Chief Complaint Of Chest Pain Research Articles

Abstract 3118: An Unusual Case Of Severe Multivessel Atherosclerotic Coronary Artery Disease In A Very Young Patient

Introduction: Premature coronary artery disease (CAD) is defined as CAD prior to the age of 55 for men and 65 for women, while CAD in young is defined as age <45 years. In the last decade, incidence of global premature CAD has increased by 25 %. Case presentation: A 20-year-old female with medical history of dyslipidemia, hypertension, type 1 diabetes mellitus and family history of premature coronary artery disease presented to the emergency room with chief complaint of chest pain and shortness of breath. EKG revealed sinus tachycardia and poor R-wave progression on anterior precordial leads. Serum troponin trend was unremarkable. Echocardiogram revealed severely reduced left ventricular (LV) ejection fraction of 20-25% with global LV hypokinesis, trace mitral and tricuspid regurgitation. Given new onset cardiomyopathy and family history of premature CAD, CT heart with coronary calcium scoring was performed which was concerning for severe LAD disease. Surprisingly, coronary angiogram revealed severe atherosclerotic disease in LAD, left circumflex and right coronary artery territories. Patient was started on guideline directed medical therapy for cardiomyopathy and has been referred to tertiary center for surgical revascularization. Discussion: To our best knowledge only one case has been reported before in the literature when a 21-year-old male patient had multivessel CAD requiring surgical revascularization. However, we report a case, which will be the youngest ever to have severe multivessel CAD needing surgical revascularization in the future. Cole et al, in a study of 800 young patients with CAD at long term follow up of 15 years, showed an overall mortality rate of 30 %, with 83% mortality rate in patients with EF< 30%, thus carrying a poor long-term prognosis.(2) Hence, an early initiation of treatment, including both medical therapy and revascularization should strongly be considered in these young patient population. Conclusion: With the increasing prevalence of premature CAD and associated risk factors, age alone should not be taken as a reliable indicator for risk stratifying patients. Emphasizing awareness among young adults with high risk of CAD that primary prevention and early lifestyle modification are of paramount importance.

Inflammatory myofibroblastic tumor directly invading the right first rib treated with oral steroids: a case report

BackgroundWe present a case of an inflammatory myofibroblastic tumor cured with a short period of steroid administration, a treatment previously unreported for such cases.Case presentationA 49-year-old man had a chief complaint of chest pain for more than 3 days. Computed tomography (CT) revealed a tumoral lesion suspected to have infiltrated into the right first rib and intercostal muscles, with changes in lung parenchymal density around the lesion. The maximal standardized uptake value on 18 F-fluorodeoxyglucose positron emission tomography/computed tomography was high (16.73), consistent with tumor presence. CT-guided biopsy revealed an inflammatory myofibroblastic tumor with no distant metastases. Surgery was indicated based on the disease course. However, he had received an oral steroid before the preoperative contrast-enhanced CT scan due to a history of bronchial asthma, and subsequent CT showed that the tumor shrank in size after administration; he has been recurrence-free for more than a year.ConclusionsSurgery is still the first choice for inflammatory myofibroblastic tumors, as the disease can metastasize and relapse; however, this condition can also be cured with a short period of steroid therapy.

Utility of Cardiac POCUS in the Evaluation of Pediatric Chest Pain in the Emergency Department

Background/Objective:Chest pain in children is rarely caused by a life-threatening pathology. Despite the rarity of potentially life-threatening disease, most children presenting to EDs are evaluated with chest radiographs and laboratory tests without yielding helpful information that significantly changes immediate management. While the utilization of cardiac Point-of-Care Ultrasound (POCUS) by adult emergency physicians has become standard of practice, the data in pediatric emergency departments (PED) is not as robust. This study aims to describe practice patterns in the evaluation of pediatric chest pain presenting in a PED and determine clinical outcomes.
 Methods:We reviewed charts of previously healthy children aged <18 years old who presented to Riley Children’s Hospital from January 2019 to July 2020 with a chief complaint of chest pain. Patients with known medical history, prior evaluations by a pediatric cardiologist, transfers from other hospital with existing workup were excluded. Patient demographics, laboratory tests and imaging ordered while in the ED, electrocardiography (EKG), consults with subspecialties, disposition and follow up plans were analyzed. We categorized clinical significance of PED interventions as minor, moderate, or major.
 Results:Out of three hundred and nineteen patients included in the study, 79.6% (254) received chest radiographs, 93.4% (298) underwent EKG, and 4.1% (13) received cardiac POCUS. The findings of these orders prompted minor interventions in 92.8% (296) of patients, moderateintervention in 4.7% (15) of patients, and major intervention in 2.5% (8) of patients.
 Conclusion and Implications:These results show a lack of use for POCUS in pediatric patients presenting with chest pain while chest radiography is preferred in the ED. Additionally, POCUS did not result in any moderate or major significant clinical outcomes.

Early rule-out of major adverse cardiac events in acute chest pain patients using a risk score and self-reported computerised history taking

Abstract Introduction Risk scores, such as the History, ECG, Age, Risk factors, and Troponin (HEART) score, Emergency Department Assessment of Chest Pain Score Accelerated Diagnostic Protocol (EDACS-ADP), and Troponin-only Manchester Acute Coronary Syndrome (T-MACS), are recommended for the evaluation of acute chest pain patients. Obtaining a structured medical history by self-reported computerised history taking (CHT) may provide an automated and improved risk assessment in the emergency department (ED). Purpose We aimed to determine the diagnostic accuracy of three well-established acute chest pain risk scores using CHT to predict 30-day major adverse cardiovascular event (MACE). Methods Prospective cohort of clinically stable patients aged ≥18 years presenting with a chief complaint of chest pain and an ECG not indicating an acute coronary syndrome (ACS), at a tertiary hospital ED during 2017–2019. Medical histories were self-reported on a tablet using a CHT program (Clinical Expert Operating System, CLEOS), owned by a public university. With >17,000 decision nodes, CLEOS mimics a physician interview and tailors each interview depending on previous answers. Data acquired is in a binary structured format and can be used for input in clinical decision support systems. The HEART score, EDACS-ADP, and T-MACS were calculated from the CHT and the electronic health records (EHR). Relevant EHR data, including medical history, vital signs, and lab data, was extracted manually by the research staff in a predetermined standardised way. The EHR was subsequently reviewed for ACS and intervention procedure International Classification of Diseases (ICD) codes for any 30-day 3-point MACE. Results Of the 1,000 consecutive participants enrolled (mean age 55±17 years; 54% women), the HEART score, EDACS-ADP, and T-MACS could be calculated in 65%, 65% and 68%, respectively using only CHT acquired data. Main reasons for premature termination of the CHT were early discharge from ED or getting tired. A 30-day MACE occurred in 7.2% of the total population. The sensitivity, specificity, positive and negative predictive values of any 30-day MACE are presented in Table 1. The diagnostic accuracy for each risk score using CHT was similar to previous studies, where physician-collected data was used. Conclusions CHT can provide relevant risk scores in a majority of acute chest pain patients, and allow a safe and early rule-out of a 30-day MACE. The use of CHT may enable automation and improve the management of a large proportion of low-risk acute chest pain patients in the ED.Example of a question in the CHT program

Abstract 14386: High Sensitivity Troponin: Implementation Before Education

Introduction: Troponin T is strong indicator of Acute Myocardial Injury, however, concerns regarding its sensitivity have led to the inception of high sensitivity troponin (hscTn). The use of hscTn in clinical practice allows for an increased negative predictive value, which in turn can expedite triage and disposition of patients presenting with Acute Coronary Syndrome. The ACC/AHA have developed algorithms to provide a road map to aide in the interpretation of hscTn values and their indications. However, the understanding of the interpretation of test is integral hscTn in guiding management. Hypothesis: Evaluate if the implementation of hscTn within our hospital system decreased the amount of inappropriate diagnostic testing and admissions. Methods: A total of 602 patients consisting of two patient groups seen in our emergency department with the chief complaint of chest pain were studied. The troponin T group consisted of patient admitted between Jan 2021 to June 2021 (n=246) and the hscTn group between July 2021 - December 2021 (n=356). Baseline demographic and clinical comorbid characteristics were compared between both groups. Notable outcomes of interest were rates of admission as well as cardiac testing. Analysis was performed using T test for continuous variables and Chi squared test for categorical variables. Results: Admission rates were significantly increased in the hscTn group in comparison to the regular troponin group with proportions of 60.3% vs 39.7% respectively (p < 0.001). An 11 percent increase in inpatient cardiology consultation of the total visits occurred within the hscTn group vs the regular troponin group. When evaluating admitted patients, based on AHA guidelines for significant hscTn findings only 2% of those patients who were admitted met the criteria. Conclusions: The introduction of hscTn troponin within our hospital did not appear to decrease chest pain admissions regardless of its improved sensitivity and specificity. In contrast, rates were increased even when elevation was not significant, this may not be due to the test's efficacy but instead to the lack of education on its indications.

Abstract 14955: Use of Cardiac Stress Testing in Nonagenarians With Chest Pain

Background: Nonagenarians represent a growing population in the United States. Cardiac stress testing is commonly used for risk stratification in patients with chest pain. However, there is limited evidence on the benefits of stress testing in nonagenarians. Aims: The goal of this study was to investigate the utilization of cardiac stress testing in nonagenarian evaluated in outpatient clinics for chest pain, and to evaluate the incremental prognostic value of stress testing in this population. Methods: This is a retrospective observational study that included patients 90 years and above who presented for outpatient evaluation of chest pain. Referral for cardiac stress testing was captured using electronic health records. Patients were followed for one year. The associations between cardiac stress testing and subsequent cardiac catheterization, coronary revascularization, and myocardial infarction were evaluated using logistic regression models. Results: Between 2017 and 2021, 11763 patients 90 years and above presented to a clinic visit with a chief complaint of chest pain. There were 50.3% male, 61.4% White, 9.0% Black, 20.0% Hispanic, and 9.3% Asian. In this group, 320 (2.7%) underwent cardiac stress testing. Patients referred for testing had fewer cardiac risk factors, with a lower prevalence of hypertension, hyperlipidemia, and diabetes. At one year of follow-up, 6.9% of patients in the stress test group underwent cardiac catheterization, compared to 2.5% of patients in the no testing group (adjusted OR 2.87, 95% CI 1.81-4.57). Revascularization occurred in 0.63% patients in the stress testing group compared to 0.78% in the no testing group (adjusted OR 0.78, 95% CI 0.19-3.21). Myocardial infarction occurred in 3.4% in the stress testing group compared to 4.4% in the no testing group (adjusted OR 1.67, 95% CI 0.79-2.9). Conclusion: Among nonagenarians who underwent outpatient evaluation of chest pain, cardiac stress testing was associated with a significantly increased odds of subsequent cardiac catheterization, but no difference in revascularization or myocardial infarction. These observations suggest the clinical benefits of stress testing in nonagenarians may be limited.

Herpetic esophagitis in healthy young adult.

Herpetic esophagitis (HE) is common in immunocompromised patients but rarely reported in healthy young adults. A 28-year-old healthy male patient visited our clinic with a chief complaint of chest pain. An esophagogastroduodenoscopy revealed widely spread superficial multiple ulcers in the middle to the distal esophagus, and repeated biopsies from the ulcer were performed but revealed inconsistent findings with HE. Thus, he was clinically diagnosed with HE based on endoscopic findings and serologic tests of immunoglobulin M (IgM)/immunoglobulin G (IgG) for herpes simplex virus. He responded to valacyclovir, and all esophageal ulcers had scarred.

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

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

Positron emission tomography rubidium-82 myocardial perfusion imaging in diagnosing uncommon paediatric acute coronary syndrome: a case report

BackgroundAcute coronary syndrome (ACS) is uncommon among the paediatric population with no guideline in the management in this age group up to this date. This case report aims to introduce the Positron Emission Tomography Rubidium-82 (PET Rb-82 MPI) as one of the non-invasive diagnostic tools in paediatric acute coronary syndrome.Case presentationPatient is an 11-year-old boy with underlying Nephrotic syndrome who was referred to our hospital with the chief complaint of chest pain. This was associated with raised cardiac enzyme and S–T depression on the posterior leads of electrocardiogram. On his arrival, we noted raised lipid profile as well as proteinuria and hypoalbuminaemia. He had frequent relapse of Nephrotic syndrome with the latest episode was three months ago. He has a strong family history of ischaemic heart disease whom his father had an episode of myocardial infarction at the age of 40 as well as a strong family history of hypercholesterolaemia. His father and paternal uncle were diagnosed with hypercholesterolaemia at their early age. He was arranged for Coronary Computed Tomography Angiography which subsequently followed by PET Rb-82 MPI. The PET Rb-82 MPI demonstrated a large area of stress induced ischaemia in the left anterior descending, left circumflex and right coronary artery territories. The left ventricular size is normal with good systolic function and normal wall motion. Global coronary flow reserve was still preserved at 2.07. Following the multi-disciplinary meeting, diagnosis of ACS was established. Patient was treated with dual anti-platelets, and he was then arranged for coronary angiography. The coronary angiography showed complete occlusion of the left circumflex artery from the proximal segment. There was a mild disease at mid segment of the diagonal artery with myocardial bridging. There was also a moderate disease from proximal segment of the dominant right coronary artery. Paclitaxel drug coated balloons were inserted into the diagonal and left circumflex arteries.ConclusionsThis rare case report on paediatric ACS highlights the diagnostic value of PET Rb-82 MPI as one of the non-invasive imaging tools in diagnosing paediatric acute coronary syndrome.

Implementation of high-sensitivity troponin with a rapid diagnostic algorithm reduces emergency department length of stay for discharged patients

IntroductionHigh sensitivity troponin (hs-cTn) and diagnostic algorithms are used to rapidly triage patients with symptoms of acute myocardial infarction in emergency departments (ED). However, few studies have evaluated the impact of simultaneously implementing hs-cTn and a rapid rule-out algorithm on length of stay (LOS). MethodsWe assessed the impact of transitioning from contemporary cTnI to hs-cTnI in 59,232 ED encounters over three years. hs-cTnI was implemented with an orderable series that included baseline, two-, four-, and six-hour specimens collected at provider discretion and operationalized with an algorithm to calculate the change in hs-cTnI from baseline and provide interpretations of “insignificant”, “significant,” or “equivocal.” Patient demographics, results, chief complaint, disposition, and ED LOS were captured from the electronic medical record. ResultscTnI was ordered for 31,875 encounters prior to hs-cTnI implementation and 27,357 after. The proportion of cTnI results above the 99th percentile upper reference limit decreased from 35.0% to 27.0% for men and increased from 27.8% to 34.8% for women. Among discharged patients, the median LOS decreased by 0.6 h (0.5–0.7). LOS among discharged patients with a chief complaint of chest pain decreased by 1.0 h (0.8–1.1) and further decreased by 1.2 h (1.0–1.3) if the initial hs-cTnI was below the limit of quantitation. The rate of acute coronary syndrome upon re-presentation within 30 days did not change post-implementation (0.10% versus 0.07%). ConclusionImplementation of an hs-cTnI assay with a rapid rule-out algorithm decreased ED LOS among discharged patients, particularly among those with a chief complaint of chest pain.

Cocaine user with chest pain.

A 52-year-old male presented to the emergency department with a past medical history of active cocaine use and a chief complaint of chest pain that radiated to the back. Physical exam revealed a well-appearing, comfortable male with normal cardiac sounds, regular rate and rhythm, bilateral equal pulses in all four extremities, and intact motor and sensation in the extremities. A bedside ultrasound was performed and revealed an ascending aorta dissection (Figure 1 and Video 1). This was confirmed on intraoperative transesophageal echocardiogram that demonstrated the proximity of the aortic dissection flap to the aortic valve (Figure 2). Computed tomography angiography (CTA) of the chest confirmed the diagnosis of Stanford A (type 1) aortic dissection extending from the supravalvular region to the level of the renal arteries. The patient was placed on nicardipine and esmolol drips and cardiothoracic surgery was emergently consulted. The patient underwent surgery where he had an intraoperative transesophageal echocardiogram, stenting of the aortic root, ascending aorta, and descending aorta. He recovered from his surgery and was ultimately discharged to home. Aortic dissection is a relatively rare disease with an estimated global death rate of 2.78 per 100,000.1 The diagnosis is typically made with CTA of the chest. Thoracic aortic dissection is classified into two categories: Stanford type A that involves the proximal ascending aorta before the left subclavian and Stanford type B that involves the aorta only distal to the left subclavian.2 The treatment of aortic dissection includes blood pressure and heart rate reduction. Early surgical consultation is important because type A aortic dissection is a true surgical emergency.

Refractory pleuritic chest pain: A troublesome consequence of pulmonary embolism.

A sixteen-year-old girl presented to the Emergency Department (ED) with the chief complaint of chest pain This article is protected by copyright. All rights reserved.

PULMONARY AND CORONARIES OF THE HEART SHOULD STAY APART: A CASE OF MULTIPLE CORONARY TO PULMONARY ARTERY FISTULAS

PULMONARY AND CORONARIES OF THE HEART SHOULD STAY APART: A CASE OF MULTIPLE CORONARY TO PULMONARY ARTERY FISTULAS

LET'S SPILL THE TEA: ACUTE AORTIC DISSECTION

LET'S SPILL THE TEA: ACUTE AORTIC DISSECTION

Chest pain in the emergency department: From score to core-A prospective clinical study.

High-sensitivity troponin assay brought new challenges as we detect elevated concentration in many other diseases, and it became difficult to distinguish the real cause of this elevation. In this notion, diagnosis of acute coronary syndrome (ACS) remains a challenge in emergency department (ED).We aim to examine different approaches for rule-in and rule-out of ACS using risk scores, copeptin, and coronary computed tomography angiography (CCTA).A prospective observational study was designed to evaluate chest pain patients. Consecutive adult patients admitted to the ED with a chief complaint of chest pain due to any cause were included.All patients were followed-up for 6 months after discharge for major adverse cardiovascular events and readmissions. Admission data, ED processes, and diagnoses were analyzed.One hundred forty-six patients were included, average age was 63 ± 13.4 years, and 95 (65.1%) were male. Global Registry of Acute Coronary Events (GRACE) and History, ECG, Age, Risk factors, Troponin (HEART) scores showed good prognostic abilities, but HEART combination with copeptin improves diagnoses of myocardial infarction (area under the curve [AUC] 0.764 vs AUC 0.864 P = .0008). Patients with elevated copeptin were older, had higher risk scores, and were more likely to be admitted to hospital and diagnosed with ACS in ED. For copeptin, AUC was 0.715 (95% confidence interval 0.629–0.803), and for combination with troponin, AUC of 0.770 (0.703–0.855) did not improve rule-in of myocardial infarction. High-sensitivity troponin I assay alongside prior stroke, history of carotid stenosis, dyslipidemia, use of diuretics, and electrocardiogram changes (left bundle branch block or ST depression) are good predictors of myocardial infarction (χ² = 52.29, AUC = 0.875 [0.813–0.937], P < .001). The regression analysis showed that combination of copeptin and CCTA without significant stenosis can be used for ACS rule-out (χ² = 26.36, P < .001, AUC = 0.772 [0.681–0.863], negative predictive value of 96.25%).For rule-in of ACS, practitioner should consider not only scores for risk stratification but carefully analyze medical history and nonspecific electrocardiogram changes and even with normal troponin results, we strongly suggest thorough evaluation in chest pain unit. For rule-out of ACS combination of copeptin and CCTA holds great potential.

Does switching type of mRNA COVID-19 vaccine increases the risk of myocarditis and pericarditis? A case report and literature review

Introduction: Myocarditis and Pericarditis are caused by diverse etiologies, such as infection, toxins, drugs, and vaccines. Myocarditis has been reported previously after smallpox vaccination; however, the incidence was rare. Currently, there are two types of COVID-19 vaccines, mRNA vaccines, and viral vector vaccines. Many cases of myocarditis/Pericarditis after the mRNA COVID-19 vaccine have been reported to the VARES (Vaccine Adverse Event Reporting System). Case Presentation: A 20-year-old male with a history of mild asthma, who previously received two Pfizer covid -19 vaccines, presented to the emergency department with a chief complaint of chest pain two days after receiving a third booster dose of the Moderna vaccine. Troponin and C- Reactive Protein was Elevated, ECG findings revealed acute pericarditis, and MRI showed myocarditis. Echocardiography was normal except for moderate hypokinesis of the septal and inferior left ventricular regional wall segments and trivial pericardial effusion. The patient was admitted for treatment with aspirin, colchicine, metoprolol, and famotidine. His condition was improved, and he was discharged with a follow-up plan.Discussion: So far, most of the cases of Myocarditis/Pericarditis associated with mRNA COVID-19 vaccine were after the second dose; however, not many cases were reported after the booster dose or switching the type of mRNA vaccine. The risk of myocarditis/pericarditis in our patient, with his history of asthma and two doses of Pfizer vaccine, might be increased after switching his booster vaccine to Moderna; nevertheless, the patient still responds well to the treatment without complications. Conclusion: Myocarditis/Pericarditis following receipt of mRNA COVID -19 vaccine is a rare side effect; however, the occurrence of a potentially extremely rare adverse event after an immunization should not lessen the value and the effective benefit of the mRNA COVID-19 vaccine. Further studies are needed to determine the risk of complications following switching between the type of mRNA vaccine.

Mature teratoma with somatic-type solid malignancy in the mediastinum: A case report of rare and poor prognosis tumour

Background: Germ cell tumor with somatic-type solid malignancy is a germ cell tumor accompanied by a non-germ cell, the somatic-type malignant component in the form of sarcomas or carcinomas. These germ cell tumors are rare, accounting for only about 2% of all germ cell tumors in men. About 25-30% of these tumors occur in the mediastinum. These tumors are often located in the anterior mediastinum and occur in adult males with a peak incidence between 20-40 years. Case description: A 19-year-old female patient came with chief complaints of chest pain and shortness of breath about three months ago. Chest CT scan images showed a right lung reactive pneumonia with suspicious atelectasis at the second and third segments of the right lung. The image also showed a tumor mass with heterogeneous density at the mediastinum. Then thoracotomy surgery and tumor resection were performed. Macroscopically, there was a multicystic tumor mass measuring 14.0x11.0x6.5 cm, partly solid with 7.0x5.0x5.0 cm. Microscopic examination of the tumor mass showed three components of the germ layer, namely ectodermal, mesodermal and endodermal. No immature component appears. The tumor also contains neoplastic epithelial cells that form a solid, cribriform, acinic and papillary structure in the extracellular mucinous pool. Conclusion: Based on the clinical finding, radiologic, and routine histopathological examination, this case was concluded as mature teratoma with somatic-type solid malignancy in the form of mucinous adenocarcinoma.

Computerized history taking improves HEART score determination in acute chest pain patients

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Robert Bosch Stiftung (Stuttgart, Germany) Region Stockholm (ALF project; Stockholm, Sweden) Introduction Chest pain is a common chief complaint in emergency departments (EDs). The Acute Cardiovascular Care Association recommends the use of History, ECG, Age, Risk factors, and Troponin (HEART) score for risk stratification. In hectic and overcrowded EDs computerized history taking (CHT) is one structured way for collecting the components of HEART score, which include medical history (H- and R-variables). Purpose To determine the proportion of acute chest pain patients where CHT can be used to calculate HEART score, and what interrater reliability the included variables have with physician acquired medical history. Methods Prospective cohort study with acute chest pain patients self-reporting medical histories using a CHT program (Clinical Expert Operating System, CLEOS) on a tablet. CLEOS, with &amp;gt;17,000 decision nodes, mimics a physician interview and tailors each interview continuously depending on previous answers. Clinically stable women and men aged &amp;gt;18 years with a chief complaint of chest pain and non-diagnostic ECG or serum markers for acute coronary syndrome were enrolled. Patients unable to carry out a CHT interview (e.g., severe impaired vision or confusion) were excluded. As recommended in regional guidelines a modified HEART score using the traditional classification of anginal symptoms, i.e. 1) central chest pain, 2) provoked by physical exertion and/or emotional stress, and 3) relieved by rest and/or nitrates, and traditional risk factors was used (see Table 1). Observations to each discrete H- and R-variable and medical history data were extracted from electronic health records (EHR) and the CHT database by the research staff. Cohen’s kappa statistics and interpretation according to Landis &amp; Koch was used to describe the interrater reliability. Results A total of 1,000 consecutive patients were enrolled in one tertiary university hospital ED during 2017–2019 (mean age 55±17 years; 54% women), comparable to the general chest pain population (mean age 58±19 years; 50% women). A complete HEART score could be calculated in 60% of patients (H-variable 91%; R-variable 60%). Registered observations from EHR and CHT and interrater reliability data are presented in Table 1. Interrater reliability for the H-variable (classical anginal symptoms) was slight to moderate (kappa 0.19-0.44) and the R-variable (traditional risk factors) was moderate to almost perfect (kappa 0.56-0.88). Conclusions HEART score could be calculated in a majority of acute chest pain patients by the use of CHT. Interrater reliability was high for traditional risk factors but low to moderate for classical anginal symptoms. Our ongoing studies assess whether CHT combined with a risk score such as HEART score in an acute setting can be useful for improved risk stratification and, more important, to improve clinical outcomes.

Chest pain in a pediatric emergency department: clinical assessment and management reality in a third-level Portuguese hospital.

Background:Chest pain in children and adolescents is a common complaint in the emergency department (ED), being mostly benign. A thorough patient history and physical examination should be enough in most cases for its proper management. Regarding non-cardiac chest pain, anxiety plays an important role.Methods:Retrospective analysis of all admissions in a pediatric ED of a Portuguese third-level hospital with a chief complaint of chest pain between January and December 2018. Chi-square test was used to compare different etiologies, considering a significance level of 5%.Results:A total of 798 visits were included: 53.6% girls, 80.8% adolescents (mean age: 13years old). According to the Pediatric Canadian Triage and Acuity Scale, 77.7% was prioritized as level IV: less urgent; 65.3% reported associated symptoms including dyspnea (31.8%), cough (18.2%), and palpitations (16.1%). In physical examination, 45.5% had alterations: 62.8% with chest wall tenderness. Further investigation was done in 84% of patients: 62.4% electrocardiograms (altered in 14.7%), 52.6% chest radiographies (altered in 17.1%) and 8.9% cardiac biomarkers (altered in 12.7%). The 3 main causes of chest pain were musculoskeletal (33%), idiopathic (24.4%) and psychogenic (21.6%), with 1.1% of cardiac etiology. Less than 3% needed hospital admission and 18.9% were oriented to an outpatient consultation. 7.1% readmissions reported. When compared to other causes as a group, psychogenic chest pain presented a statistically significant association with female sex, adolescence, psychiatric antecedents, previous stressful event, and normal physical examination. Of these, <30% were oriented to a pedopsychiatry/psychology consultation.Conclusions:Opposing to the low priority level in triage, benign diagnosis found, and low hospital admissions, there was a high percentage of complementary diagnostic tests performed with few altered results. In psychogenic chest pain there was a low postdischarge referral. The authors highlight the importance of clinical algorithms to reduce unnecessary tests performed and readmissions and improve orientation and follow-up, particularly in psychogenic etiology.

The Feasibility of Ultra-Sensitive Phonocardiography in Acute Chest Pain Patients of a Tertiary Care Emergency Department (ScorED Feasibility Study)

Background: Thoracic pain is one of the most frequent chief complaints at emergency departments (EDs). However, a respective workup in cases without clear electrocardiographic signs is complex. In addition, after having ruled out acute coronary syndrome (ACS), patients are often left with an unclear etiology of their symptoms. Ultra-sensitive phonocardiography is already used to rule out stable coronary artery disease (CAD); however, its feasibility in an ED-setting remains unknown. Methods: We prospectively used ultra-sensitive phonocardiography via the CADScor®System to measure hemodynamically stable patients with the chief complaint of chest pain during routine waiting times at a high-volume tertiary ED. Results: A total of 101 patients (49% male; 94% Caucasian; 61 (51–71) years; BMI 28.3 (24.2–31.6)) were enrolled. Patient workflow was not hindered, and no adverse events were recorded. In 80% of cases, a score was successfully calculated, with 74% at the first, 5% at the second, and 1% at the third attempt. Feasibility was judged as 9.0 (±1.8) by the patients, and 8.9 (±2.6) by the investigators on a 10-point Likert scale. Conclusions: Ultra-sensitive phonocardiography was found to be feasible in acute chest pain patients presenting to a tertiary ED. Thus, the CAD score measured during routine waiting times could potentially serve as an additional tool in a diagnostic pathway for thoracic pain.