy with corticosteroid, colchicine and mepolizumab resulted in a remission of disease activity. Discussion Physicians should thus be alert to the possibility of CSS as a differential diagnosis in patients presenting with pericarditis, whenever the clinical setting is appropriate.

Churg-Strauss Syndrome Presenting with Pericarditis

Churg-Strauss syndrome (CSS) is a rare systemic vasculitis, that affects medium-sized vessels, involves multiple organs and in the majority of cases is related to asthma and eosinophilia. We report the case of a young woman with acute pericarditis. Case History A 22-year-old woman with a history of allergic rhinitis, asthma and nasal polyposis was admitted at our emergency department for chest pain and bilateral lower extremity weakness with paresthesia. Laboratory tests showed eosinophilia, elevated C-reactive protein (112 mg/dl) and elevated biochemical markers of myocardial injury (troponin 0.46 ng/ml). The electrocardiogram was negative. Transthoracic echocardiography revealed a small pericardial effusion with no other abnormalities. Hearth magnetic resonance imaging was permormed and confirmed a diagnosis of pericarditis. Immunologic study showed ANA and ANCA positive, in particular ANA 1:100, p-ANCA 134 U/l, and elevated IgE. Electromyography revealed sensory-motor symmetric axonal neuropathy. She had also arthritis of the right wrist. This presentation led to a diagnosis of CSS and appropriate therapy with corticosteroid, colchicine and mepolizumab resulted in a remission of disease activity. Discussion Physicians should thus be alert to the possibility of CSS as a differential diagnosis in patients presenting with pericarditis, whenever the clinical setting is appropriate.

Frequency of non-st segment elevation myocardial infarction (NSTEMI) in acute coronary syndrome among patients presenting with the chest pain in emergency department of tertiary care hospital.

Objective: To determine the frequency of NSTEMI (non- st elevation myocardial infarction) in acute coronary syndrome patients presenting with the chest pain in emergency department of tertiary care hospital. Study Design: Cross Sectional study. Setting: Jinnah Post graduate Medical College Hospital Karachi. Period: June 20, 2023. Methods: Enrolling 112 consecutive volunteers was carried out Interview questions focused on the participants' smoking, blood pressure, diabetes, and type of chest pain. Whether or not the participants had ACS, their diagnosis was documented. NSTEMI frequency was computed. Results: We have 112 patients enrolled with mean age was 52.73±14.24 years. Sixty five (58%) were male while forty seven (41.9 %) were females. out of 112 patients 45 (40.1%) were hypertensive, 32(28.5%) were diabetes and 29 (25.8%) were smoker. Among the participants 21 (18.7%) had NSTEMI and showed positive correlation with age, gender, nature of chest pain, hypertension and smoking. Conclusion: Among the individuals, one of the most frequent causes of chest pain was acute coronary syndrome. High suspicion and additional testing are they key tools for early diagnosis and management.

The Impact of a High Sensitivity Troponin HEART Pathway Based Clinical Decision Protocol on Observation Visits.

Use of high-sensitivity troponin (hs-cTn) might lead to an increase in hospital observation visits due to higher number of abnormal troponin levels. To determine the impact of incorporating hs-cTn into a chest pain clinical decision protocol (CDP) on observation visits in a large academic health system. This is a retrospective observational cohort study of all chest pain observation patients in four hospitals in an academic health system over 24 months. All hospitals used the Beckman Coulter Unicel Dxi instrument, and all shared the same emergency department (ED) chest pain protocol, which used the HEART pathway and serial troponins and directed ED dispositions to either an observation stay, ED discharge, or inpatient admission. Outcomes studied before and after introduction of a hs-cTn protocol included daily chest pain observation census, cost, observation hours, and inpatient admit rate. Census was reported as the daily chest pain observation census and as a proportion of all observation visits. Data was retrieved from a health system data warehouse and a cost accounting program. There were 6,712 chest pain observation visits over 24-months, with 4,087 visits before and 2,634 visits after the hs-cTn protocol implementation. Comparison groups were similar in terms of age, gender, and type of insurance. There were 10.59 (95% CI: 10.24 - 10.95) daily chest pain observation visits before and 7.66 (95% CI: 7.34 - 7.97) visits after implementation, with a 28% (95% CI: 35% - 20%) decrease in the total daily census. As a portion of all observation visits, there was a 22% drop in the proportion that were observed for chest pain. The daily number of chest pain patients requiring inpatient admission was unchanged. The daily total direct cost for chest pain observation decreased with an effective daily cost savings of $4,313 USD (95% CI: $1,534 - $6,998). The total daily number of chest pain observation bed hours also decreased by 41.5 hours (95% CI 13.4 - 96.4 hr). Implementation of a hs-cTn chest pain protocol was associated with a significant decrease in the number and proportion of observation visits, a decrease in total daily cost and bed hours used, and no increase in inpatient admissions.

Diagnostic testing for chest pain in a pediatric emergency department and rates of cardiac disease before and during the COVID-19 pandemic: a retrospective study.

Chest pain is a common chief complaint in pediatric emergency departments (EDs). Coronavirus disease-2019 (COVID-19) has been shown to increase the risk of cardiac disease. It remains unclear how COVID-19 changed how pediatric emergency clinicians approach patients presenting with chest pain. The goal of this study was to characterize the diagnostic testing for chest pain in a pediatric ED before and during the COVID-19 pandemic. This was a retrospective study of children between the ages of 2-17 years presenting to a pediatric ED from 1/1/2018-2/29/2020 (Pre-COVID-19) and 3/1/2020-4/30/2022 (COVID-19) with chest pain. We excluded patients with a previous history of cardiac disease. Of the 10,721 encounters during the study period, 5,692 occurred before and 5,029 during COVID-19. Patient demographics showed minor differences by age, weight, race and ethnicity. ED encounters for chest pain consisted of an average of 18% more imaging studies during COVID-19, including 14% more EKGs and 11% more chest x-rays, with no difference in the number of echocardiograms. Compared to Pre-COVID-19, 100% more diagnostic tests were ordered during COVID-19, including cardiac markers Troponin I (p < 0.001) and BNP (p < 0.001). During COVID-19, 1.1% of patients had a cardiac etiology of chest pain compared with 0.7% before COVID-19 (p = 0.03). During COVID-19, pediatric patients with chest pain underwent more diagnostic testing compared to Pre-COVID-19. This may be due to higher patient acuity, emergence of multisystem inflammatory syndrome in children (MIS-C) that necessitated more extensive testing and possible changes in ED clinician behavior during COVID-19.

A Single High-Sensitivity Cardiac Troponin T Strategy for Ruling Out Myocardial Infarction.

Ruling out acute myocardial infarction (AMI) in the emergency department (ED) is challenging. Studies have shown that a high-sensitivity cardiac troponin T (hs-cTnT) <5 ng/L or <6 ng/L at presentation (0 h) can be used to rule out AMI. The objective of this study was to identify whether an even higher hs-cTnT threshold can be used for a safe rule out of AMI in the ED. The derivation cohort consisted of 24,973 ED patients with a primary complaint of chest pain. In this cohort, we identified the highest concentration of 0 h hs-cTnT that corresponded to a negative predictive value (NPV) of ≥99.5% for the primary endpoint of AMI/all-cause death within 30 days and the secondary endpoint of all-cause death within one year. The results were validated in two cohorts consisting of 132,021 and 1167 ED chest pain patients. The 0 h hs-cTnT threshold corresponding to a NPV of ≥99.5% for the primary endpoint was <9 ng/L (NPV: 99.6% and 95% CI: 99.5-99.7). This cutoff provided a sensitivity of 96.2% (95% CI: 95.2-97.1) and identified 59.7% of the patients as low risk compared to 35.8% and 43.9% with a 0 h hs-cTnT <5 ng/L and <6 ng/L, respectively. The results were similar in the validation cohorts and seemed to perform even better in patients where the 0 h hs-cTnT was measured >3 h after symptom onset and in those with a nonischemic ECG and nonhigh risk history. A 0 h hs-cTnT cutoff of <9 ng/L safely rules out AMI/death within 30 days in a majority of chest pain patients and is a more effective strategy than the currently recommended <5 ng/L and <6 ng/L cutoffs. This trial is registered with NCT03421873.

Improvement of Emergency Department Chest Pain Evaluation Using Hs-cTnT and a Risk Stratification Pathway

BackgroundChest pain is among the most common reasons for presentation to the emergency department (ED) worldwide. Additional studies on most cost-effective ways of differentiating serious vs. benign causes of chest pain are needed. ObjectivesOur study aimed to evaluate the effectiveness of a novel risk stratification pathway utilizing 5th generation high-sensitivity cardiac troponin T assay (Hs-cTnT) and HEART score (History, Electrocardiogram, Age, Risk factors, Troponin) in assessing nontraumatic chest pain patients in reducing ED resource utilization. MethodsA retrospective chart review was performed 6 months prior to and after the implementation of a novel risk stratification pathway that combined hs-cTnT with HEART score to guide evaluation of adult patients presenting with nontraumatic chest pain at a large academic quaternary care ED. Primary outcome was ED length of stay (LOS); secondary outcomes included cardiology consult rates, admission rates, number of ED boarders, and number of eloped patients. ResultsA total of 1707 patients and 1529 patients were included pre- and postimplementation, respectively. Median overall ED LOS decreased from 317 to 286 min, an absolute reduction of 31 min (95% confidence interval 22–41 min), after pathway implementation (p < 0.001). Furthermore, cardiology consult rate decreased from 26.9% to 16.0% (p < 0.0001), rate of admission decreased from 30.1% to 22.7% (p < 0.0001), and number of ED boarders as a proportion of all nontraumatic chest pain patients decreased from 25.13% preimplementation to 18.63% postimplementation (p < 0.0001). ConclusionsImplementation of our novel chest pain pathway improved numerous ED throughput metrics in the evaluation of nontraumatic chest pain patients.

Acute chest pain... Where?

Acute chest pain is a common symptom in emergency medicine. Approaching acute chest pain in emergency departments is a challenge epidemiologically, clinically and organizationally [1]. This symptom requires increased attention from medical professionals, this requiring a primary and careful evaluation for patient, imagining and paraclinical investigations. Attention should also be paid to cardiovascular risk factors (age, high blood pressure, smoking, pre-existing cardiovascular disease, obesity) [2]. In emergency medicine, primary assessment consists of ABCDE evaluation (1. Airway, 2. Breathing, 3. Circulation, 4. Disability, 5. Exposure) [3].

Syntropy - gastroesophageal reflux disease and ischemic heart disease - diagnostic methods and treatment tactics

Introduction. Studies describe chest pain as the common symptom for the association of gastroesophageal reflux disease (GERD) and coronary artery disease (ICD). Among the patients evaluated at the emergency department for chest pain &gt;50% do not show signs of coronary ischemia and require further investigation. Materials and methods. The study was carried out by searching the articles that were published in the period 2016-2023, using the PubMed, NCIB, Medscape, Mendeley databases, using the keywords: „GERD”, „coronary artery disease”, „diagnosis” , „treatment”, as well as their association. Results. Both nosologies are clinically manifested by chest pain caused by gastrointestinal acid irritation, which activates the vagal reflex, and endothelial dysfunction, which causes ischemia and coronary vasoconstriction. Paraclinical findings are characterized by increased levels of IL1,6,8 and NO metabolites involved in disease pathogenesis. ECG and pH measurement for 24 h are sufficient at the first stage to determine the cause of attacks of recurrent chest pain. PPIs are the first line of treatment for chest pain relief in these patients. Conclusions. GERD and BCI represent diseases with a global impact, and the interdisciplinary therapeutic approach of these diseases, culminating in a targeted treatment program, determines the improvement of symptoms with an improvement of the patient’s quality of life.

Prior electrocardiograms not useful for machine learning predictions of major adverse cardiac events in emergency department chest pain patients

At the emergency department (ED), it is important to quickly and accurately determine which patients are likely to have a major adverse cardiac event (MACE). Machine learning (ML) models can be used to aid physicians in detecting MACE, and improving the performance of such models is an active area of research. In this study, we sought to determine if ML models can be improved by including a prior electrocardiogram (ECG) from each patient. To that end, we trained several models to predict MACE within 30 days, both with and without prior ECGs, using data collected from 19,499 consecutive patients with chest pain, from five EDs in southern Sweden, between the years 2017 and 2018. Our results indicate no improvement in AUC from prior ECGs. This was consistent across models, both with and without additional clinical input variables, for different patient subgroups, and for different subsets of the outcome. While contradicting current best practices for manual ECG analysis, the results are positive in the sense that ML models with fewer inputs are more easily and widely applicable in practice.

Clinical efficacy of Kuanxiong aerosol for patients with prehospital chest pain: A randomized controlled trial

BackgroundKuanxiong Aerosol (KXA)(CardioVent®), consisting of Asarum sieboldii Miq. oil, Santalum album L. oil, Alpinia officinarum Hance oil, Piper longum L. oil and borneol, seems to relieve the symptoms of chest pain and serve as a supplementary treatment for prehospital chest pain in emergency department. Style of the studyThis randomized controlled trial aimed to determine the clinical effect and safety of KXA for patients with prehospital chest pain. MethodsA total of 200 patients were recruited from Guangdong Provincial Hospital of Chinese Medicine and randomly divided into KXA group (n = 100) and Nitroglycerin Aerosol (NA) group (n = 100) by SAS 9.2 software. All patients were treated with standardized Western medicine according to the pre-hospital procedure. The experimental group and NA group was additionally treated with KXA and NA respectively. The primary outcome was the relieving time of prehospital chest pain (presented as relief rate) after first-time treatment. The secondary outcomes included the evaluation of chest pain (NRS scores, degree of chest pain, frequency of chest pain after first-time treatment), efficacy in follow-up time (the frequency of average aerosol use, emergency department visits, 120 calls, medical observations and hospitalization at 4 weeks, 8 weeks, 12 weeks), alleviation of chest pain (Seattle angina questionnaire, chest pain occurrence, and degree of chest pain at 12-weeks treatment) and the change of TCM symptoms before and after 12-weeks treatment. In addition, the safety of KXA was also assessed by the occurrence of adverse events. The database was created using Epidata software, and statistical analysis was conducted by SPSS 23.0 software. ResultsA total of 194 participants finally completed the trial, the results showed that after first-time treatment, KXA had a higher relief rate (72.2%) of chest pain within 30 min than that of NA group (59.4%, p = 0.038), KXA group had a lower degree of chest pain (p = 0.005), lower NRS score (p = 0.011) and higher reduction of NRS score (p = 0.005) than the NA. In the follow-up period, KXA group decreased the frequency of 120 call better than that of NA group at 4 weeks (p = 0.040), but KXA had a similar efficacy as NA in the improvement on the of frequency of chest pain, aerosol use, emergency department visits, 120 call, medical observation and hospitalization at 4 weeks, 8 weeks and 12 weeks (p>0.05). There also had no difference between the two groups on the occurrence of chest pain, degree of chest pain, physical limitation, angina stability, treatment satisfaction, and disease perception between the two groups at 12 weeks (p>0.05). In addition, KXA and NA both improved the patient's chest pain, but not the TCM symptoms. In terms of safety, KXA showed similar safety as NA in this study. ConclusionsKXA relieved prehospital chest pain faster than NA and had a better remission effect on the prehospital chest pain than that of the NA group in short-period. In long-period, KXA showed similar efficacy on the improvement of prehospital chest pain as NA. KXA may be a safe and reliable therapy for prehospital chest pain.

Coronary vasomotor disorders in ANOCA patients: insights from the CADOSA registry

Abstract Background Patients with Angina and Non-Obstructive Coronary Arteries (ANOCA), require further investigation to elucidate the underlying cause of their symptoms (i.e. functional coronary angiography to assess the presence of coronary vasomotor disorders) but are frequently discharged with the non-diagnostic label of ‘unspecified chest pain’. Purpose To compare the 3-year clinical outcomes (mortality and readmission) in ANOCA patients with a ‘coronary vasomotor disorder’ diagnosis with those discharged with an ‘unspecified chest pain’ diagnosis. Methodology Using the CADOSA (Coronary Angiogram Database of South Australia) registry, consecutive patients undergoing coronary angiography between 2012-2018 were included. Among 8,932 symptomatic patients undergoing elective angiography, 2,245 were ANOCA (stenosis &amp;lt;50%) patients. Of this cohort, 170 (8%) had documented coronary vasomotor diagnosis (vasospastic angina 3% and microvascular angina 5%), and the remaining 2,075 (92%) were discharged with ‘unspecified chest pain’. Results In the overall ANOCA cohort (n=2,245, 61±11 years, 59% female) only 6% underwent functional coronary angiography. Compared to the unspecified chest pain cohort, those with a coronary vasomotor disorder diagnosis were (a) younger (61±11 vs 58±11, p&amp;lt;0.05), (b) more often to present to the emergency department with chest pain in the year prior to their coronary angiogram (19% vs 35%, p&amp;lt;0.05), (c) more likely prescribed anti-ischaemic medications at discharge (74% vs 88%, p&amp;lt;0.05), but (d) less likely to be discharged with cardioprotective medications (81% vs 73%, p&amp;lt;0.05). At 3-year follow-up, all-cause mortality was similar between those with coronary vasomotor diagnosis and those with unspecified chest pain (1% vs 2%, p&amp;gt;0.05), but those with a coronary vasomotor disorder were more likely to (i) present to the emergency department for chest pain (38% vs 16%) and (ii) be readmitted for chest pain (29% vs 10%), compared to those with unspecified chest pain, all p&amp;lt;0.05. Conclusion In this analysis of real-world practice, few ANOCA patients undergo functional angiography. Consequently, many ANOCA patients are discharged without thorough investigation to aid in appropriate diagnosis. Even when a diagnosis is made, ongoing symptom burden is severe. This study highlights the need to both appropriately investigate and identify patients at high risk for ongoing high symptom burden so treatment can be personalised to optimise management.