Diagnosis Of Acute Coronary Syndrome Research Articles

Effect of a Triage-Based Screening Protocol on Diagnosis and Treatment of Acute Coronary Syndrome in a Tanzanian Emergency Department: A Prospective Pre-Post Study.

BackgroundEvidence suggests that acute coronary syndrome (ACS) is underdiagnosed in sub‐Saharan Africa. Triage‐based interventions have improved ACS diagnosis and management in high‐income settings but have not been evaluated in sub‐Saharan African emergency departments (EDs). Our objective was to estimate the effect of a triage‐based screening protocol on ACS diagnosis and care in a Tanzanian ED.Methods and ResultsAll adults presenting to a Tanzanian ED with chest pain or shortness of breath were prospectively enrolled. Treatments and clinician‐documented diagnoses were observed and recorded. In the preintervention phase (August 2018 through January 2019), ACS testing and treatment were dictated by physician discretion, as per usual care. A triage‐based protocol was then introduced, and in the postintervention phase (January 2019 through October 2019), research assistants performed ECG and point‐of‐care troponin I testing on all patients with chest pain or shortness of breath upon ED arrival. Pre‐post analyses compared ACS care between phases. Of 1020 total participants (339 preintervention phase, 681 postintervention phase), mean (SD) age was 58.9 (19.4) years. Six (1.8%) preintervention participants were diagnosed with ACS, versus 83 (12.2%) postintervention participants (odds ratio [OR], 7.51; 95% CI, 3.52–19.7; P<0.001). Among all participants, 3 (0.9%) preintervention participants received aspirin, compared with 50 (7.3%) postintervention participants (OR, 8.45; 95% CI, 3.07–36.13; P<0.001).ConclusionsIntroduction of a triage‐based ACS screening protocol in a Tanzanian ED was associated with significant increases in ACS diagnoses and aspirin administration. Additional research is needed to determine the effect of ED‐based interventions on ACS care and clinical end points in sub‐Saharan Africa.

Prevalence of digestive diseases in patients with acute coronary syndrome

Purpose of the study. To study the prevalence of digestive diseases in patients with acute coronary syndrome.Materials and methods. A retrospective study included 1079 patients with acute coronary syndrome who were treated in the cardiology department No. 2 of the Chelyabinsk Regional Clinical Hospital in 2015. After further examination, the diagnosis of acute coronary syndrome was withdrawn in 40 patients (3.7%). In the future, this group was not studied due to the small number of patients. Of the group of patients with acute coronary syndrome (n = 1039 people), patients were distributed taking into account gender and age, of which 679 (65.4%) were men, 360 (34.6%) were women. The average age of all patients was (61.9 ± 11.9) years, men (58.9 ± 11.9) years, women (67.6 ± 12.0) years. Statistical analysis was performed using Microsoft Offi ce applications and SPSS Statistics programs (version 21.0).Results. Among all concomitant diseases in patients with acute coronary syndrome, digestive diseases take the third place. Among the risk factors in patients with acute coronary syndrome and digestive diseases, hypertension and hypercholesterolemia were most often recorded. Multivascular damage to the coronary arteries was more often observed in patients with myocardial infarction in the presence of digestive diseases. At the time of discharge from the hospital in patients with acute coronary syndrome in the presence of diseases of the gastroduodenal zone, monotherapy (clopidogrel / ticagrelor) was recommended three times more often in comparison with the group without digestive diseases. Inhibitors of the proton pump (omeprazole) in the presence of pathology of the digestive system are recommended in almost 100% of cases, regardless of the clinical form of acute coronary syndrome.

Accuracy of telephone triage in primary care patients with chest discomfort: a cross-sectional study.

ObjectiveTo assess the accuracy of semi-automatic assisted telephone triage in patients with acute chest discomfort against the diagnosis of acute coronary syndrome (ACS) or other life-threatening events (LTEs).MethodsA cross-sectional study was performed of telephone conversations with 2023 patients with acute chest discomfort (pain, pressure, tightness or discomfort) who called out-of-hours services for primary care (OHS-PC) between 2014 and 2016. Sensitivity, specificity, positive and negative predicted values were calculated for a high urgency (patient seen within one hour) against the diagnoses of ACS and other LTEs. Diagnoses were retrieved from the patients' medical records in general practice, including hospital specialists' discharge letters.ResultsOf 2023 patients who called because of chest discomfort, 227 (11.2%) had an ACS (men 14.9%, women 8.2%) and 58 (2.9%) had another LTE (men 3.6%, women 2.3%). The sensitivity and specificity of a high Netherlands Triage System (NTS) urgency allocation against ACS/other LTEs were 0.73 (95% CI 0.68 to 0.78) and 0.43 (95% CI 0.40 to 0.45), respectively. In 13.2% of the calls the triage nurse overruled the NTS urgency, mostly by upscaling (11.0%). The sensitivity and specificity of the final urgency allocation were 0.86 (95% CI 0.81 to 0.90) and 0.34 (95% CI 0.32 to 0.37). The positive and negative predictive values of the final urgency were 0.18 (95% CI 0.17 to 0.19) and 0.94 (95% CI 0.92 to 0.95), respectively.ConclusionsThe semi-automatic triage NTS tool underestimated the urgency in 27% of patients with ACS/other LTEs. Overruling by triage nurses improved safety, but still 14% of men and women with ACS/other LTEs received too low urgency, while efficiency remained poor.Trial registration numberNTR7331.

Diagnosis of acute coronary syndrome in the emergency room: the dictatorship of high-sensitivity cardiac troponin and major adverse cardiac events

Diagnosis of acute coronary syndrome in the emergency room: the dictatorship of high-sensitivity cardiac troponin and major adverse cardiac events

The Serum Metabolic Biomarkers in Early Diagnosis and Risk Stratification of Acute Coronary Syndrome.

Despite advances in the treatment of coronary diseases, acute coronary syndrome (ACS) remains the leading cause of death worldwide. ACS is associated with metabolic abnormalities of lipid oxidation stress. In this study, based on liquid chromatograph mass spectrometry technique, we conducted the metabolic profiling analysis of serum samples from stable plaques (SPs) and vulnerable plaques (VPs) in ACS patients for exploring the potential biomarkers of plaque stability. The results showed that four differential metabolites were identified between the SPs and VPs, including betaine, acetylcarnitine, 1-heptadecanoyl-sn-glycero-3-phosphocholine, and isoundecylic acid. Meanwhile, the diagnostic model was identified using stepwise logistic regression and internally validated with 10-fold cross-validation. We analyzed the correlations between serum metabolic perturbations and plaque stability, and the serum betaine and ejection fraction-based model was established with a good diagnostic efficacy [area under the curve (AUC) = 0.808, sensitivity = 70.6%, and specificity = 80.0%]. In summary, we firstly illustrate the comprehensive serum metabolic profiles in ACS patients, suggesting that the combined model of serum betaine and ejection fraction seems to be used as the potential diagnostic biomarker for the vulnerability of plaque stability.

In-hospital statin initiation characteristics and one-year statin adherence rates in patients hospitalised for acute coronary syndrome

Introduction In the present study, we aimed to evaluate compliance to lipid lowering guidelines regarding statin prescription on discharge and statin adherence rates during a follow-up period of one year in patients hospitalised with a diagnosis of acute coronary syndrome (ACS). Methods In-hospital records of 3506 ACS patients, of which 771 had experienced an ST-elevation myocardial infarction (STEMI) and 2735 had experienced a non-STEMI, were collected. We calculated medication possession ratios (MPRs) for each subject. We designated patients with ≥9 statin refills/year (MPR ≥ 0.75) as the statin-adherent group and patients with <9 statin refills/year (MPR < 0.75) as the statin-non-adherent group. Results During a 12-month follow-up period, 234 patients in the STEMI group (30.3%) and 391 patients in the non-STEMI group (14.3%) had 12 refills of statin. Thus, only 17.8% of the total study population had complete adherence to statin therapy with an MPR of 1. When patients with ≥9 statin prescriptions were categorised as the statin-adherent group, only 1575 patients (44.9%) were found to be adherent to statin treatment. In multivariate analysis, patients with a non-STEMI diagnosis and high intensity statin treatment had higher rates of non-adherence (OR:1.685, 95%CI:1.412–2.012, p < .01 and OR:1.344, 95% CI: 1.147–1.574, p < .01, respectively). Patients with prior statin treatment had lower rates of non-adherence(OR:0.437, 95%CI: 0.346–0.553, p < .01). Conclusion The present study shows that compliance with guidelines regarding statin initiation during hospitalisation and statin adherence rates during a one-year follow-up period are low for patients treated for ACS. Considering the overwhelming clinical benefits of high-intensity statins in patients with ACS, every effort should be made to increase the rate of optimal use of statins in secondary prevention.

The effect of religiosity of patients with Coronary Artery Disease on in-hospital anxiety and depression

Introduction: Religious faith and spirituality often seem to affect physical and psychological functioning of patients with chronic diseases. Aim: To investigate the relationship between religiosity/spirituality of coronary patients with anxiety and depression which may be experienced during their hospitalization. Methods: A cross-sectional study was conducted involving 172 patients (23 female and 149 male) with coronary artery disease, who were hospitalized in a general hospital of Attica region with an acute coronary syndrome diagnosis. HADS scale was used for the investigation of hospital anxiety and depression and the Belief and Values Scale was used to evaluate the patients’ religious faith and spirituality. Results: Moderate levels of religiosity/spirituality and no to moderate levels of anxiety and depression were found in coronary patients. No statistically significant correlations were found between the HADS subscales and the Beliefs and Values Scale (p&gt; 0.001), although individuals who have experienced strong spiritual experiences, experienced less anxiety and depression in hospital. There were found statistically significant correlations (p &lt;0.001) with gender, religious beliefs, patients’ age with Belief and Values Scale. There were also statistically significant correlations (p&lt;0.001) of HADS subscales with family status, age, smoking habits, stress and medication. Conclusion: Highly religious coronary patients are less likely to experience anxiety and depression during hospitalization, though confounders seem to interfere and make it difficult to interpret this relationship. Further research is required in order to explore the impact of religiosity on psychological distress of hospitalized coronary patients.

Acute coronary syndrome in employees of the Ministry of Internal Affairs. Inpatient stage of treatment and medical rehabilitation

The aim of the study: to analyze the ratio of acute myocardial infarction and unstable angina, the stages of medical rehabilitation in the structure of acute coronary syndrome in employees and senior citizens of the Ministry of Internal Affairs during treatment and medical rehabilitation. Materials and methods: The study examined 805 patients with ACS for the period 2012-2018, of which 227 were employees of the Ministry of Internal Affairs. All patients underwent a complete diagnosis of acute coronary syndrome in accordance with the standards of examination and treatment. With clinical validity, in some cases, coronary angiography and stenting of the coronary bed were performed. Results: The number of cases of hospitalization with ACS of employees and pensioners of the Ministry of Internal Affairs with ACS in 2012-2018. It was distributed as follows: in 2012 - 144, 2013 - 114, in 2014 - 158 and in 2015 - 135, 2016 - 147, 2017 - 66 and in 2018 - 41, respectively. The maximum frequency of hospitalizations with ACS among employees of the Ministry of Internal Affairs was recorded in 2014 - 91. The largest number of hospitalizations with ACS from 2012 to 2018 inclusively occurred among pensioners of the Ministry of Internal Affairs - 578 and 227 ACS among employees of the Ministry of Internal Affairs, respectively. At the same time, out of the total number of patients with ACS, 805-604 (75%) underwent MR stage I, 201 (25%) were transferred to stage II MR in the Pakhra branch of the SCG, Thus, with AMI and NS, employees and pensioners In 25% of clinical cases, the Ministry of Internal Affairs requires stage II MR. Conclusion: With the development of ACS, AMI prevails among the employees of the Ministry of Internal Affairs, NS is more often diagnosed among pensioners of the Ministry of Internal Affairs. In the treatment and rehabilitation of AMI, employees of the Ministry of Internal Affairs less than half the cases, namely up to 38%, require transfer to a rehabilitation center as part of one hospitalization, which is an optimizing element in the stage medical rehabilitation of employees of the Ministry of Internal Affairs who underwent ACS. At the same time, a comprehensive program consisting of exercise therapy: therapeutic exercises for patients with coronary heart disease, breathing exercises, physiotherapy: sinusoidal modulated currents according to the standard method (pulse frequency: 80-100 Hz.) In alternation with balneotherapy, is effective at the rehabilitation stage.

The impact of optimal medical therapy on patients with recurrent acute myocardial infarction: Subanalysis from the BleeMACS study

BackgroundAcute myocardial infarction (AMI) recurrence is still high despite great progress in secondary prevention. Patients with recurrent AMI suffer worse prognosis compared to those with first AMI. The objective was to evaluate the effect of optimal medical therapy (OMT) on these patients with recurrent AMI. Methods and resultsSub-analysis was performed including 13,343 patients with AMI from the international multicenter Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome (BleeMACS) registry. OMT was defined as the combination of aspirin, any P2Y12 inhibitor, statin, angiotensin converting enzyme inhibitor/angiotensin receptor blocker, and beta-blocker. Among 1285 patients with prior AMI, 56.8% received OMT prescription. Patients receiving OMT suffered from less congestive heart failure, peripheral artery disease, malignancy, and bleeding history. Kaplan-Meier survival estimates revealed that OMT was strongly related to decreased in all-cause death (4.2% vs. 10.1%, p < .001) and the composite endpoint of death/re-AMI (11.1% vs. 16.9%, p = .005) at 1-year follow-up. OMT was the independent protect factor of primary endpoint even after adjusting for multiple possible confounders (HR, 0.46; 95% CI, 0.27–0.78; p = .004). However, no significant difference was observed regarding re-AMI between OMT and non-OMT groups. OMT also reduced all-cause death in patients with recurrent AMI after propensity score matching. ConclusionsThe prescription of OMT was seriously insufficient in patients with recurrent AMI, especially high-risk patients, even though OMT was associated with improved prognosis. Further improvements in pharmacological therapy are needed to reduce subsequent recurrent events.

A rare long-term undetected pheochromocytoma leading to Takotsubo syndrome in an older male patient: a case report

BackgroundTakotsubo syndrome is an uncommon, acute, and reversible cardiomyopathy that occurs primarily in postmenopausal females. The clinical presentation of the syndrome resembles acute coronary syndrome, but coronary angiography reveals no obstructive coronary artery disease. Rarely, a catecholamine surge due to pheochromocytoma may induce Takotsubo syndrome. The clinical features of pheochromocytoma include paroxysmal hypertension, headache, palpitations, and profuse sweating. However, owing to the episodic, rather than continued, symptoms and signs of pheochromocytoma, its timely diagnosis poses a challenge for clinicians. Here, we report a rare case of long-term undetected pheochromocytoma leading to Takotsubo syndrome in an older male patient.Case presentationA 70-year-old man presented with paroxysmal chest distress and chest pain. Examinations revealed acute coronary syndrome with normal coronary arteries, heart failure, reversible left ventricular regional wall motion abnormalities, labile blood pressure, a giant left adrenal mass, and extremely high levels of metanephrine and normetanephrine. Clinical manifestations, laboratory reports, and imaging findings suggested a diagnosis of Takotsubo syndrome caused by pheochromocytoma. Supportive therapy, administration of alpha- adrenergic receptor blockers, and left adrenal mass resection resolved the patient’s symptoms. A histological examination confirmed the presence of pheochromocytoma. We reviewed his history of midbrain hemorrhage 6 years prior and found a mass in the left adrenal region by reviewing the computed tomography images of the lung that were also taken 6 years prior, on which the pheochromocytoma was evident.ConclusionsOur case illustrates the importance of understanding the link between pheochromocytoma and Takotsubo syndrome. A diagnosis of pheochromocytoma-induced Takotsubo syndrome should be considered during the differential diagnosis of acute coronary syndrome, especially in patients with labile blood pressure and normal coronary angiography findings; meanwhile, assessments of catecholamines and its metabolites and abdominal computed tomography scan should be performed at the right time. Clinicians should also be alert to potential pheochromocytoma in patients with unexplained cerebral hemorrhage, even in the absence of symptoms of catecholamine excess.

Challenges and Perspectives on Biosensors for Highly Sensitive Quantification of Salivary Troponins: A Review

Troponins are recognized as one of the most specific and sensitive biomarkers for the diagnosis and prognosis of acute coronary syndromes. The use of troponins as acute cardiac isquemic biomarkers impacts positively on the treatment costs and on the mortality rate due to cardiovascular diseases. Nowadays, efforts have been made to develop new methods to detect and quantify troponins in a non-invasive way, reducing the need for blood samples and venipuncture. Saliva started to be increasingly recognized as an attractive diagnostic fluid. However, the challenges in achieving statistically significant correlations between saliva and serum concentrations, the limitations dealing with this high viscosity fluid and the background interferences, have limited the application of biosensors for troponin quantification in saliva. This review briefly approaches the mechanisms of troponin release and reports the methods found in literature for detection of troponin in saliva. Finally, the authors present a discussion of the challenges and perspectives on this topic.

Serum Exosomal MicroRNA-21, MicroRNA-126, and PTEN Are Novel Biomarkers for Diagnosis of Acute Coronary Syndrome.

Acute coronary syndrome (ACS) is a serious threat to public health. Based on clinical manifestations, ACS can be classified into unstable angina (UA) pectoris and acute myocardial infarction (AMI). The purpose of this study was to explore the possibility of using serum exosomal microRNA (miR)-126, miR-21, and phosphatase and tensin homolog (PTEN) expression levels as biomarkers of UA and AMI and to investigate whether these levels were positively correlated with the severity of coronary stenosis based on the Gensini score. Exosomes were isolated by ultracentrifugation from the serum of 34 patients with AMI, 31 patients with UA, and 22 healthy controls. The isolated exosomes were characterized by electron microscopy and particle size analysis; exosomal identity was further confirmed by western blotting using exosome-specific antibodies. Real-time quantitative polymerase chain reaction indicated that the serum exosomal levels of miR-126 and miR-21 were significantly higher in the patients with UA and AMI than in the healthy controls. Enzyme-linked immunosorbent assay showed that the serum exosomal PTEN levels were significantly higher in the UA and AMI groups than in the control group. Receiving operating characteristic curve analysis demonstrated the diagnostic efficiency of serum exosomal miR-126, miR-21, and PTEN levels for predicting AMI and UA. In addition, the circulating exosomal miR-126 level was positively correlated with the severity of coronary artery stenosis in patients with UA and AMI based on the Gensini score.

Incidence of aspirin resistance is higher in patients with acute coronary syndrome and atrial fibrillation than without atrial fibrillation.

In patients with atrial fibrillation, standard anticoagulation with a vitamin K antagonist plus dual antiplatelet therapy with a P2Y12 inhibitor and aspirin is the standard of care after percutaneous coronary intervention (PCI). While this therapy reduces the risk of thrombosis and stroke, it increases the risk of bleeding. It is unclear whether the antiplatelet effect of aspirin and clopidogrel may worsen atrial fibrillation (AF). OBJECTIVE Thus we aimed to analyze platelet aspirin resistance (AR) and clopidogrel resistance (CR) in acute coronary (ACS) patients based on sinus rhythm (SR) and AF. METHODS In this prospective trial, we included 543 patients (mean age: 62± 12 years; range: 26 - 89 years) who were on aspirin and clopidogrel therapy after the diagnosis of acute coronary syndrome. AR and CR were analyzed by a Multiplate® MP-0120 device by using the method of whole blood aggregometry. RESULTS AF patients had significantly higher age, mean platelet volume, and High-Sensitivity C-Reactive Protein (p< 0.01 for each parameter). Similarly, Arachidonic-acid induced (ASPI) aggregation was higher in AF patients compared to SR patients (666±218 vs. 187±179, p<0.001). Among the ACS patients, significantly more female patients had AF (p<0.001). The incidence of hypertension in the AF group was higher compared to the SR group (p<0.001). However, adenosine diphosphate levels were not at a significant level in the two groups. CONCLUSION Our findings indicate that the platelet inhibitory effect of Aspirin was worse for patients with AF, suggesting that the effectiveness of aspirin may be less in the prophylaxis of thromboembolism and more a bleeding risk.

The correlation of retinol-binding protein-4 and lipoprotein combine index with the prevalence and diagnosis of acute coronary syndrome

Retinol-binding protein-4 (RBP-4) along with the lipid profile plays crucial roles in Acute coronary syndrome (ACS). The study aimed to investigate the correlation of RBP-4, lipoprotein combine index (LCI), and RBP-4 + LCI with ACS. 163 ACS and 77 non-CAD in patients were consecutively enrolled in this study. The serum level of RBP-4 was measured via enzyme-linked immunosorbent assay. LCI was calculated using the formula: total cholesterol × triglyceride × low-density lipoprotein cholesterol/high-density lipoprotein cholesterol. RBP-4 ≥4 ng/ml, LCI ≥16 and LCI ≥16 + RBP-4 ≥4 ng/ml were new independent risk factors of ACS, and OR value of LCI ≥16 + RBP-4 ≥4 ng/ml was higher than that of RBP-4 and LCI combined (all p < 0.05). The AUC for LCI + RBP-4 was higher than that for LCI and RBP-4 individually. The risk of high LCI in 1 lesion vessel was greater than those of 2 or ≥3 lesion vessels (all p < 0.05). In 1 lesion vessel or ≥3 lesion vessels group, the risk associated with LCI and RBP-4 combined was higher than the risk of LCI or RBP-4 alone (all p < 0.05). The risk of hypertension, diabetes mellitus, smoking and history of MI increased with numbers of vessels lesion (all p < 0.05). Increase in RBP-4 and LCI values were found to be independent risk factors for ACS, and the risk of the combined rise in LCI and RBP-4 values was higher than LCI or RBP-4 alone. The combined tests of LCI and RBP-4 might be a potential diagnostic marker for ACS.

Assessment of apolipoprotein B/apolipoprotein A-I ratio in non-ST segment elevation acute coronary syndrome patients

BackgroundThe apolipoprotein B/apolipoprotein A-I ratio was shown to be strongly related to the risk of myocardial infarction in several large-scale studies. The current study aimed at exploring the diagnostic and short-term prognostic values of apolipoprotein B/apolipoprotein A-I ratio in patients presenting with non-ST segment elevation acute coronary syndrome. One hundred patients with non-ST segment elevation acute coronary syndrome were prospectively enrolled, in addition to a matched group of 100 patients with chronic stable angina. Serum levels of total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, and apolipoproteins B and A-I were quantified in both groups. Patients with non-ST segment elevation acute coronary syndrome underwent coronary angiography.ResultsThe mean age of the study population was 57 ± 6 years, 65% being males. The non-ST segment elevation acute coronary syndrome group showed significantly unfavorable lipid profile parameters, including apolipoprotein B/apolipoprotein A-I ratio. Higher apolipoprotein B/apolipoprotein A-I ratio was associated with more coronaries showing significant stenosis and more complex lesion morphology. Receiver operating characteristic curve analysis reached an optimal cut-off value of 0.93 for diagnosis of non-ST segment elevation acute coronary syndrome (sensitivity 70% and specificity 88%) and 0.82 for predicting the presence of multi-vessel disease (sensitivity 90% and specificity 97%).ConclusionApolipoprotein B/apolipoprotein A-I ratio is a useful tool of risk assessment in patients presenting with non-ST segment elevation acute coronary syndrome including prediction of coronary multivessel affection.Apolipoprotein B/apolipoprotein A-I ratio was shown to be strongly related to risk of myocardial infarction. Higher ratios of apolipoprotein B/apolipoprotein A-I were recorded in NSTE-ACS patients (versus stable angina patients). Higher apolipoprotein B/apolipoprotein A-I ratios were associated with more diseased coronaries and complex lesions. Apolipoprotein B/apolipoprotein A-I ratio is a useful tool for acute risk assessment in cardiac ischemic patients.

Incentivising the rapid diagnosis of acute coronary syndromes in England and Wales.

Incentivising the rapid diagnosis of acute coronary syndromes in England and Wales.

Diagnosis and treatment of acute coronary syndrome during the novel coronavirus infection COVID-19 pandemic

The novel coronavirus infection COVID-19 pandemic has spread to more than 180 countries. Cardiovascular patients belong to one of the susceptible population cohorts. There is a peculiar pathogenesis and variety of clinical manifestations of COVID-19, as well as difficulties with early diagnosis. Other unresolved issues are routing, surgery and therapy of such patients and comorbidities. Due to absence of well-defined algorithms and guidelines, the treatment of patients with acute coronary syndrome (ACS) in different countries is carried out differently. Interactions between antiviral and coronary artery disease medications are also not completely clear. Based on the available data, the main organizational and therapeutic approaches for ACS during the COVID-19 pandemic are reflected.

Highly Sensitive Cardiac Troponins: The Evidence Behind Sex-Specific Cutoffs.

Emergence of various highly sensitive cardiac troponin assays into clinical practice provides a new tool for clinicians diagnosing acute coronary syndrome. These assays also create a challenge for laboratories and clinicians who have yet to familiarize themselves with sex‐specific cutoffs. Healthy men and women, studied across various age groups and geographic locations, have notable differences in baseline values of highly sensitive cardiac troponin I and T, leading to establishment of sex‐specific upper reference limits and cutoffs. Several differences in cardiac physiology, size, and structure may account for baseline differences in highly sensitive cardiac troponins and outcomes between the sexes. The clinical utility of implementing sex‐specific cutoffs for diagnosis and management of acute coronary syndrome remains unclear. Presently, the only prospective study failed to show improved outcomes for men or women with use of sex‐specific cutoffs; however, a major limitation is the frequent lack of diagnostic, therapeutic, and preventive interventions prescribed to women with low‐level troponin elevations. Based on the current literature, we posit that there may nonetheless be clinical value in the use of sex‐specific cutoffs for evaluating suspected acute coronary syndrome, especially in select patient populations such as younger women who tend to have lower baseline values of highly sensitive cardiac troponins. Future studies should prospectively evaluate differences in diagnostic, pharmacologic, and interventional management in men and women using myocardial infarctions classified with sex‐specific cutoffs of the highly sensitive cardiac troponin assays.

SAT-181 Pheochromocytoma Masquerading as Acute Coronary Syndrome. To Cath or Not to Cath?

BackgroundPheochromocytoma had been known as the “Great Mimic” as it can present with signs and symptoms consistent with numerous differentials [1]. Cardiac ischemia is one in particular which creates a diagnostic dilemma and poses significant risk for misdiagnosis.Clinical Case62-year-old female with recent onset hypertension and type II diabetes(HbA1C of 6.9%) presented to the ER with new episodes of nausea, vomiting, and substernal chest pain. During the preceding four months she also experienced episodic headaches, palpitations, and flushing.Initial vital signs were significant for blood pressure 157/81 mm Hg. Physical exam was unremarkable. An Electrocardiogram showed normal sinus rhythm with right axis deviation and ST segment depressions in the inferior leads II, III and aVF.Labs revealed a troponin peak at 2.95 (<0.04 ng/mL) and d-dimer of 403 (<400 ng/mL). Serum chemistry, TSH, and complete blood count were within normal limits. A CT Chest with angiography was negative for pulmonary emboli. However, it did note a heterogenous 7.6 cm right adrenal mass. At this juncture there was clinical concern for pheochromocytoma and serum free metanephrines was ordered.Prior to receiving medical treatment for her pheochromocytoma, she underwent cardiac catheterization which showed no evidence of coronary artery disease. The procedure was uncomplicated. However, post-procedurally she did develop worsening paroxysms and severe hypertensive episodes with heart rate up to 140 beats per minute and systolic blood pressure up to 220 mm Hg. She was subsequently started on alpha blockage with phenoxybenzamine 10mg twice daily to which she responded favorably. Her initial serum free metanephrine was 6087(< 57 pg/mL) and free normetanephrine 2489 (<148 pg/mL).ConclusionsThis case highlights the importance of maintaining a high index of suspicion for pheochromocytoma for all patients with acute chest pain and hypertension. Her untreated pheochromocytoma could have been fatal during or immediately after the cardiac catheterization. Given the suspicion for pheochromocytoma in this case, it would have been most appropriate to have begun alpha blockade after blood was drawn for metanephrines and before attempting any invasive procedures. Pheochromocytoma should be included in the differential diagnosis of acute coronary syndrome because it can mimic an ischemic episode.

Physical Activity and Factors Affecting Its Maintenance Among Patients With Coronary Heart Disease Not Undergoing Cardiac Rehabilitation in China.

BackgroundThe level of physical activity (PA) among patients with coronary heart disease (CHD) living in Chinese communities who do not participate in cardiac rehabilitation programs and the factors contributing to patient maintenance of PA are unclear.ObjectiveThis cross-sectional study, guided by the Transtheoretical Model, evaluated (1) the maintenance of PA in Chinese patients with CHD 12 months after hospital discharge and (2) the demographic, clinical, and psychological characteristics associated with maintenance of PA.MethodsA total of 1162 patients completed 6 questionnaires at 12 months posthospitalization to assess their maintenance of PA, stage of change, symptoms of depression and anxiety, and health-related quality of life and sleep.ResultsOnly 40% of patients with CHD maintained regular PA 12 months after hospital discharge. Walking was their primary PA. Thirty-seven percent of patients reported no intention of having regular PA. Male sex (odds ratio [OR], 1.69), awareness of PA's cardiac benefit (OR, 4.12), a history of regular PA before the cardiac event (OR, 6.08), history of chronic disease (OR, 1.43), mild depressive symptoms (OR, 1.40), moderate and severe depressive symptoms (OR, 0.41), smoking (OR, 0.54), and years of CHD (OR, 0.96) were related to maintenance of regular PA. Patients with CHD who maintained regular PA had better quality of life and sleep (P < .001) and fewer unplanned clinic visits (P = .001) and cardiac cause readmissions (P = .012) and reported fewer declines in PA capacity (P < .001).ConclusionsWalking is the most common form of PA 12 months posthospitalization among patients with CHD in China. Patient education and counseling about the cardiac benefits of PA, taking into account stage of change, are important considerations to improve maintenance of PA.