Chest Pain Of Cardiac Origin Research Articles

Effect of a High-Sensitivity Troponin I and Associated Diagnostic Protocol on Emergency Department Length of Stay: A Retrospective Cohort Study

BackgroundThe objective of this study was to assess the introduction of a high-sensitivity troponin I (hs-TnI) assay and its associated accelerated protocol on emergency department (ED) length of stay (LOS) for patients presenting with chest pain, compared to an accelerated diagnostic protocol using conventional troponin (TnI) testing. MethodsWe conducted a retrospective cohort study of all adults with a primary presenting complaint of chest pain of cardiac origin and a Canadian Triage and Acuity Scale score of 2 or 3, between November 8, 2019 and November 9, 2021, to a tertiary-care urban Canadian ED. The primary outcome was ED LOS. Secondary outcomes included consultation proportions and major adverse cardiac events within 30 days of the index ED visit. ResultsA total of 2640 patients presenting with chest pain were included, with 1333 in the TnI group and 1307 in the hs-TnI group. Median ED LOS decreased significantly, from 392 minutes for the TnI group, and 371 minutes for the hs-TnI group (median difference = 21 minutes; 95% confidence interval: 5.3, 36.7). The numbers of consultations and admissions were not statistically different between study periods. The major adverse cardiac events outcomes did not change following the implementation of the hs-TnI test (13.6% vs 13.1%; P = 0.71). ConclusionsThe implementation of an accelerated chest pain protocol using an hs-TnI assay in a tertiary-care Canadian ED was associated with a modest reduction of LOS for all patients, and a substantial reduction of LOS for patients undergoing serial troponin testing. This strategy was safe, with no increase in adverse outcomes.

Characteristics of Chest Pain Associated with Other Symptoms Experienced by Coronary Artery Disease Patients

Cardiovascular diseases (CVDs) take the lives of 17.7 million people every year, 31 percent of all global deaths. There is considerable overlap in chest pain of cardiac as well as non-cardiac origin. However, vigilant evaluation of characteristics of chest pain in history taking may help overcome this dilemma. This study was sought to identify characteristics of chest pain associated with other symptoms which are due to cardiac reason and to fi nd out association between characteristics of chest pain and other symptoms with the selected demographic variables. The study was conducted among 60 patients of coronary artery disease (CAD). Characteristics of chest pain associated with other symptoms were assessed by structured questionnaires administered through interview schedule. In this study, 40 percent samples had pain on retrosternal side and 20 percent on left side of chest, while 31.67 percent samples had pain location other than retrosternal and left side of chest; 46.67 percent samples had characterized their pain as heaviness, 30 percent as chocking, 20 percent felt burning pain; 42 percent had pain duration of 1-30 minutes, 77 percent samples had pain severity >7 on 0-10 scale, 41.67 percent samples had pain radiation to left arm, 20 percent on right arm, 25 percent to neck, 20 percent having no radiation of pain. 73.33 percent samples had diaphoresis as associated symptoms, 58.33 percent had dyspnea, 53.33 percent had nausea & vomiting, 60 percent had weakness/fatigue. To conclude, chest pain of cardiac origin can occur anywhere in chest and abdomen, which is usually severe in nature and characterised by chocking and heaviness usually associated with nausea, dyspnea, diaphoresis and weakness. So, patient should be carefully evaluated to prevent mis-diagnosis.

Significant reduction in the visits to the emergency room department during the COVID-19 pandemic in a tertiary hospital in Greece: Indirect victims of the pandemic?

COVID-19 pandemic caused a major crisis, affecting and straining health care systems, including some very advanced ones. The pandemic may have also indirectly affected access to health care for patients with other conditions, not related to COVID-19, even in countries not overwhelmed by an outbreak.We analyzed and compared visits to the emergency room (ER) department during the same calendar period of 2019 and 2020 (from March 1 to March 31 of each year) in our hospital, a medium size, tertiary center, located in the center of Athens, which is not a referral center for COVID-19.Total ER visits were reduced by 42.3% and the number of those requiring hospitalization by 34.8%. This reduction was driven by lower numbers of visits for low risk, non-specific symptoms and causes. However, there was a significant decrease in admissions for cardiovascular symptoms and complications (chest pain of cardiac origin, acute coronary syndromes, and stroke) by 39.7% and for suspected or confirmed GI hemorrhage by 54.7%. Importantly, number of ER visits for infections remained unchanged, as well as the number of patients that required hospitalization for infection management; only few patients were diagnosed with COVID-19.During the initial period of the pandemic and lock-down in Greece, there was a major decrease in the patients visiting ER department, including decrease in the numbers of admissions for cardiovascular symptoms and complications. These observations may have implications for the management of non-COVID-19 diseases during the pandemic.

Evaluation of Plasma Fibrillin-1 Fragment Levels in Patients Without Aortic Pathology

Fibrillin-1 is a structural component muscular arteries, and plasma fibrillin-1 fragment levels (PFFLSs) are detectable in patients with aortic dissections and thoracic aortic aneurysms. However, little is known regarding PFFLSs in patients without aortic pathology or in patients with other cardiovascular conditions, thereby limiting its use as a biomarker for aortic pathology. We sought to determine the detectability and concentration of PFFLSs in patients without aortic pathology who present with acute chest pain of cardiac and noncardiac origin. Three hundred patients older than 18 years presenting to the emergency department with chief complaint of chest pain were prospectively enrolled. Patients with aortic pathology, malignancy, or postoperative pain were excluded from analysis. Demographic data, medical comorbidities, and the determined cause of chest pain was determined from the electronic medical record. PFFLSs were determined using a modified sandwich enzyme-linked immunosorbent assay with biotinylated capture antibodies and alkaline phosphatase-conjugated detector antibodies. Patients were categorized into three groups based on the cause of chest pain: group 1, ischemic cardiac chest pain (ICCP), group 2, non-ICCP (NICCP), and group 3, noncardiac chest pain (NCCP). The ICCP group consisted of patients presenting with myocardial infarction or angina. The NCCP included patients presenting with arrhythmia, heart failure, hypertensive urgency, and pericarditis/myocarditis/endocarditis. Differences in categorical variable were assessed using Fisher’s exact test and differences in continuous variables were assessed using Kruskal-Wallis test and Wilcoxon rank-sum test as appropriate. Two hundred sixty-five patients (135 men and 130 women) were included in the analysis. The cause of chest pain was determined to be ICCP in 30 patients, NICCP in 39 patients, and NCP in 196 patients. Detectable PFFLSs were found in 192 (72%) patients and detectability did not differ between genders or diagnosis groups (P = .74). Mean PFFLSs are lower in the ICCP group compared to the NICCP and NCCP groups (0.19, 0.38, and 0.56 μg/mL, respectively; P < .013). PPFLs were lower in ICCP patients with diabetes and there was a trend toward lower PPFLs in men in the ICCP group (Tables I and II). PFFLS are detectible in the majority of all patients presenting with chest pain. PFFLS are lower in patients presenting with ICCP. In patients presenting with chest pain of cardiac origin (ICCP and NICCP), PFFLSs are lower in men and patients with diabetes. Further characterization of PFFLs in patients with and without cardiovascular disease and risk factors has the potential to lead to biomarker development and mechanistic insights into cardiovascular disease development.Table IMean and interquartile values of plasma fibrillin-1 fragment levels by diagnosis groupPFFL (μg/mL)ICCP (n = 30)NICCP (n = 39)NCCP (n = 196)25th percentile00050th percentile0.020.060.0875th percentile0.060.160.23Mean0.19a0.380.56Standard deviation0.830.961.9ICCP, Ischemic cardiac chest pain; NCCP, noncardiac chest pain; NICCP, nonischemic cardiac chest pain; PFFL, plasma fibrillin-1 fragment level.aP < .013. Open table in a new tab Table IIMedian and interquartile plasma fibrillin-1 fragment levels categorized by diagnosis group, gender and presence of diabetes mellitus (DM)PPFL (μg/mL)ICCP (n = 30)NICCP (n = 39)NCCP (n = 196)DM 25th percentile0.0100.03 50th percentile0.030.040.13 75th percentile0.070.380.36 Mean0.04a0.160.55 SD0.040.221.2No DM 25th percentile000 50th percentile0.010.040.07 75th percentile0.040.380.21 Mean0.290.160.57 SD1.10.222.0Male 25th percentile000 50th percentile0.020.060.08 75th percentile0.080.160.22 Mean0.05b0.240.47 SD0.070.381.7Female 25th percentile000 50th percentile0.010.030.07 75th percentile0.040.080.23 Mean0.520.570.4 SD1.51.32.0ICCP, Ischemic cardiac chest pain; NCCP, noncardiac chest pain; NICCP, nonischemic cardiac chest pain; PFFL, plasma fibrillin-1 fragment level; SD, standard deviation.aP < .05 compared to patients with DM in the NICCP and NCCP groups.bP < .07 compared to patients with men in the NICCP and NCCP groups. Open table in a new tab

Follow-up study of patients admitted to the pediatric emergency department for chest pain.

Chest pain is a relatively common cause of admission to the Emergency Department, being related in most of the cases to benign conditions with only a minority of the cases affected by heart disease. Limited data are available about the follow up of these patients in terms of risk of recurrence of symptoms, Emergency Department re-admissions, level of impairment, and school absenteeism. We identified 761 children who visited our ED with the chief complaint of chest pain, equal to 0.68% of all admissions. Twenty-four patients were excluded for a previous history of cardiac disease. Eight (1%) patients were determined to have chest pain of cardiac origin. Ninety-seven percent of patients were successfully contacted by telephone: 69% agreed to answer the questionnaire. Of these, 33% experienced recurrent chest pain, up to 41% was forced to be absent from school, about 20% was limited in its daily activities, and about 20% repeated a cardiologic evaluation.Conclusion: Chest pain is mainly due to benign causes and is a recurrent symptom in a high percentage of patients, associated with re-admission and school absenteeism.What is Known:• Chest pain is a relatively common cause of admission to the Emergency Department.• It is mainly due to benign causes and is among the most common reasons for referral to the pediatric cardiologist.What is New:• Chest pain is a recurrent symptom associated with re-admission and school absenteeism.• As a family history of cardiac disease or exertional symptoms are a well-known red flag for chest pain of cardiac origin, school absenteeism should be considered a red flag for symptoms related to psychological distress in patients with non-cardiac chest pain.

Abstract P209: Trends in Presenting Symptoms Among Acute Myocardial Infarction Patients in Community Surveillance: the Atherosclerosis Risk in Communities Study

Introduction: Recent research shows changing incidence rates of AMI by subtype (ST segment elevation [STEMI] and non-ST segment elevation [NSTEMI]), anatomical location, and severity. However, trends in AMI symptom presentation are less well examined. Not all AMI patients present with classic chest pain of cardiac origin. Presentation without cardiac chest pain has been associated with delayed hospital arrival, lower likelihood of receiving medical therapies and cardiac procedures, and higher mortality, as well as female sex, black race/ethnicity, and diabetes. Objective: We examined trends in symptom presentation in subsets of STEMI and NSTEMI by sex and race in the community surveillance of the ARIC Study from 2005 to 2014. Methods: Poisson regression was used to estimate sex- and race-specific event rates for AMI with and without classic chest pain of cardiac origin stratified by NSTEMI and STEMI. Events were defined as definite or probable MI with an assigned NSTEMI or STEMI subtype. Event rates were age-standardized to the US 2010 Census population. We examined average annual percent change in event rates over time, and compared comorbidities, in-hospital complications, and 28-day case-fatality of CHD death by symptom presentation, sex, and race, evaluating heterogeneity between sex and race via interaction terms. All analyses were weighted using ARIC sampling fractions. Results: Between 2005 and 2014, we observed 12,184 AMI events without classic chest pain and 39,512 events with classic chest pain. Events without chest pain were more often NSTEMI vs. STEMI (22% vs. 13%). The decline in event rates over time was similar among NSTEMI patients regardless of presentation symptoms; however, this decline was greater among STEMI patients without classic cardiac pain (-8.03, 95% CI: -10.12, -5.89) than among STEMI patients presenting with classic cardiac pain (-3.02, 95% CI: -4.83, -1.18). The average annual percent decline in event rates differed by race for STEMI but not NSTEMI. Presentation without classic cardiac chest pain was associated with comorbidities such as diabetes, as well as in-hospital complications in both NSTEMI and STEMI patients. Twenty-eight-day case fatality was greater among STEMI patients presenting without classic cardiac chest pain (9.4%, 95% CI: 5.8, 12.9) compared to those with classic cardiac chest pain (4.8%, 95% CI: 3.7, 5.9). Conclusion: AMI without classic chest pain comprised a larger percent of NSTEMI than STEMI events, and while event rates declined over 2005 to 2014, AMI without classic cardiac chest pain was associated with greater 28-day case fatality and in-hospital complications. Future research should explore care pathways and other reasons why these outcomes may differ by cardiac pain presentation.

CRYPTIC CHEST PAIN: WELLEN’S SYNDROME DUE TO MYOCARDIAL BRIDGING

SESSION TITLE: Cardiovascular Disease 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Chest pain of cardiac origin is commonly ischemic in etiology. However, the phenomenon of myocardial bridging as a cause of chest pain has come to attention recently. Herein, an epicardial coronary artery develops a transient myocardial course. During systole, a portion of the vessel is mechanically compressed and results in ischemia. This has been attributed to as a rare cause of angina. Here we present our experience with a patient who was diagnosed with the same. CASE PRESENTATION: A 51 year old man with no past medical history, presented to the emergency room with pressure like chest pain of two days duration. He had multiple episodes of pain and each lasted for around 20 minutes. It was associated with palpitations, and exacerbated by physical exertion. He was a former smoker and reportedly quit smoking 20 years back. His blood pressure was 153/95 mmHg; temperature 98.1F; heart rate 73/min regular; respiratory rate 18/min. ECG showed Type 1 Wellen's biphasic pattern in V2, V3. Three sets of cardiac troponins were normal. Wellens pattern on ECG is highly specific (89%) for critical left anterior descending artery (LAD) stenosis. [1] [2]. Therefore, the patient was sent for emergent cardiac catheterization. Coronary angiography revealed normal left main, left circumflex and right coronary artery. However, LAD artery showed moderate myocardial bridging. DISCUSSION: In myocardial bridging, a coronary artery that normally runs on the epicardium, develops a transient intra-myocardial course. This section of the artery gets compressed during ventricular systole. Generally asymptomatic, bridging sometimes results in angina, arrhythmias myocardial ischemia. Most myocardial bridging has been found to occur in the middle portion of the LAD artery. However, on autopsy right coronary and left circumflex arteries have shown bridging at comparable rates. [3]. Proximal portion of the bridged segment is prone to accelerated atherosclerosis.Hypertrophic obstructive cardiomyopathy (HOCM) has shown increased association with myocardial bridging. Treatment is with beta blockers and non-dihydropyridine calcium channel blockers. Therapeutic benefit results from decreased chronotropy and inotropy. In cases refractory to medical management, surgical myotomy, coronary artery stenting or coronary artery bypass grafting (CABG) can be pursued. Our patient was started on aspirin, amlodipine, metoprolol, and rosuvastatin. His hospital course was uneventful and he was discharged on pharmacological therapy. CONCLUSIONS: Myocardial Bridging is being recognized increasingly as a cause of refractory angina. However, it is still not widely included as a differential diagnosis. Since the treatment is fairly specific, we wish to underscore the importance of recognizing myocardial bridging as an atypical cause of chest pain. Reference #1: C. de Zwaan, F.W. Bar, H.J. Wellens. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J, 103 (1982), pp. 730-736. Reference #2: C. de Zwaan, F.W. Bar, J.H. Janssen, et al. Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. . Am Heart J, 117 (1989), pp. 657-665. Reference #3: Polacek P, Kralove H. Relation of myocardial bridges and loops on the coronary arteries to coronary occlusions. Am Heart J. 1961;61:44-52 DISCLOSURES: No relevant relationships by Paurush Ambesh, source=Web Response No relevant relationships by Stephan Kamholz, source=Web Response No relevant relationships by Dikshya Sharma, source=Web Response No relevant relationships by Ankur Sinha, source=Web Response

Stable Coronary Syndromes: The Case for Consolidating the Nomenclature of Stable Ischemic Heart Disease

Angina pectoris, first described by William Heberden in the Royal College of Physicians, London, in 1768, is chest pain of cardiac origin. Despite being a symptom, angina is a disease-based diagnosis ( International Classification of Diseases , I20). Practice guidelines use somewhat different terms. The nomenclature of the American guidelines includes chronic stable angina (2002) and stable ischemic heart disease (2012), whereas the guidelines of the European Society of Cardiology (2013) refer to stable coronary artery disease. Thus, there are multiple terms and abbreviations for stable ischemic heart disease and cohesion is lacking. By contrast, acute coronary syndrome is a unifying hierarchical term that subtends the distinct subgroups of unstable angina and myocardial infarction and is used consistently worldwide. The established diagnostic pathways for patients with suspected angina have been appropriately developed to identify obstructive coronary artery disease (CAD) with a view to evidence-based treatment. In recent years, however, multiple clinical studies have disclosed that more than one-third of symptomatic patients do not have obstructive CAD.1 Furthermore, ischemia may be substantial in this subgroup, and the prognosis is not benign.2 Exclusion of obstructive CAD in a patient with angina presents a conundrum. Angina without obstructive CAD may be frustrating for the patient and the clinician, and, in the absence of a unifying diagnosis, treatment becomes empirical and potentially suboptimal. The lack of evidence from randomized controlled clinical trials in this …

Assessing sensitivity and specificity of the Manchester Triage System in the evaluation of acute coronary syndrome in adult patients in emergency care: a systematic review protocol.

REVIEW QUESTION / OBJECTIVE The objective of this review is to assess the sensitivity and specificity of the Manchester Triage System in the evaluation of adult patients with acute coronary syndrome in emergency departments. INCLUSION CRITERIA Types of participants This review will consider studies that include adult patients (over 18 years) who have sought emergency care with any complaint, have been classified by the Manchester Triage System, and have received a medical diagnosis of Acute coronary syndrome. Studies involving children (18 years or under) will be excluded, as although the instrument can be used for evaluating children, this is a population with very specific characteristics, and the inclusion of studies conducted on children could bias the results. Furthermore, Acute coronary syndrome generally affects the adult population and incidences are highly related to risk factors such as age, sex, smoking, hypertension and diabetes. Types of intervention(s)/phenomena of interest This review will consider studies that evaluate the use of the Manchester Triage System without modifications in risk classification of patients. No comparator will be used. Types of outcomes This review will consider studies that include the following outcome measures: Priority level established by the Manchester Triage System in the evaluation of patients with medical diagnosis of Acute coronary syndrome. Analysis of the sensitivity or specificity of Manchester Triage System in the evaluation of patients with Acute coronary syndrome. The Manchester Triage System can be seen as a test; in the case of evaluation of patients with Acute coronary TRUNCATED AT 250 WORDS

155 Evaluation of the Rapid Access Chest Pain Clinic Service

<h3>Introduction</h3> Rapid access chest pain clinics (RACPC) evolved to urgently assess and manage patients with recent onset chest pain of cardiac origin. In 2010, NICE guidance transformed our assessment of recent onset chest pain with subsequent increase use of resource. We therefore sought to evaluate our contemporary RACPC service as part of plans to develop and improve our service. <h3>Methods</h3> A retrospective cohort analysis of patients attending RACPC was performed over a 6-month period (01/10/2013 to 31/03/2014). Data pertaining to the patient episode including baseline demographics, referral source, waiting time, chest pain description, cardiovascular risk factors, subsequent investigations and patient disposal were collated from patient medical records. Patients with pre-existing ischaemic heart disease (IHD) were excluded from further analysis. Primary endpoints include final diagnosis of coronary artery disease (CAD), all-cause mortality and subsequent hospitalisation with chest pain. Statistical analyses were performed using StatView for Windows Version 5.0 and 95% confidence intervals were taken as statistically significant in all analyses. <h3>Results</h3> In the 6-month period, 625 patients attended RACPC with 57 (9.1%) excluded as they had a pre-existing diagnosis of IHD. Most patients were referred from primary care (PC) (82.9%). The mean time to referral was 12.5 days (s.d = 8.0) with 91% seen within 14 days. Mean age was 58.0 years (s.d. = 12.6) and 51.1% were male. No significant difference in age (years) (58.2 ± 12.6 vs 56.7 ± 12.5, <i>p = 0</i>.2802), gender (male) (51.2% vs 50.5%, <i>p = 0</i>.9068) or risk factors (smoking (19.8% vs 25.9%,<i>p = 0</i>.3944), diabetes (14.6% vs 19.3%, <i>p = 0</i>.2682), hypertension (34.6% vs 28.7%, <i>p = 0</i>.2827), hyperlipidaemia (20.0% vs 24.7%, <i>p = 0</i>.3222) and family history (39.2% vs 31.1%, <i>p = 0</i>.1454)) were observed between PC or Accident and Emergency (A&amp;E) referrals. Referrals from A&amp;E compared to PC were more likely declared non-cardiac chest pain (40.2% vs 24.4%, <i>p = 0</i>.0006), discharged after first review (40.2% vs 24.0%, <i>p = 0</i>.0010) and had fewer investigations ordered (67.0% vs 83.9%, <i>p</i> = &lt;0.0001). Diagnosis of CAD was established in only 10.7% of all referrals with similar rates observed from A&amp;E and PC (7.2% vs 11.5%, <i>p = 0</i>.1865). Crude all-cause mortality was 0.9% and hospitalisation with chest pain was 4.4%. No adverse outcome was observed in patients referred from A&amp;E. <h3>Conclusion</h3> Our current RACPC service provides low diagnostic yield of CAD (10.7%) and adverse outcomes are otherwise small. This is particularly apparent in patients referred from A&amp;E, possibly explained by differences in chest pain presentation. This data has implications for our future RACPC service suggesting improved triage of patients’ may improve the efficiency and cost-effectiveness of the service.

Awareness and Pattern of Cardiovascular Risk Factors among Patients Attending Cardiac Emergency with Acute Chest Pain of Cardiac Origin in Lucknow

Background : Lack of awareness about the risk factors is an important reason for delay in seeking medical care among patients with acute chest pain of cardiac origin. Objectives : To study the prevalence and awareness of cardiovascular risk factors and its sociodemographic determinants in patients attending cardiac emergency with acute chest pain of cardiac origin of Lucknow district. Material and Method : A Descriptive Longitudinal study was conducted in the cardiac emergency of CSMMU, a tertiary care center, following systematic random sampling technique on a sample size of 220 during study period of one year August 2010 to August 2011.Data was collected through preformed and pretested schedule and analysed using SPSS 17.0 software. Results : It was found that distribution of cardiovascular risk factors among patients attending cardiac emergency with acute chest pain of cardiac origin of Lucknow district were as follows: tobacco use 47.3%, alcohol 17.3%, hypertension 23.2%, diabetes mellitus 32.7%, dyslipidaemia 15%, overweight 23.6%, obesity 9.1%, past history of CAD 21.4% and family history in 9.5% of the patients. The awareness of risk factor was maximum for tobacco use (70%) and least for dyslipidaemia (40.9%). The awareness was less in rural patients, females, low SES class and illiterates. Conclusions : Public awareness campaigns to be conducted periodically to educate people about signs and symptoms of acute chest pain of cardiac origin, to create awareness about the seriousness of the problem and risk factors, as these factors were the major barriers in delay in health seeking.

Value of serum pregnancy-associated plasma protein A for predicting cardiovascular events among patients presenting with cardiac chest pain

Pregnancy-associated plasma protein A (PAPP-A) has been suggested as a candidate marker for the identification of unstable plaques in coronary arteries. We assessed the value of PAPP-A for predicting short-term cardiovascular events in a large cohort of patients presenting with cardiac chest pain. We included consecutive patients who presented to a teaching hospital in Germany with chest pain of cardiac origin confirmed by coronary angiography. We analyzed PAPP-A levels from serum samples drawn within 30 minutes after arrival in the emergency department or in the catheterization laboratory. Patients were followed for 90 days or until death for major adverse cardiovascular events, defined as the combined outcome of stent thrombosis, myocardial (re)infarction, ischemic stroke or cardiovascular-related death. A total of 2568 patients (mean age [± standard deviation (SD)] 68 ± 11 years; 74% male) presented with cardiac chest pain: 55% had stable angina and 45% had acute coronary syndrome. The PAPP-A levels ranged from 4 to 2154 mIU/L (median 14.0 mIU/L, interquartile range 9.3-25.2 mIU/L). Major adverse cardiovascular events occurred in 203 patients (7.9%). The mean PAPP-A level was higher among patients who had an event than among those who did not (62 ± 156 v. 21 ± 23 mIU/L, p < 0.001). In a multivariable analysis, PAPP-A remained a significant independent predictor of the primary outcome within 90 days (hazard ratio per 1 SD increase in PAPP-A level 1.96, 95% confidence interval 1.74-2.21). The optimal prognostic cutoff value was a PAPP-A level of 34.6 mIU/L. Higher levels of serum PAPP-A were independently associated with an increased short-term risk of cardiovascular events in patients presenting with cardiac chest pain. Further studies are required to validate the use of PAPP-A in routine clinical practice to predict future cardiovascular events.

Pre-Hospital Electrocardiography by Emergency Medical Personnel: Effects on Scene and Transport Times for Chest Pain and ST-Segment Elevation Myocardial Infarction Patients

This study sought to measure the impact of pre-hospital (PH) electrocardiography (ECG) on scene-to-hospital time for patients with chest pain of cardiac origin and those with ST-segment elevation myocardial infarction (STEMI).Pre-hospital ECG decreases door-to balloon (D2B) time for STEMI patients. However, obtaining a PH ECG might prolong scene time. We investigated the impact of obtaining a PH ECG on both scene and transport times for patients with chest pain suspected of cardiac origin.City of San Diego Emergency Medical System runsheets of patients with chest pain from January 2003 to April 2008 were analyzed. The scene times and transport times were compared before (from January 2003 to December 2005) and after (from January 2006 to April 2008) implementation of the PH ECG. Among patients with a PH ECG, median scene times and transport times were compared in patients with and without STEMI.There were 21,742 patients evaluated for chest pain during the study period. Implementation of PH ECG resulted in minimal increases in median scene time (19 min, 10 s vs. 19 min, 28 s, p = 0.002) and transport time (13 min, 16 s vs. 13 min, 28 s, p = 0.007). However, compared with chest pain patients, in STEMI patients (n = 303), shorter median scene time (17 min, 51 s vs. 19 min, 31 s, p < 0.001), transport time (12 min, 34 s vs. 13 min, 31 s, p = 0.006), and scene-to-hospital time was observed (30 min, 45 s vs. 33 min, 29 s, p < 0.001).Obtaining a PH ECG for patients with chest pain minimally prolongs scene and transport times. Further, for STEMI patients, both scene times and transport times are actually reduced leading to a potential reduction in total ischemic time.

Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain

Background Chest pain is a frequent chief complaint among the pediatric population. To date, limited data exist on the full spectrum of emergent cardiac disease among such patients; and existing data have been limited to relatively small cohorts. Objectives The aims of the study were to investigate the emergent cardiac etiologies of chest pain in a large cohort of patients presenting to a tertiary care pediatric emergency department (PED) and to examine the use of resources (electrocardiogram, chest radiograph, echocardiogram, and laboratories) in those with and without cardiac-related chest pain. Methods Patient visits to 2 tertiary care PEDs were evaluated over a 3 and half-year period. Records of patients less than 19 years of age with a chief complaint of chest pain and no history of cardiovascular disease were reviewed. Patients were categorized as having cardiac or noncardiac etiologies or history of cardiovascular disease at the time of discharge, based on PED attending's final diagnoses. Final diagnoses classified as emergent cardiac etiologies were determined a priori. Results Four thousand four hundred thirty-six patients reported a chief complaint of chest pain during the study period. Three percent were excluded secondary to a history of heart disease. Only 24 (0.6%) of the remaining 4288 were determined to have chest pain of cardiac origin. Those with cardiac-related chest pain had a rate of admission of 50% compared to those without cardiac disease at 4% ( P < .001). Nine patients had an arrhythmia, 6 had pericarditis, 4 had myocarditis, 3 had acute myocardial infarction, and 1 had pulmonary embolism and pneumopericardium. Ninety-two percent of the cardiac-related chest pain cohort received electrocardiograms compared to those without cardiac-related chest pain at 27% ( P < .01). Only 1 (4%) of 24 subjects with cardiac-related chest pain had a prior emergency department visit within 72 hours suggesting a high detection rate upon initial presentation. The most common noncardiac etiologies for the chest pain were 56% musculoskeletal disorders; 12% related to wheezing, asthma, and cough; 8% infectious causes; 6% gastrointestinal; and 4% related to sickle cell anemia. Conclusion Cardiac-related chest pain in pediatric patients is rare but potentially serious. Arrhythmia was the most common cardiac-related etiology among this cohort. Those with myocarditis and myocardial infarction were the most acutely ill. An electrocardiogram in addition to history and physical examination was most useful in detecting relatively uncommon but significant cardiac-related chest pain. Using a thorough physical examination and potentially an electrocardiogram evaluation by a pediatric emergency care physician has an excellent rate of detection of cardiac-related causes.

Acute Coronary Syndrome: Risk stratification and management

No abstract available.

Pain Recollection after Chest Pain of Cardiac Origin

Memory for pain is an important research and clinical issue since patients ability to accurately recall pain plays a prominent role in medical practice. The purpose of this prospective study was to find out if patients, with an episode of chest pain due to suspected acute myocardial infarction could accurately retrieve the pain initially experienced at home and during the first day of hospitalization after 6 months. A total of 177 patients were included in this analysis. The patients rated their experience of pain on a numerical rating scale. The maximal pain at home was retrospectively assessed, thereafter pain assessments were made at several points of time after admission. After 6 months they were asked to recall the intensity of pain and once again rate it on the numerical rating scale. The results from the initial and 6-month registrations were compared. In general, patients rated their maximal intensity of chest pain as being higher at the 6-month recollection as compared with the assessments made during the initial hospitalization. In particular, in patients with a high level of emotional distress, there was a systematic overestimation of the pain intensity at recall.

An evaluation of paramedics' ability to recognize chest pain of cardiac origin

An evaluation of paramedics' ability to recognize chest pain of cardiac origin

A decision analytic approach to commissioning ambulance cardiac services.

The paper discusses how a decision analytic framework has been used by an English health authority in relation to the commissioning of ambulance cardiac services. Strategies for the management by ambulance personnel of victims of cardiac arrest and persons with acute chest pain of cardiac origin were modelled in a decision-event tree, and a bibliographic database established. The international research literature prior to 1997 was searched in order to derive probability values for the tree. However, after checking whether the subgroupings of results in the papers were in accordance with the variables in the tree, the number of useful papers on acute chest pain was found to be only two. In the almost complete absence of information--even from small observational studies--on the management of the great majority of patients with cardiac symptoms transported by ambulance, the local ambulance service and the main providers of hospital services in the district are now collaborating in field studies of cardiac care in order to improve the inputs into the model.

Audit of patients with chest pain presenting to an accident and emergency department over a 6-month period.

The results of a 6-month retrospective audit of patients presenting with chest pain to an accident and emergency (A&E) department to which 46,000 new patients per year present are discussed. The computer diagnostic code assigned to the patients by the A&E doctor, referral rates for second opinion and disposal after assessment in the A&E department are examined, with particular reference to patients who may have had serious cardiac pathology, such as acute myocardial infarction (AMI) or unstable angina. Audit showed that overall 61% of patients with chest pain of all causes were assessed and discharged home by A&E doctors without recourse to second opinion. Of patients thought by the A&E doctors to have chest pain of cardiac origin, who were referred to the duty medical registrar or cardiologist, 88% were admitted. As a result of these findings a policy of more open referral for second opinion was instituted to reduce the likelihood of discharging patients home with serious cardiac pathology. In addition, the clinical problems of AMI and unstable angina are emphasized to all senior house officers early in their educational programme after joining A&E. Published literature on the diagnosis and misdiagnosis of AMI and unstable angina in the A&E department is reviewed. These studies are almost exclusively from North America, and a need for similar work in the U.K. is discussed.

The use of C-reactive protein in the evaluation of chest pain of cardiac origin.

Raised C-reactive protein (CRP) has long been recognized as a general, non-specific response to most forms of infective and non-infective inflammatory processes, cellular and tissue necrosis.' Serum CRP concentrations can rise dramatically following myocardial infarction. The increase occurs within 24-48 h and is non-specific, cannot be interpreted without a complete clinical history and comparison with the value at presentation.t-' Pepys' proposed that the main physiological role of CRP is to bind and neutralize potentially toxic autogenous materials released from damaged tissues into the plasma and facilitate their clearance. The measurement of CRP concentrations may assist in the diagnosis of the cause of chest pain because a rise in such cases without raised CK-MB, strongly suggests a non-infarctive or non-cardiac pathology. 2 We studied the use of serial CRP concentrations in patients admitted to the coronary care unit with chest pain syndrome.