Diagnosis Of Acute Coronary Syndrome Research Articles

Clinical decision aids and computed tomography coronary angiography in patients with suspected acute coronary syndrome

BackgroundThe HEART score, the T-MACS model and the GRACE score support early decision-making for acute chest pain, which could be complemented by CT coronary angiography (CTCA). However, their performance has...

RESIDUAL CARDIOVASCULAR RISK AND SEVERITY OF CORONARY DISEASE

Abstract Background The presence of residual risk in patients with a history of atherosclerotic cardiovascular disease (ASCVD) is a cause of additional cardiovascular events. The aim of this study is to correlate residual cardiovascular risk with the severity of coronary disease. Methods We enrolled 52 patients hospitalized with a diagnosis of acute coronary syndrome from September to October 2023 at the Clinical and Rehabilitation Cardiology of the San Filippo Neri Hospital. All patients were treated with percutaneous and/or surgical coronary revascularization and had a history of ASCVD. Thirty of these patients had a single–vessel coronary disease and 22 had a multivessel coronary disease. We analyzed the main cardiovascular risk factors and the received therapies in both groups. Results Triglyceride levels were significantly higher in the group with a multivessel coronary disease (132.94 ± 65.41 mg/dl vs 94.06 ± 37.63 mg/dl; p=0.01) as well as the levels of glycated hemoglobin (50.91 ± 15.23 mmol/mol vs 42.92 ± 6.65 mmol/mol; p=0.01) and high–sensitivity C–reactive protein (hs–CRP, 1.25 ± 1.48 mg/dl vs 0.65 ± 0.46 mg/dl; p=0.04). We found no significant differences between the two groups for the other main cardiovascular risk factors and the therapies. Conclusions Our data show that higher levels of triglycerides, glycated hemoglobin and hs–CRP, an inflammatory biomarker, are associated with a more extensive coronary disease. This finding suggests that a better metabolic control, in terms of glycated hemoglobin and triglyceride levels, and inflammation could contribute to the reduction of coronary disease extension.

IS IT REALLY A CASE OF TAKOTSUBO? SOMETIMES APPEARENCES CAN BE DECEPTIVE

Abstract We report the case of a 22–year–old female with a history of David procedure and mechanical valve replacement (ATS 22 mm) due to bicuspid aortic valve and severe AR with ascending aorta aneurysm in 2015. Regular annual clinical follow–up (EKG and ultrasound) was always normal. Since 2022 the patient suffered from episodes of dyspnea, chest pain and sadness diagnosed as Panic Disorder. Home–therapy: Warfarin, estroprogestinic pill. At the latest outpatient visit she was asymptomatic and in good overall condition, but her EKG showed novel alterations (T wave inversion in antero–lateral leads and QT prolongation). She was then sent to the ED. LAB: troponin levels were normal (6.8 ng/ml) with an elevated Nt–proBNP (425 ng/ml) and a low INR (1.53). Questioned about recent events she reported a road trauma which occurred two weeks prior. She was then admitted to Cardiology clinic. Ultrasound: apical akinesia with reduced wall thickness, EF 48%, E/E‘ 10, and normal right ventricular function. The aortic valve prosthesis was functional without pathological regurgitation, and other echocardiographic parameters were within normal limits. EKG and ultrasound abnormalities along with a recent history of trauma supported Takotsubo Syndrome diagnosis (InterTAK score = 79.8% – 67pt), even though troponin levels were normal. Throughout hospitalization there were no changes in the EKG or pathological increases in troponin, and the patient remained asymptomatic. The patient was treated with LMWH to achieve adequate INR levels and initiated on B–blocker, ACEi, and SGLT2i for HFmrEF. Cardiac MRI revealed apical segment akinesia with dilation and reduced wall thickness (EDV 97 ml/m²), EF 41%, transmural ischemic LGE in the apical region and a ventricular thrombus (16x4 mm). The patient underwent coronary angiography which showed normal epicardial coronary arteries. Upon careful history–taking, the patient admitted irregular intake of VKA in the previous months. Given this information, the MRI and angiographic findings the diagnosis of unrecognized prior acute coronary syndrome, likely due to coronary thromboembolism in a patient with PHV and suboptimal compliance with VKA, was established. The patient was discharged home upon achieving a persistently therapeutic INR, with instructions to discontinue contraceptive therapy. Conclusion: coronary thromboembolism is a rare complication of PHV with inadequate anticoagulation leading, in this case, to an unrecognized MI.

Development of the first Iranian clinical practice guidelines for the diagnosis, treatment, and secondary prevention of acute coronary syndrome.

This article introduces the first national guidelines for the management including diagnosis, treatment, and secondary prevention of acute coronary syndrome (ACS) in Iran. The members of the guideline development group (GDG) were specialists and experts in fields related to ACS and were affiliated with universities of medical sciences or scientific associations in the country. They carefully examined the evidence and clinical concerns related to ACS management and formulated 13 clinical questions that were sent to systematic review group who developed related evidence using Grade method. Finally the GDG developed the recommendations and suggestions of the guideline. The first three questions in the guideline focus on providing recommendations for handling a patient who experience chest pain at home, in a health house or center, during ambulance transportation, and upon arrival at the emergency department (ED) as well as the initial diagnostic measures in the ED. Subsequently, the recommendations related to the criteria for categorizing patients into low, intermediate and high-risk groups are presented. The guideline addressed primary treatment measures for ACS patients in hospitals with and without code 247 or having primary percutaneous coronary intervention (PCI) facilities, and the appropriate timing for PCI based on the risk assessment. In addition, the most efficacious antiplatelet medications for ACS patients in the ED as well as its optimal duration of treatment are presented. The guideline details the recommendations for therapeutic interventions in patients with ACS and acute heart failure, cardiogenic shock, myocardial infarction with nonobstructive coronary arteries (MINOCA), multivessel occlusion, as well as the indication for prescribing a combined use of anticoagulants and antiplatelet during hospitalization and upon discharge. Regarding secondary prevention, while emphasizing the referral of these patients to rehabilitation centers, other interventions that include pharmaceutical and nonpharmacological ones are addressed, In addition, necessary recommendations for enhancing lifestyle and posthospital discharge pharmaceutical treatments, including their duration, are provided. There are specific recommendations and suggestions for subgroups, such as patients aged over 75 years and individuals with heart failure, diabetes, and chronic kidney disease. Developing guidelines for ACS diagnosis, treatment and secondary prevention according to the local context in Iran can improve the adherence of our health care providers, patients health, and policy makers plans.

Quantitative Detection of Multiple Cardiovascular Biomarkers by an Antibody Microarray-Based Metal-Enhanced Fluorescence Assay.

Accurate detection of multiple cardiovascular biomarkers is crucial for the timely screening of acute coronary syndrome (ACS) and differential diagnosis from acute aortic syndrome (AAS). Herein, an antibody microarray-based metal-enhanced fluorescence assay (AMMEFA) has been developed to quantitatively detect 7 cardiovascular biomarkers through the formation of a sandwich immunoassay on the poly(glycidyl methacrylate-co-2-hydroxyethyl methacrylate)-decorated GNR-modified slide (GNR@P(GMA-HEMA) slide). The AMMEFA exhibits high specificity and sensitivity, the linear ranges span 5 orders of magnitude, and the limits of detection (LODs) of cardiac troponin I (cTnI), heart-type fatty acid binding protein (H-FABP), C-reactive protein (CRP), copeptin, myoglobin, D-Dimer, and N-terminal pro-brain natriuretic peptide (NT-proBNP) reach 0.07, 0.2, 65.7, 0.6, 0.2, 8.3, and 0.3 pg mL-1, respectively. To demonstrate its practicability, the AMMEFA has been applied to quantitatively analyze 7 cardiovascular biomarkers in 140 clinical plasma samples. In addition, the expression levels of cardiovascular biomarkers were analyzed by the least absolute shrinkage and selector operator (LASSO) regression, and the area under receiver operator characteristic curves (AUCs) of healthy donors (HDs), ACS patients, and AAS patients are 0.99, 0.98, and 0.97, respectively.

Gender perspective in the care experience and in the results of patients who consult for chest pain in an emergency department

Clinical practice guidelines suggest performing an electrocardiogram (EKG) in patients with chest pain within the first 10 minutes in the emergency department, warning about subdiagnosis in women. Possible differences based on sex were analyzed. An observational and retrospective study in an Emergency Department, with adult patients admitted to the Chest Pain Unit in 2021. There were 1,469 patients, of whom 774 were men (52.7%). The men were younger (60 vs. 65 years), were less overweight (17.18 vs. 22.16%), and had more previous admissions to the Coronary Unit (12 vs. 7%), compared to women. No gender differences were observed in EKG performance (91 vs. 90%), EKG time (median 4.1 vs. 4.5 minutes), or delay in care attention (median 25 vs. 26 minutes). In terms of healthcare resources, men underwent more biomarkers: troponins (63 vs. 55%; odds ratio [OR]: 1.35; 95% confidence interval [95%CI]: 1.10-1.67) and creatine phosphokinase (24.8 vs. 19.1%), received more aspirin (6.7 vs. 3.1%), nitrates/nitrites (6 vs. 3%), and hospitalization (17.18 vs. 10.50%; OR: 1.76; 95%CI; 1.30-2.40). Of 206 hospitalized, 112 had a final diagnosis of acute coronary syndrome (54%), more men than women (81 vs. 31). There were no significant differences in revascularization time, medication schedule at discharge, hospital stay, or mortality. Gender did not affect precordial pain care, diagnosis, and treatment times, highlighting the quality of hospital care.

Comparative Effectiveness and Safety of Ticagrelor and Clopidogrel in Patients With or Without Chronic Liver Disease: A Nationwide Cohort Study

BackgroundAlthough the effectiveness and safety of ticagrelor versus clopidogrel may differ in patients with chronic liver disease, there is a scarcity of evidence comparing ticagrelor and clopidogrel in patients with chronic liver disease. We aimed to evaluate the risk of major adverse cardiovascular events (MACE) and major bleeding associated with ticagrelor versus clopidogrel in patients undergoing percutaneous coronary intervention (PCI) due to acute coronary syndrome by chronic liver disease status. MethodsUsing the Korean healthcare claim database, we included adult patients who underwent PCI and initiated ticagrelor or clopidogrel treatment within 7 days of an acute coronary syndrome diagnosis. Patients were classified into 2 mutually exclusive groups: patients with chronic liver disease and patients without chronic liver disease. Within each group, the hazard ratios (HRs) with 95% confidence intervals (CIs) of MACE and major bleeding associated with ticagrelor versus clopidogrel were calculated using a Cox proportional hazards model within a 1:1 propensity score (PS) matched cohort. ResultsThe final cohort included 14,261 and 148,535 patients with and without chronic liver disease, respectively. After PS matching, the risk of MACE (with chronic liver disease, HR: 1.01, 95% CI: 0.91-1.13; without chronic liver disease, HR: 1.02, 95% CI: 0.98-1.05; P for homogeneity: 0.865) and major bleeding (with chronic liver disease, HR: 1.07, 95% CI: 0.71-1.61; without chronic liver disease, HR: 1.32, 95% CI: 1.15-1.53; P for homogeneity: 0.342) for ticagrelor versus clopidogrel do not vary with chronic liver disease status. ConclusionsAmong acute coronary syndrome patients undergoing PCI, the use of ticagrelor versus clopidogrel was associated with a similar risk of MACE and an increased risk of major bleeding, but these risks did not vary with chronic liver disease status.

Diagnosis of acute coronary syndrome

Acute coronary syndrome is one of the most important differential diagnostic considerations in emergency medicine. It describes the constellation of newly occurring clinical symptoms, often accompanied by typical 12-lead ECG changes and the release of cardiac troponins. The spectrum includes unstable angina pectoris, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). It is important to consistently carry out the diagnostic steps that are crucial for further therapeutic procedures to avoid delaying life-saving invasive coronary diagnostics, without losing sight of the diverse, sometimes time-critical differential diagnoses. Anamnesis and clinical examination form the basis of the further procedure. Further developments of biomarker assays with personalized limit values, new imaging modalities with ever higher resolution and faster imaging methods as well as advances in automated ECG analysis with integration of all findings through artificial intelligence will continue to offer many optimization options in the future diagnosis of acute coronary syndrome.

Health Promotion Model-Based Health Education Program in Acute Coronary Syndrome Patient: An Experimental Study

Objective: This study was conducted to examine the effect of a Health Promotion Model-based health education program on increasing the health-promoting behaviors of acute coronary syndrome patients.
 Methods: This is an experimental study that used a pretest-posttest design with a control group. The sample consisted of 101 patients hospitalized with the diagnosis of acute coronary syndrome in Turkey. The data were collected by using a Patient Monitoring Form and the Health Promoting Lifestyle Profile-II. While the patients in the control group received routine procedures, the patients in the experimental group were included in the health education program.
 Results: The health promoting-behaviors of the control group were found to be higher than those of the experimental group in the first follow-up (p

The role of C-reactive protein:albumin ratio and Neutrophil:lymphocyte ratio in predicting coronary artery disease.

Acute coronary syndrome (ACS), one of the most common causes of death worldwide, is a condition characterised by ischaemia and/or infarction due to reduced coronary blood flow. The most prevalent cause of ACS is coronary artery disease. In this study, we aimed to investigate the relationship between blood parameters that we commonly use in the laboratory [C-reactive protein (CRP), albumin, neutrophils and lymphocytes] and coronary artery disease (CAD). This retrospective, single-centre study included 100 patients who underwent coronary angiography, with the diagnosis of acute coronary syndrome between January and June 2023, and 106 patients with high clinical suspicion and normal coronary arteries as a control group. The NLR was obtained from the ratio of neutrophils to lymphocytes and the CAR was obtained from the ratio of CRP to albumin. We analysed the relationship between CAD and NLR and CAR according to laboratory findings and demographic characteristics of the patients. The average age of the study group was 59 ± 10 years. NLR and CAR values were higher in the patient group than the control group (5.2 ± 3.3 vs 2.27 ± 1.2, p = 0.004 and 0.5 ± 0.1 vs 0.097 ± 0.095, respectively, p < 0.001). Albumin ratios were found to be statistically significantly lower in the patient group than the patient group (42.4 ± 4 vs 44 ± 3.3, respectively, p = 0.01). In addition, CAR and NLR showed a significant diagnostic value for CAD in receiver operating characteristic curve analysis (area under the curve: 0.68 ± 0.07, p = 0.003; 0.66 ± 0.09 p ≤ 0.001). NLR and CAR values, which are important indicators of inflammation, were found to be higher in the patient group. We believe it may be important to monitor these patients more frequently and follow them closely in terms of CAD, especially if the rate is higher in individuals without CAD who come for out-patient clinic check-ups.

Artificial intelligence based prediction model of in-hospital mortality among females with acute coronary syndrome: for the Jerusalem Platelets Thrombosis and Intervention in Cardiology (JUPITER-12) Study Group.

Despite ongoing efforts to minimize sex bias in diagnosis and treatment of acute coronary syndrome (ACS), data still shows outcomes differences between sexes including higher risk of all-cause mortality rate among females. Hence, the aim of the current study was to examine sex differences in ACS in-hospital mortality, and to implement artificial intelligence (AI) models for prediction of in-hospital mortality among females with ACS. All ACS patients admitted to a tertiary care center intensive cardiac care unit (ICCU) between July 2019 and July 2023 were prospectively enrolled. The primary outcome was in-hospital mortality. Three prediction algorithms, including gradient boosting classifier (GBC) random forest classifier (RFC), and logistic regression (LR) were used to develop and validate prediction models for in-hospital mortality among females with ACS, using only available features at presentation. A total of 2,346 ACS patients with a median age of 64 (IQR: 56-74) were included. Of them, 453 (19.3%) were female. Female patients had higher prevalence of NSTEMI (49.2% vs. 39.8%, p < 0.001), less urgent PCI (<2 h) rates (40.2% vs. 50.6%, p < 0.001), and more complications during admission (17.7% vs. 12.3%, p = 0.01). In-hospital mortality occurred in 58 (2.5%) patients [21/453 (5%) females vs. 37/1,893 (2%) males, HR = 2.28, 95% CI: 1.33-3.91, p = 0.003]. GBC algorithm outscored the RFC and LR models, with area under receiver operating characteristic curve (AUROC) of 0.91 with proposed working point of 83.3% sensitivity and 82.4% specificity, and area under precision recall curve (AUPRC) of 0.92. Analysis of feature importance indicated that older age, STEMI, and inflammatory markers were the most important contributing variables. Mortality and complications rates among females with ACS are significantly higher than in males. Machine learning algorithms for prediction of ACS outcomes among females can be used to help mitigate sex bias.

High-sensitive cardiospecific troponins: the role of sex-specific concentration in the diagnosis of acute coronary syndrome (mini-review).

Cardiospecific troponins are specifically localized in the troponin-tropomyosin complex and the cytoplasm of cardiac myocytes. Cardiospecific troponin molecules are released from cardiac myocytes upon their death (irreversible damage in acute coronary syndrome) or reversible damage to cardiac myocytes, for example, during physical exertion or the influence of stress factors. Modern high-sensitive immunochemical methods for detecting cardiospecific troponins T and I are extremely sensitive to minimal reversible damage to cardiac myocytes. This makes it possible to detect damage to cardiac myocytes in the early stages of the pathogenesis of many extra-cardiac and cardiovascular diseases, including acute coronary syndrome. So, in 2021, the European Society of Cardiology approved diagnostic algorithms for the acute coronary syndrome, which allow the diagnosis of acute coronary syndrome in the first 1-2 hours from the moment of admission of the patient to the emergency department. However, high-sensitive immunochemical methods for detecting cardiospecific troponins T and I may also be sensitive to physiological and biological factors, which are important to consider in order to establish a diagnostic threshold (99 percentile). One of the important biological factors that affect the 99 percentile levels of cardiospecific troponins T and I are sex characteristics. This article examines the mechanisms underlying the development of sex-specific serum levels of cardiospecific troponins T and I and the importance of sex-specific cardiospecific troponin concentrations in diagnosing acute coronary syndrome.

Troponin efficacy in the diagnosis of acute coronary syndrome in patients with chronic renal failure.

There is no consensus on whether cardiac troponins with high reliability values should be different diagnostic criteria for acute myocardial infarction in patients with and without renal dysfunction. Although it is often emphasized that the etiology of elevated troponin levels in chronic kidney disease (CKD) remains unclear, elevated cardiac troponin (cTnT) levels have been associated with increased subclinical cardiac damage in these patient groups. In this study, we investigated the value of cTnT value in diagnosing acute coronary syndrome in CKD patients with high clinical suspicion of acute coronary syndrome and without acute ST segment elevation on electrocardiogram. The aim was to prevent cardiac ischemia from being overlooked in CKD patients. Coronary angiography revealed vessel occlusion in 192 patients, and the mortality rate after treatment decisions was 6.7%. The first measured troponin results showed a significant difference in patients who did not survive, indicating the prognostic value of troponin levels. Troponin values were compared with cardiovascular pathologies obtained by angiography, and elevated troponin levels strongly correlated with pathologic angiography results. The conclusion highlighted that despite prognostic uncertainties, biomarkers used for acute myocardial infarction diagnosis in patients with renal insufficiency are reliable in those with renal dysfunction. Elevated cTnT levels in CKD patients are considered a clear marker of cardiac ischemia, emphasizing the need for careful consideration of troponin values in this population.

Myocardial infarction in a young woman without cardiovascular risk factors: a case report

Myocardial infarction usually occurs in people over 50 years of age, but younger patients can also be affected. The article presents a case of a young patient, 34 years old, who was admitted to the cardiology department with a diagnosis of lowrisk non-ST segment elevation acute coronary syndrome. The patient complained of anginal pain that occurred for the first time. However, she did not have typical risk factors for cardiovascular diseases. Coronary angiography showed a critical stenosis of 99% in the proximal third of the 2nd segment of the right coronary artery. A case clearly demonstrates the importance of a thorough examination of young patients with complaints of chest pain, which is often mistakenly interpreted as a pathology of other organs and systems other than the cardiovascular one. No risk factors in a patient does not guarantee low risk of myocardial infarction, and a detailed examination of the patient will help to avoid underdiagnosis of acute coronary syndrome.

Cardiac Troponin Serum Concentration Measurement Is Useful Not Only in the Diagnosis of Acute Cardiovascular Events.

Cardiac troponin serum concentration is the primary marker used for the diagnosis of acute coronary syndrome. Moreover, the measurement of cardiac troponin concentration is important for risk stratification in patients with pulmonary embolism. The cardiac troponin level is also a general marker of myocardial damage, regardless of etiology. The purpose of this study is to conduct a literature review and present the most important information regarding the current state of knowledge on the cardiac troponin serum concentration in patients with chronic cardiovascular disease (CVD), as well as on the relationships between cardiac troponin serum concentration and features of subclinical cardiovascular dysfunction. According to research conducted to date, patients with CVDs, such as chronic coronary syndrome, chronic lower extremities' ischemia, and cerebrovascular disease, are characterized by higher cardiac troponin concentrations than people without a CVD. Moreover, the literature data indicate that the concentration of cardiac troponin is correlated with markers of subclinical dysfunction of the cardiovascular system, such as the intima-media thickness, pulse wave velocity, ankle-brachial index, coronary artery calcium index (the Agatston score), and flow-mediated dilation. However, further research is needed in various patient subpopulations and in different clinical contexts.

Simulation training for medical emergencies: Evaluation of dentists' long-term learning skills and confidence.

As the population ages and more patients experience medical emergencies during dental treatments, dentists must competently and confidently manage these situations. We developed a simulation training course for medical emergencies in the dental setting using an inexpensive vital sign simulation app for smartphones/tablets without the need for an expensive simulator. However, the duration for which this effect is maintained is unclear. This study was performed to evaluate the long-term educational effect at 3, 6, and 12 months after taking the course. Thirty-nine dental residents participated in this course. Scenarios included vasovagal syncope, anaphylaxis, hyperventilation syndrome, and acute coronary syndrome, each of which the participants had to diagnose and treat. The participants were evaluated using a checklist for anaphylaxis diagnosis and treatment skills immediately after and 3, 6, and 12 months after the course. The participants were also surveyed about their confidence in diagnosing and treating these conditions by questionnaire before, immediately after, and 3, 6, and 12 months after the course. The checklist scores for anaphylaxis were significantly lower at 3, 6, and 12 months after the course than immediately after the course. The percentage of participants who provided a correct diagnosis and appropriate treatment for vasovagal syncope, hyperventilation syndrome, and acute coronary syndrome was lower at all reassessments than immediately after the course. Because medical emergency management skills and confidence declined within 3 months, it would be useful to introduce a refresher course approximately 3 months after the initial course to maintain skills and confidence.

Changes in Cardiac Electrical Biomarker in Response to Coronary Arterial Occlusion: An Experimental Observation.

Cardiac electrical biomarker (CEB), an indicator of ischaemia-induced change in myocyte polarity, has been proposed for diagnosis of acute coronary syndrome. However, effect of coronary occlusion on CEB has not been demonstrated. CEB was acquired before (CEB0), during maximal adenosine hyperaemia (CEBhyp), balloon inflations (CEBmax) and 1 (CEB1h), 2 (CEB2h) and 3 (CEB3h) h after percutaneous coronary intervention along with pre- and post-procedural troponin-I. CEB of subjects with non-cardiac chest pain without risk factors was used as controls (CEBc). "Late recovery" (LR) of CEB was defined as CEB3h > median-CEB0. CEB was recorded in 75 patients undergoing stenting (group 1) including 8 with FFR < 0.8 (group 1a), 25 with FFR ≥ 0.8 (group 2) and 49 controls. In group 1, CEB0 (median, IQR) was higher than CEBc (48.0; 29.5-88.3 vs 30.0; 17.0-44.0; p < 0.001). CEBmax (185; 105.0-331.0) was higher than CEB0 (p < 0.0001). CEB1h (78.0; 31.5-143.8; p < 0.0001) and CEB2h (63.0; 31.5-114.3; p = 0.039) were higher than CEB0 while CEB3h (54.0; 24.3-94.8, p = 0.152) was similar. LR occurred in 50.7% patients. CEBmax predicted LR (OR 1.01, 95% CI 1.00-1.01, p < 0.001) (AUC 0.759, p < 0.001). CEB0 in group 1a and group 2 were similar (p = 0.524). CEBhyp was higher than CEB0 in group 1a (126.0, 109.5-266.0 vs 47.5, 20.5-73.5; p = 0.016) and group 2 (44.0, 27.8-104.8 vs 39.0, 24.0-90.3; p = 0.014). CEBhyp was higher in group 1a than 2 (p = 0.039). CEBhyp (AUC 0.75, p = 0.017) accurately predicted FFR < 0.8. Coronary arterial occlusion increases CEB that retains a "memory" of the ischaemic event. CEBhyp was higher only when FFR was ischaemic and accurately identified FFR < 0.8.

Machine Learning for Myocardial Infarction Compared With Guideline-Recommended Diagnostic Pathways.

Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome (CoDE-ACS) is a validated clinical decision support tool that uses machine learning with or without serial cardiac troponin measurements at a flexible time point to calculate the probability of myocardial infarction (MI). How CoDE-ACS performs at different time points for serial measurement and compares with guideline-recommended diagnostic pathways that rely on fixed thresholds and time points is uncertain. Patients with possible MI without ST-segment-elevation were enrolled at 12 sites in 5 countries and underwent serial high-sensitivity cardiac troponin I concentration measurement at 0, 1, and 2 hours. Diagnostic performance of the CoDE-ACS model at each time point was determined for index type 1 MI and the effectiveness of previously validated low- and high-probability scores compared with guideline-recommended European Society of Cardiology (ESC) 0/1-hour, ESC 0/2-hour, and High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome) pathways. In total, 4105 patients (mean age, 61 years [interquartile range, 50-74]; 32% women) were included, among whom 575 (14%) had type 1 MI. At presentation, CoDE-ACS identified 56% of patients as low probability, with a negative predictive value and sensitivity of 99.7% (95% CI, 99.5%-99.9%) and 99.0% (98.6%-99.2%), ruling out more patients than the ESC 0-hour and High-STEACS (25% and 35%) pathways. Incorporating a second cardiac troponin measurement, CoDE-ACS identified 65% or 68% of patients as low probability at 1 or 2 hours, for an identical negative predictive value of 99.7% (99.5%-99.9%); 19% or 18% as high probability, with a positive predictive value of 64.9% (63.5%-66.4%) and 68.8% (67.3%-70.1%); and 16% or 14% as intermediate probability. In comparison, after serial measurements, the ESC 0/1-hour, ESC 0/2-hour, and High-STEACS pathways identified 49%, 53%, and 71% of patients as low risk, with a negative predictive value of 100% (99.9%-100%), 100% (99.9%-100%), and 99.7% (99.5%-99.8%); and 20%, 19%, or 29% as high risk, with a positive predictive value of 61.5% (60.0%-63.0%), 65.8% (64.3%-67.2%), and 48.3% (46.8%-49.8%), resulting in 31%, 28%, or 0%, who require further observation in the emergency department, respectively. CoDE-ACS performs consistently irrespective of the timing of serial cardiac troponin measurement, identifying more patients as low probability with comparable performance to guideline-recommended pathways for MI. Whether care guided by probabilities can improve the early diagnosis of MI requires prospective evaluation. URL: https://www.clinicaltrials.gov; Unique identifier: NCT00470587.

Tele-ECG improves diagnosis of acute coronary syndrome and ST-elevation myocardial infarction in Côte d'Ivoire.

The emergence of cardiovascular risk factors in sub-Saharan Africa suggests an increasing incidence of acute coronary syndromes and STEMI. The aim of the study was to define the prevalence of STEMI and to describe the characteristics of patients diagnosed with STEMI within the tele-electrocardiogram (ECG) network in Côte d'Ivoire. A retrospective study was conducted from January 2015 to August 2019. All adult patients managed by one of the six hospitals within the telemedicine network who benefited from a remote interpretation of their ECG by the cardiology department of Bouaké University Hospital were included. The main reason for ECG interpretation, patient and ECG characteristics, diagnosis, response time and treatment were described. A total of 5649 patients were included. The prevalence of STEMI was 0.7% (n = 44 cases) with a mean age of 58.6 ± 11.8 years and a M/F sex ratio of 1.93. Among STEMI patients, chest pain was the main reason for ECG testing (56.8%). Most ECGs were interpreted within 12 hours (72.8%). The anterior inter-ventricular artery location (59.1%, n = 26) was predominant. The Q wave of necrosis was absent in 18% (n = 8) of cases. All patients received double anti-platelet aggregation and 50% (n = 22) additional heparin therapy. No patient underwent primary angioplasty or thrombolysis, 65.9% (n = 29) were referred to the Bouaké Cardiology Department and 34.1% (n = 15) to the Abidjan Heart Institute. Scheduled angioplasty was performed in 20% (n = 3) of patients in Abidjan. Tele-ECG was an effective means of STEMI screening in Côte d'Ivoire. Systematic telethrombolysis of all patients diagnosed could improve their prognosis.

Allergic Acute Coronary Syndrome: A Case Report and Literature Review

Introduction: Kounis Syndrome was first described in 1991 by Kounis and Zavras as “the concurrence of chest pain during an allergic reaction, accompanied by clinical laboratory findings of classical angina pectoris caused by inflammatory mediators released during the allergic insult” [1].&#x0D; The mechanism of Kounis Syndrome most likely involves the release of cytokines through mast-cell degranulation, which leads to coronary vasospasm and atheromatous plaque erosion or rupture following the allergic reaction to an allergen.[2]&#x0D; The treatment is specific to acute coronary syndrome and anaphylaxis, with the added complication that the drugs used, while indicated in each of the two disorders separately, may present contradictions when administered jointly in one patient.[3]&#x0D; The purpose of this review is to briefly revise the existing literature regarding its overlooked diagnosis and contradictory joint management of anaphylaxis and acute coronary syndrome.&#x0D; We will conduct a brief review of the current literature on Kounis Syndrome while describing a suspected case of a female patient presented with both anaphylaxis symptoms and angina pectoris.&#x0D; Conclusions: Kounis syndrome is defined as the co-incidental occurrence of an acute coronary syndrome with hypersensitivity reactions following an allergic reaction. Treatment of allergic reactions may be sufficient in type I KS. In contrast, coronary intervention is needed in the other two types, accompanied by vasodilator drugs, including nitrates and calcium antagonists, each of which may have contradictory effects.