Diagnosis Of ACS Research Articles

A STUDY TO IDENTIFY THE PRESENCE OF SEVERE CORONARY ARTERY DISEASE IN PATIENTS WITH NO ELECTROCARDIOGRAPHIC, BIOCHEMICAL AND ECHOCARDIOGRAPHIC EVIDENCE OF CAD USING CT CORONARY ANGIOGRAPHY

INTRODUCTION:Acute chest pain is one of the most common reasons for seeking care in the emergency department (ED), accounting for approximately 10% of all visits. The difficulty lies in discriminating patients with ACS or other lifethreatening conditions from those with non-cardiovascular,non-life-threatening chest pain.The diagnosis ofACS is missed in approximately 2%ofpatients.But itis essential to rule out cardiovascular etiology of chestpain to avoidunnecessary cost and complications of investigations and treatment. This study aims at identifying the prevalence of significant coronary artery disease in patients with no electrocardiographic and biochemical evidence of coronary artery disease. AIM OF STUDY: To identifying the presence of severe coronary artery disease in the patients with no electrocardiographic, biochemical and echocardiographic evidence of CAD using CT Coronary Angiography. MATERIAL AND METHODS: The study was conducted on 50 patients during a period of 4 months,admitted with history of chest pain without any ECG evidence of STEMI, negative cardiac markers, no evidence of RWMA on 2D ECHO, or previous history of myocardial infarction.RESULTS: Out of the 50 patients studied, 38 (76%) were males and 12 (24%) were females.A total of 6 patients (12%) were found to have severe stenosis in major coronary arteries (stenosis > 70%) of which 4 were males (10.5%) and 2 were females (16.67%).CADRAD score≥3 was found in 9 patients (18%):6 males (15.78%) and 3 females (12%).Average age of patients who presented with chest pain with no electrocardiographic and biochemical evidence of coronary artery disease was found to be 61.7 years in males and 60.1 in females.66.7% of the female patients and 78.94% of male patients were over the age of 55 years.CONCLUSION: Furtherworkupofpatientswith chestpainwith no electrocardiographic and biochemicalevidenceofcoronaryarterydiseaseisnecessarytoavoidmissingdiagnosisofCAD

P4575UA and NSTEMI in the era of high-sensitivity Troponin: impact on patient risk profile and management

Abstract Aim High-sensitivity troponin assays (HST) entered the clinical arena to facilitate exclusion of ACS in the emergency department (ER) in patients presenting with chest pain. Due to its higher sensitivity there is the potential for an overestimation of the diagnosis of NSTEMI, and possibly ACS overall. We assessed the impact of HST in the classification of ACS (NSTEMI vs UA) and its ability to predict obstructive coronary disease (CAD), in a population of pts referred to coronary angiography (ICA). Methods Retrospective analysis of 1844 pts with suspected NSTEMI or UA referred for ICA from a single ER between Feb 2013 and Nov 2018. Standard Troponin-I was used until Feb 2016 and HST thereafter. The characteristics of UA and NSTEMI pts before and after the introduction of HST were compared. Multivariate binary logistic regression models were used to access the association of different troponin assays with CAD (>50% for LM and >70% for the remaining). Sensitivity, specificity, NPV and PPV for angiographic CAD were also determined. Results The relative proportion of patients with UA and NSTEMI was similar between study periods: 31% vs 29% and 69% vs 71%, respectively (p=0.3). Clinical and angiographic characteristics did not differ in UA pts before and after the use of HST. NSTEMI patients in the HST era were less frequently women (39% vs 32%, p=0.026), had higher creatinine (0.93 IQR 0.75–1.3 vs 1.0 IQR 0.82–1.38), higher number of lesions (2 IQR 1–4 vs 3 IQR 1–4) and a lower rate of normal coronary arteries (10.5% vs 3.9%, p<0.001). The prevalence of significant CAD in this population, before and after HST, was 65% and 73%, respectively (p=0.001). However, when clinically relevant characteristics and judgement were accounted for, both standard troponin (OR 0.99, 95% CI 0.99–1.01) and HST (1.0, 95% CI 1.0–1.0) were poor predictors of significant CAD. Sensitivity was 69% vs 72%, specificity 30% vs 30%, PPV 65% vs 73% and NNP 34% vs 28%, respectively. Finally, rates of percutaneous intervention did not differ between the two periods (30% vs 33.5%, p=0.157), nor between ACS types within each period. CAD/PCI in ACS within each period Conclusion The introduction of HST did not result in an increase of the diagnosis of NSTEM vs UA, suggesting that clinical judgment remains an important determinant of the diagnosis of ACS. Also there was no evidence of an increase in PCI rates, despite worse CAD severity in NSTEMI patients.

P1756The protein APRIL predicts adverse outcomes in DAPT patients better than NT-proBNP and troponin

Abstract Aim Dual antiplatelet therapy (DAPT) is a mainstay of post-ACS treatment. However, prediction of adverse events in these patients needs improving. We show here that the TNFα-related protein APRIL (which is produced in platelets and atherosclerotic plaque) is a superior predictor of MACE and new MI in DAPT recipients post-ACS. Methods We prospectively recruited 518 patients presenting with the primary complaint of acute chest pain to our hospital ED. Patients were adjudicated to have ACS by 2 independent cardiologists in accordance with ESC guidelines with hsTnI as biomarker. Plasma EDTA samples taken at presentation and 2 hours after were interrogated for APRIL measurements using a two site ELISA. Clinical data/variables, standard biochemistry analytes, hsTnT and NT-proBNP were also measured. Statistical assessments were made using SPSS v23 (IBM). Data for all biomarkers were treated as continuous variables and are presented as median (interquartile range, (IQR)). Statistical assessment of the comparative diagnostic abilities of APRIL, hsTnT, NT-proBNP and hsTnI were assessed using receiver operator curve (ROC) area under the curve (AUC) analysis. The comparative power of each biomarker (log values) to predict new MACE, MI, bleeding and mortality in 1) the whole group and in 2) DAPT recipients alone, within 2 yrs of index presentation was undertaken using a logistic regression base model (95% CI) that included all clinical variables and hsTnI and hsTnT, with APRIL and NT-proBNP each included in additional multivariate analyses. Results Of the 518 recruited patients (median age 63 (IQR: 54–73, 35% female), 152 were adjudicated to have ACS (29%, 115 MI, 37 UAP). Presentation APRIL levels were higher in those with a cardiac versus non-cardiac cause for presentation (3.0, (2.0–4.7) vs. 2.4, (1.6–3.8) ng/mL, P=0.001) and positively correlated with hsTnT and NT-proBNP (all P<0.001), but it did not add to the hsTnI (ROC = 0.96) or hsTnT (ROC =0.92) assisted diagnosis of ACS. In all 518 patients, in the multivariate regression model, APRIL was a significant independent predictor of mortality (n=54, P=0.032), new MI (n=43, P=0.006), new ADHF (n=24, P=0.016) and MACE (n=71, P=0.005) that was additive to NT-proBNP and troponin. In DAPT recipients alone (n=156), APRIL was the only biomarker to independently predict new MI (n=27, 95% CI: 1.125–3.982, P=0.020) and MACE (n=37, 95% CI: 1.058–3.389, P=0.031). None of the markers, only age, predicted bleeding episodes. Conclusion APRIL is an platelet/plaque derived marker that provides independent risk assessment in ACS patients. In DAPT recipients, the ability of APRIL to predict new MI and MACE is superior to that of cardiac troponins and NT-proBNP and could be used to identify high risk individuals. Acknowledgement/Funding Health Research Council of New Zealand; Heart Foundation of New Zealand

Sensitivity, Specificity, and Sex Differences in Symptoms Reported on the 13‐Item Acute Coronary Syndrome Checklist

BackgroundClinical symptoms are part of the risk stratification approaches used in the emergency department (ED) to evaluate patients with suspected acute coronary syndromes (ACS). The objective of this study was to determine the sensitivity, specificity, and predictive value of 13 symptoms for a discharge diagnosis of ACS in women and men.Methods and ResultsThe sample included 736 patients admitted to 4 EDs with symptoms suggestive of ACS. Symptoms were assessed with the 13‐item validated ACS Symptom Checklist. Mixed‐effects logistic regression models were used to estimate sensitivity, specificity, and predictive value of each symptom for a diagnosis of ACS, adjusting for age, obesity, diabetes, and functional status. Patients were predominantly male (63%) and Caucasian (70.5%), with a mean age of 59.7±14.2 years. Chest pressure, chest discomfort, and chest pain demonstrated the highest sensitivity for ACS in both women (66%, 66%, and 67%) and men (63%, 69%, and 72%). Six symptoms were specific for a non‐ACS diagnosis in both women and men. The predictive value of shoulder (odds ratio [OR]=2.53; 95% CI=1.29 to 4.96) and arm pain (OR 2.15; 95% CI=1.10 to 4.20) in women was nearly twice that of men (OR=1.11; 95% CI=0.67 to 1.85 and OR=1.21; 95% CI=0.74 to 1.99). Shortness of breath (OR=0.49; 95% CI=0.30 to 0.79) predicted a non‐ACS diagnosis in men.ConclusionsThere were more similarities than differences in symptom predictors of ACS for women and men.

The clinical significance of serum hs-CRP, BNP and cTNI in patients with acute coronary syndrome

Objective To evaluate the clinical significance of serum hs-CRP,BNP and cTNⅠ in patients with acute coronary syndrome.Methods 43 cases of ACS and 46 health examinees in our hospital were recruited as study object.The serum levels of hs-CRP,BNP and cTNⅠ were tested by ELISA and compared between two groups.Results The serum levels of hs-CRP,BNP and cTNI in ACS group were (6.88 ± 2.11) mg/L,(311.6 ± 88.9) pg/ml and (17.4 ± 9.1) pg/ml respectively,those in control group were (2.67 ± 1.12) mg/L,(21.8 ± 8.9) pg/ml,(0.14 ± 0.10) pg/ml respectively.The serum levels of hs-CRP,BNP and cTNⅠ in ACS group were significantly higher than those in control group (P ＜ 0.05).The serum level of cTNⅠin patients with ACS was related to the serum levels of hs-CRP and BNP,with Pearson correlation coefficients of 0.81 and 0.47 (P ＜ 0.05).Conclusions The serum levels of hs-CRP,BNP and cTNⅠ in patients with ACS are significantly increased,which can be used as serum biomarker for the diagnosis of ACS. Key words: Hs-CRP; Brain natriuretic peptide; Cardiac troponin Ⅰ; Acute coronary syndrome

Evaluation on ischemia-modified albumin，D-dimer and cTnI in the early diagnosis of acute coronary syndrome

Objective To investigate the early diagnosis value of IMA and D-dimer and cTnⅠin ACS. Methods All the 113 blood samples of patients with chest pain in the emergency department of the Third Hospital of Hebei Medical University were selected.Thirty healthy people were selected as the control group.Patients were divided into two groups：one of 52 cases was within 3 hours after onset of chest pain, the other of 61 cases was between 3 to 6 hours.According to the final clinical diagnosis, 31 cases were divided into non-ischemic chest pain group (NICP) and 82 cases were divided into the ACS group.The ACS group was divided into the UA group (51 cases), NSTEMI group (18 cases) and STEMI group (13 cases).IMA was measured with albumin-cobalt binding test, and D-dimer was measured with the automated blood coagulation analyzer, and cTnⅠ was measured with the automatic biochemical analyzer.Levels of IMA, D-dimer, cTnⅠwere compared in the different groups and their sensitivity, specificity and accuracy to the early diagnosis of ACS were evaluated by Four format diagnositic test. Results The levels of IMA in ACS group, which include the UA group, NSTEMI group and STEMI group were （0.722±0.181），（0.601±0.122），（0.631±0.153） ABSU respectively .The levels of D-dimer were （0.485±0.124），（0.571±0.181），（0.748±0.094） mg/L respectively.The levels of cTnⅠ were （0.076±0.027），（0.059±0.038），（0.065±0.015） μg/L respectively.Concentrations of IMA, D-dimer and cTnⅠin ACS group were significantly higher than those of the NICP group ［IMA （0.338±0.065） ABSU, D-dimer （0.368±0.078） mg/L, cTnⅠ （0.022±0.007） μg/L］ and the controls group ［IMA （0.292±0.058） ABSU, D-dimer （0.267±0.052） mg/L, cTnⅠ （0.029±0.016） μg/L］.There were significant differences between the ACS group and the NICP group and the control group, F value was 3.613，3.289 and 3.521 respectivily, and P<0.05.The levels of IMA in ACS group within 3 hours and between 3 to 6 hours, which is （0.665±0.104），（0.520±0.073） ABSU, were significantly higher than that of the controls (0.292±0.058) ABSU (F value was 3.58, P<0.05).The levels of D-dimer and the cTnⅠ in the group between 3 to 6 hours ［which were （0.634±0.213） mg/L and （0.079±0.032） μg/L］ were significantly higher than those of the controls ［（0.267±0.052） mg/L and （0.029±0.016） μg/L］ (q was 4.24 and 3.46, P<0.05).The sensitivity, specificity and accuracy was 83.36%, 70.97% and 81.42% of the IMA in a separate diagnosis of ACS, but the sensitivity, specificity and accuracy were 97.56%, 58.06% and 86.73% of the IMA, D-dimer and cTnⅠ with the affiliation diagnosis. Conclusion The serum IMA is a more sensitive indicator of ACS in early myocardial ischemia than cTnⅠ and plasma D-dimer.Serum IMA in combination with D-dimer and cTnⅠ could improve the sensitivity and specitivity, and had value to guide cinical diagnosis of ACS in the early stage.（Chin J Lab Med，2012,35：443-447） Key words: Acute coronary syndrome; Serum albumin; Biological markers; Troponin Ⅰ

Potential role of the ventilation and perfusion (V/Q) lung scan in the diagnosis of acute chest syndrome in adults with sickle cell disease

The current criteria for diagnosing ACS are chest pain and presence of a new infiltrate on the chest radiograph (CXR). This study was designed to evaluate the role of ventilation and perfusion (V/Q) scan to assist in the early diagnosis of ACS. An abnormal V/Q scan was associated with a diagnosis of ACS that reached a statistical significance (P < 0.038). The sensitivity and specificity were found to be 60% and 100%, respectively. We conclude that V/Q scan may play a role in the early diagnosis of ACS.