Evaluation Of Acute Coronary Syndrome Research Articles

Evaluating the Rates of Mortality and Cardiac Catheterization Using High-Sensitivity Troponin and Conventional Troponin Assays.

Non-ST segment elevation myocardial infarction (NSTEMI) is an acute coronary syndrome event where myocardial ischemia is present, with an increase of cardiac troponins without an elevation of the ST segment.One of the fundamental measures used to diagnose or rule out acute coronary syndrome (ACS) is troponin levels in the blood.Troponin is a broad term used for the category of muscle contraction regulatory proteins and is commonly measured during ACS evaluation. Troponin I is only released by cardiac tissue, while some assay measurements will also pick up troponin released by skeletal muscle injury. This retrospective observational study was performed investigating troponin assays and how they relate to patient's outcomes. The troponin assays used in this Miami hospital where the database of patients was collected between 2018 and 2023 were troponin I (cTnI), the conventional troponin assay, and the newer high-sensitivity troponin I assay (hs-cTn). In this observational study patients who received an admitting diagnosis of NSTEMI corroborated by an independent cardiologist had their respective troponin assay levels included. Patients found to have ECG changes significant for non-ischemic pathologies, or echocardiogram findings suggestive of myocardial dysfunction not clinically correlated to an ACS were excluded from the study. A total of 75 patients were included in this study and the mean age was 75.97 ±14.72 years, with a presentation of chest pain, dyspnea and general weakness recorded in 59% (n = 45) of patients. The median time between troponin samples was 6.63 hours across both assays and hs-cTn showed a 4.99% increase in variation between samples while cTnI had a decrease of 2.53%. The study objective is to support whether there is a difference in rates of cardiac catheterization or mortality based on the type of troponin testing. There was no significant association found between, the type of troponin assay used during hospital admission, and the outcomes of catheterization and death (p > 0.009).

Prospective Bidirectional Relationship Between Sleep Duration and Posttraumatic Stress Disorder Symptoms After Suspected Acute Coronary Syndrome.

Sleep disturbance is a "hallmark" symptom of posttraumatic stress disorder (PTSD). Poor sleep (including short sleep) after combat-related trauma can also predict subsequent PTSD. Less is known about the association between sleep duration and PTSD symptoms when PTSD is induced by acute coronary syndrome (ACS). We examined the bidirectional relationship between sleep duration and PTSD symptoms over the year after hospital evaluation for ACS. Participants were enrolled in this observational study after emergency department evaluation for ACS. Sleep duration ("During the past month, how many hours of actual sleep did you get at night?") and cardiac event or hospitalization-induced PTSD symptoms (PTSD Checklist) were assessed at 1, 6, and 12 months after hospital discharge. Cross-lagged path analysis was used to model the effects of sleep duration and PTSD symptoms on each other. Covariates included age, sex, race/ethnicity, cardiac severity, baseline depression symptoms, and early acute stress disorder symptoms. The sample included 1145 participants; 16% screened positive for probable PTSD (PTSD Checklist score ≥33). Mean sleep duration across time points was 6.1 hours. Higher PTSD symptoms predicted shorter sleep duration at the next time point (i.e., 1-6 and 6-12 months; B = -0.14 hours/10-point difference, SE = 0.03, p < .001). Shorter sleep duration was associated with higher PTSD symptoms at the next time point (B = -0.25 points/hour, SE = 0.12, p = .04). Short sleep duration and PTSD symptoms are mutually reinforcing across the first year after ACS evaluation. Findings suggest that sleep, PTSD symptoms, and their relationship should be considered in the post-ACS period.

Abstract 13988: Post Stress Test High-Sensitivity Cardiac Troponin I in the Evaluation of Patients With Acute Chest Pain for Enhanced Ischemic Risk Assessment: A Pilot Study

Introduction: High-sensitivity cardiac troponin I (hs-cTnI) assays provide comparable diagnostic information that allow for better detection of myocardial injury. However, hs-cTnI release after cardiac stress testing and its potential utility for identifying inducible myocardial ischemia and risk-stratification are unclear. Aim: This pilot study examined integrating hs-cTnI biomarker testing into cardiac imaging stress testing to improve detection of inducible ischemia and aid in risk-stratification in patients with chest pain being evaluated for acute coronary syndrome (ACS). Methods: We prospectively enrolled 200 consecutive adult patients referred by the Emergency Room for cardiac stress testing for evaluation of possible ACS. A venous blood sample was collected between 0.5 and 2 hours post stress testing; cTnI concentrations were measured in-house by high sensitivity methods. Changes from pre-stress test hs-cTnI concentrations were calculated and association with outcome was explored using a logistic regression model. Results: Patient median age was 62 years, IQR 54-70; 49% were women. ACS known risk factors included hypertension 81.5%, cigarette smoking 49.5% and diabetes 33.5%. Median BMI was 31.63 kg/m 2 , IQR 27.24-35.84. Pre-stress test hs-cTnI median levels were 6 ng/L, IQR 5-9, for women (URL &lt;52 ng/L) and 8 ng/L, IQR 6-12, for men (URL &lt;77 ng/L). A total of 121 patients (60.5%) underwent nuclear stress tests, and 79 (39.5%) received echocardiographic stress tests. Of the 191 samples analyzed, 36% revealed increased hs-cTnI levels from pre-stress test values: 33% in nuclear stress tests (median increase 2 ng/L, IQR 1-5), 41% in echocardiographic stress tests (median increase 2 ng/L, IQR 1-5). In the 155 patients with 6 months of follow-up, changes in post-stress test hs-cTnI levels were not significantly correlated to stress test results, percutaneous coronary interventions or death (p=.85). Conclusion: This study provides insight into the potential of hs-cTnI to aid in identifying inducible myocardial ischemia in a real-world, high-throughput setting. Although a subset of patients exhibited modest increases in hs-cTnI post stress testing, overall, these did not appear to be correlated with inducible myocardial ischemia.

Flexible-Interval High-Sensitivity Troponin Velocity for the Detection of Acute Coronary Syndromes

Many algorithms for emergency department (ED) evaluation of acute coronary syndrome (ACS) using high-sensitivity troponin assays rely on the detection of a "delta," the difference in concentration over a predetermined interval, but collecting specimens at specific times can be difficult in the ED. We evaluate the use of troponin "velocity," the rate of change of troponin concentration over a flexible short interval for the prediction of major adverse cardiac events (MACEs) at 30days. We conducted a prospective, observational study on a convenience sample of 821 patients who underwent ACS evaluation at a high-volume, urban ED. We determined the diagnostic performance of a novel velocity-based algorithm and compared the performance of 1- and 2-hour algorithms adapted from the European Society of Cardiology (ESC) using delta versus velocity. A total of 7 of 332 patients (2.1%) classified as low risk by the velocity-based algorithm experienced a MACE by 30days compared with 35 of 221 (13.8%) of patients classified as greater than low risk, yielding a sensitivity of 83.3% (95% confidence interval [CI] 68.6% to 93.0%) and negative predictive value (NPV) of 97.9% (95% CI 95.9% to 98.9%). The ESC-derived algorithms using delta or velocity had NPVs ranging from 98.4% (95% CI 96.4% to 99.3%) to 99.6% (95% CI 97.0% to 99.9%) for 30-day MACEs. The NPV of the novel velocity-based algorithm for MACE at 30days was borderline, but the substitution of troponin velocity for delta in the framework of the ESC algorithms performed well. In conclusion, specimen collection within strict time intervals may not be necessary for rapid evaluation of ACS with high-sensitivity troponin.

Progress in the Metabolomics of Acute Coronary Syndrome.

Acute coronary syndrome (ACS) is a severe type of coronary heart disease (CHD) with increasing prevalence and significant challenges for prevention and treatment. Metabolomics is an emerging technology with intrinsic dynamics and flexibility to better delineate the phenotypic and metabolic alterations in organisms at the time of altered pathological states. It provides new insights into the complex pathological mechanisms of cardiovascular disease and contributes to the early detection, monitoring and evaluation of ACS. In this review, we analyze and summarize the literature related to ACS metabolomics which has contributed to the diagnosis and prevention of ACS.

Acute Coronary Syndrome in Pregnancy and the Post-Partum Period.

Cardiovascular disease is the leading cause of maternal mortality in the United States. Acute coronary syndrome (ACS) is more common in pregnant women than in non-pregnant controls and contributes to the burden of maternal mortality. This review highlights numerous etiologies of chest discomfort during pregnancy, as well as risk factors and causes of ACS during pregnancy. It focuses on the evaluation and management of ACS during pregnancy and the post-partum period, including considerations when deciding between invasive and non-invasive ischemic evaluations. It also focuses specifically on the management of post-myocardial infarction complications, including shock, and outlines the role of mechanical circulatory support, including veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Finally, it offers additional recommendations for navigating delivery in women who experienced pregnancy-associated myocardial infarction and considerations for the post-partum patient who develops ACS.

Impact of a rapid high-sensitivity troponin pathway on patient flow in an urban emergency department.

Study ObjectiveTo evaluate whether the introduction of a 1‐hour high‐sensitivity cardiac troponin‐T (hs‐TnT) pathway for patients who present to the emergency department (ED) with suspected acute coronary syndrome (ACS) improves ED patient flow without changing the rate of “missed” major adverse cardiac events (MACE), compared to use of conventional cardiac troponin with an associated 3‐hour pathway.MethodsThis was a prospective, uncontrolled observational study conducted before and after implementation of a 1‐hour hs‐TnT pathway at a high‐volume urban ED. Patients undergoing evaluation for ACS in the ED were enrolled during their initial visit and clinical outcomes were assessed at 30 and 90 days. Throughput markers were extracted from the electronic medical record and compared. The primary outcome was provider‐to‐disposition decision time.ResultsA total of 1892 patients were enrolled, 1071 patients while using conventional troponin and 821 after introduction of hs‐TnT. With the new assay and pathway, median interval between troponin tests decreased from 4.7 hours (interquartile range [IQR] 3.9–5.7 hours) to 2.3 hours (IQR 1.5–3.4 hours) (P < 0.001). However, there was no difference in median provider‐to‐disposition decision time, which measured 4.7 hours (IQR 2.9–7.2) and 4.8 hours (IQR 3.1–7.1) (P = 0.428) respectively. Total 30‐day MACE rate in discharged patients was low in both groups, occurring in only 4/472 (0.85%) encounters in the first cohort and 4/381 (1.0%) encounters in the second.ConclusionIntroduction of a 1‐hour hs‐TnT ACS evaluation pathway reduced the troponin collection interval but did not reduce provider to disposition time. There was no difference in rate of 30‐day MACE in patients discharged from the ED.

Abstract 241: Length Of Hospital Stay Is Lessened In Patients That Present With Chest Pain When Serial Troponins Are Measured Every Three Hours Compared To Every Six Hours

Troponins have close to 100% sensitivity when drawn 6 to 12 hours after the start of chest pain in acute coronary syndrome (ACS). Length of hospital stay (LOS) is a marker of efficient hospital management. Since troponin measurements at 3 (Q3H) and 6-hour (Q6H) intervals have comparable efficacy for ACS, we suggest considering Q3H troponins as opposed to Q6H in chest pain admissions to shorten LOS. A retrospective review of 389 patients who presented to Stony Brook Southampton Hospital in 2020 and 2021 with chest pain was conducted. Two patient care strategies were examined, one involved collecting troponins Q6H and the other Q3H. 319 patients with the Q6H strategy were analyzed and 61.1% were ruled in for ACS. For the Q3H strategy, 70 patients were analyzed in which 42.9% were ruled in for ACS. LOS was defined as hours between triage and submission of discharge instructions. A two-sample t-test was performed to find correlation between frequency of troponins and LOS. A two-sample t-test assuming unequal variance was conducted to compare LOS in hours between Q6H and Q3H strategies. There was a significant difference in LOS for Q6H (M = 123, SD = 201) and Q3H (M = 66, SD = 135) troponins; t = 2.91, p = 0.002. These results suggest that LOS is lessened when troponin intervals are shorter. The variance was elevated (40249,18343), possibly due to patients who stayed longer for other needs, but mean LOS and standard deviation remained decreased both when excluding patients that stayed longer than one week, and when including all patients in the analysis. Optimizing LOS has a variety of benefits. In patients with chest pain, shortening the interval of troponin collection can lessen LOS. Studies of comparable efficacy of shorter troponin intervals in evaluation of ACS have led to the practice of trending at Q3H intervals in Europe. Our study demonstrates that trending troponins Q3H is viable in a community hospital in the United States and should be further investigated and considered in the future.

Abstract 243: Length Of Hospital Stay Is Lessened In Patients That Present With Chest Pain When Admitted To The Cardiology Service Compared To Other Services Within Our Teaching Hospital

Length of stay (LOS) in the hospital for patients presenting with chest pain can be influenced by several factors. In patients evaluated for acute coronary syndrome (ACS), admission to a cardiology service may allow patients to have a shorter LOS, while admission to a non-specialty service has been shown to potentially cause worse outcomes. In this analysis, we evaluate whether specialized care decreases LOS in patients who present with chest pain. A retrospective review of 389 patients who presented to Stony Brook Southampton Hospital in 2020 and 2021 with chest pain and underwent ACS evaluation was conducted. The two strategies involved admissions to the cardiology service or to other hospital services. We analyzed 95 cardiology admissions, 56.8% of which ruled in for ACS, and 294 admissions to other hospital services, 58.2% of which ruled in for ACS. LOS was defined as hours between triage and submission of discharge instructions. A two-sample t-test was performed to find correlations between admission service and length of hospital stay. A two-sample t-test assuming unequal variance was conducted to compare LOS in hours between patients admitted to the cardiology and non-cardiology services. There was a significant difference in LOS for the cardiology service (M = 48, SD = 55) and non-cardiology service (M = 134, SD = 214) conditions; t = 6.30, p &lt; 0.001. These results suggest that LOS is lessened when chest pain patients are admitted to the cardiology service. The variance was elevated (2985, 45849), possibly due to patients who stayed longer for other needs, but mean LOS and SD remained decreased when excluding patients that stayed longer than one week, and when including all patients in the analysis. When admitting a patient, there are many ways to optimize LOS. Admission of patients who present with chest pain to a specialty cardiology service may allow patients to have a more efficient LOS and should be further investigated and considered in the future.

Data standards for acute coronary syndrome and percutaneous coronary intervention: the European Unified Registries for Heart Care Evaluation and Randomised Trials (EuroHeart).

Standardized data definitions are essential for monitoring and benchmarking the quality of care and patient outcomes in observational studies and randomized controlled trials. There are no contemporary pan-European data standards for the acute coronary syndrome (ACS) and percutaneous coronary intervention (PCI). The European Unified Registries for Heart Care Evaluation and Randomised Trials (EuroHeart) project of the European Society of Cardiology (ESC) aimed to develop such data standards for ACS and PCI. Following a systematic review of the literature on ACS and PCI data standards and evaluation of contemporary ACS and PCI registries, we undertook a modified Delphi process involving clinical and registry experts from 11 European countries, as well as representatives from relevant ESC Associations, including the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and Acute CardioVascular Care (ACVC). This resulted in final sets of 68 and 84 'mandatory' variables and several catalogues of optional variables for ACS and PCI, respectively. Data definitions were provided for these variables, which have been programmed as the basis for continuous registration of individual patient data in the online EuroHeart IT platform. By means of a structured process and the interaction with major stakeholders, internationally harmonized data standards for ACS and PCI have been developed. In the context of the EuroHeart project, this will facilitate country-level quality of care improvement, international observational research, registry-based randomized trials, and post-marketing surveillance of devices and pharmacotherapies.

Coronary Calcium to Rule Out Obstructive Coronary Artery Disease in Patients With Acute Chest Pain

ObjectivesThis study aimed to evaluate the ability of coronary artery calcium (CAC) as an initial diagnostic tool to rule out obstructive coronary artery disease (CAD) in a very large registry of patients presenting to the emergency department (ED) with acute chest pain (CP) who were at low to intermediate risk for acute coronary syndrome (ACS). BackgroundIt is not yet well established whether CAC can be used to rule out obstructive CAD in the ED setting. MethodsWe included patients from the Baptist Health South Florida Chest Pain Registry presenting to the ED with CP at low to intermediate risk for ACS (Thrombolysis In Myocardial Infarction risk score ≤2, normal/nondiagnostic electrocardiography, and troponin levels) who underwent CAC and coronary computed tomography angiography (CCTA) procedures for evaluation of ACS. To assess the diagnostic accuracy of CAC testing to diagnose obstructive CAD and identify the need for coronary revascularization during hospitalization, we estimated sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV). ResultsOur study included 5,192 patients (mean age: 53.5 ± 10.8 years; 46% male; 62% Hispanic). Overall, 2,902 patients (56%) had CAC = 0, of which 135 (4.6%) had CAD (114 [3.9%] nonobstructive and 21 [0.7%] obstructive). Among those with CAC >0, 23% had obstructive CAD. Sensitivity, specificity, PPV, and NPV of CAC testing to diagnose obstructive CAD were 96.2%, 62.4%, 22.4%, and 99.3%, respectively. The NPV for identifying those who needed revascularization was 99.6%. Among patients with CAC = 0, 11 patients (0.4%) underwent revascularization, and the number needed to test with CCTA to detect 1 patient who required revascularization was 264. ConclusionsIn a large population presenting to ED with CP at low to intermediate risk, CAC = 0 was common. CAC = 0 ruled out obstructive CAD and revascularization in more than 99% of the patients, and <5% with CAC = 0 had any CAD. Integrating CAC testing very early in CP evaluation may be effective in appropriate triage of patients by identifying individuals who can safely defer additional testing and more invasive procedures.

Role of Cardiovascular Computed Tomography in Acute Coronary Syndromes During the COVID-19 Pandemic-Single Center Snapshot Study.

Background: In clinical practice, cardiac computed tomography (CCT) has a limited role in acute coronary syndromes (ACS). Several trials evaluated CCT in low and intermediate risk patients presenting to the emergency room (ER) and noted that it was both safe and feasible. During the COVID19 pandemic, it is imperative to adopt a pathway for the evaluation of ACS that permits early discharge, reduces invasive coronary angiography and limits exposure of healthcare workers. Here, we present a single center experience by which CCT was incorporated in the clinical pathway of patients presenting to the ER with chest pain and ACS.Methods: This is a snapshot study of the first 27 patients who underwent CCT immediately after the lockdown in the city of Jeddah. ST elevation myocardial infarctions and hemodynamically unstable patients were excluded. Those with unstable angina or a Non-ST elevation myocardial infarction were screened for COVID19. The patients' COVID19 status and the results of the CCT were then used to determine the treatment strategy. Patient predisposition, hospital stay and exposure of staff are collected and reported.Results: All CCT images were interpretable with no limitations or significant artifact. CCT identified critical disease in 7 patients (26%), normal epicardial coronary arteries in 11 (41%) and mild to moderate disease in 9 (33%). All patients with normal or mild to moderate disease were assigned to a conservative strategy and discharged within 24 h. Those with a NSTEMI and critical anatomy were assigned to an additional invasive evaluation with subsequent revascularization. During the course of this study, no transmission to healthcare workers occurred.Conclusion: CCT enabled 80% of patients to be discharged within the first 24 h, the majority of whom were discharged from the emergency room. It was able to identify critical anatomy facilitating appropriate revascularization. This snapshot study warrants exploration of the role of CCT in ACS further particularly since the latest European Society of Cardiology's Non-STEACS guidelines suggest a role for CCT in the evaluation of low risk ACS.

Study of Frequency of Acute Coronary Syndromes In Patients Presenting with Chest Pain in a Primary Health Care Center (PHCC)

Background: Ischemic myocardial disease is the most common cardiovascular disease, associated with high morbidity and mortality. Objective: Study and distinguish acute heart episodes from cases of chest pain, in patients attending a PHCC located in Goura of Korinthos, Greece. Methods: Among all cases of chest pain examined during January-August 2019, 90 patients with acute coronary syndrome (ACS) were studied. Most participants were men (71%) aged 61-70 (31%). Results: A previous heart episode was mentioned by 28,6%. Among them, 22% did not comply with their medication regimen and 14.3% had been examined with coronary angiography. Percutaneous Coronary Intervention has been performed to 11.4% and 1.4% had undergone coronary-artery bypass. Risk factors were; hypertension(52.9%),smoking(37.2%), dyslipidemia (27.1%). Clinical manifestations were;chest pain 62.9%,perspiration 21.4%,numbness of extremities 18.6%, reflection of chest pain in the back 18.6% and nausea/respiratory distress 2.9%. Electrocardiographic findings consistent with STEMI were found in 32% of patients. Α new Left Bundle Branch Block was apparent in 5.7% of patients. Episodes of unstable angina with ischemic repolarization disorders were recorded in 29.4%. All patients after evaluation and initial treatment were transported to hospital. Finally, one patient (1,42%) died. Conclusion: There is a great incidence of acute coronary events in a Greek PHCC. General practitioners, following international guidelines deal with them successfully, despite lacking resources. Initial evaluation and treatment of ACS in a PHCC is of vital importance and contributes to lower morbidity and mortality rates.

Abstract 15529: Multimorbidity Clusters in Patients Presenting to the Emergency Department With Potential Acute Coronary Syndrome

Introduction: The increasing prevalence of multimorbidity (&gt; 2 chronic conditions) is a challenge for healthcare providers and systems. Multimorbidity complicates treatment and increases the risk of adverse outcomes. Objectives: To identify multimorbidity classes (clusters of &gt; 2 specific chronic conditions) in a secondary analysis of a multi-site study about symptoms in patients presenting to the emergency department (ED) for potential acute coronary syndrome (ACS). Hypothesis: Specific multimorbidity classes can predict an ACS diagnosis. Methods: Chronic conditions were measured (Charlson Comorbidity Index and ACS Patient Information Questionnaire) in patients who underwent a cardiac evaluation in the ED. Latent class analysis was used to identify multimorbidity classes, and logistic regression determined whether multimorbidity classes were predictive of being ruled-in versus ruled-out for ACS. Results: The sample ( n = 935) was 38% female, with a mean age of 59 years. Four multimorbidity classes were identified and labeled: High multimorbidity (Class 1, hyperlipidemia, hypertension [HTN], obesity, diabetes, and respiratory disorders); Low multimorbidity (Class 2, obesity); Cardiovascular multimorbidity (Class 3, HTN, hyperlipidemia, and coronary heart disease); and Cardio-oncology multimorbidity (Class 4, HTN, hyperlipidemia, and cancer). Patients in Classes 3 and 4 had a 2.8-fold and 1.7-fold increased risk of ruling-in for ACS compared to those in Class 2 who were half as likely to rule-in for ACS (OR 0.45 95% CI 0.33 to 0.61 p=0.001). Class membership differed by sex, age, and family history. Females were more likely to be in Class 1 (44.2%), younger patients in Class 2 (mean age 43.4 ± 9.8 years), older patients in class 4 (mean age 80.0 ± 6.3 years), and those with a family history of sudden cardiac death (&lt; age 55) in Class 3 (58.3%). Conclusion: Multimorbidity classes differed according to demographic and clinical variables. Membership in Classes 3 and 4 were predictive of an ACS diagnosis. Clustering patients by multimorbidity class may inform risk-stratification during evaluation for ACS.

Current Use of Cardiac Biomarkers in Various Heart Conditions

Biomarkers are increasingly recognized to have significant clinical value in early identification and progression of various cardiovascular diseases. There are many heart conditions, such as congestive heart failure (CHF), ischemic heart diseases (IHD), and diabetic cardiomyopathy (DCM), and cardiac remodeling, in which the severity of the cardiac pathology can be mirrored through these cardiac biomarkers. From the emergency department (ED) evaluation of acute coronary syndromes (ACS) or suspected acute myocardial infarction (AMI) with cardiac marker Troponin to the diagnosis of chronic conditions like Heart Failure (HF) with natriuretic peptides, like B-type natriuretic peptide (BNP), N-terminal pro-B- type natriuretic peptide (Nt-proBNP) and mid regional pro-atrial natriuretic peptide (MR- proANP), their use is continuously increasing. Their clinical importance has led to the discovery of newer biomarkers, such as the soluble source of tumorigenicity 2 (sST2), galectin-3 (Gal-3), growth differentiation factor-15 (GDF-15), and various micro ribonucleic acids (miRNAs). Since cardiac pathophysiology involves a complex interplay between inflammatory, genetic, neurohormonal, and biochemical levels, these biomarkers could be enzymes, hormones, and biologic substances showing cardiac injury, stress, and malfunction. Therefore, multi-marker approaches with different combinations of novel cardiac biomarkers, and continual assessment of cardiac biomarkers are likely to improve cardiac risk prediction, stratification, and overall patient wellbeing. On the other hand, these biomarkers may reflect coexisting or isolated disease processes in different organ systems other than the cardiovascular system. Therefore, knowledge of cardiac biomarkers is imperative. In this article, we have reviewed the role of cardiac biomarkers and their use in the diagnosis and prognosis of various cardiovascular diseases from different investigations conducted in recent years.

46 - Alexithymia is associated with increased all-cause mortality in men, but not women, in the general population

Prior posttraumatic stress disorder (PTSD) and elevated threat perceptions predict posttraumatic psychopathology after evaluation for acute coronary syndrome (ACS), but most research has measured threat retrospectively. We investigated how threat perceptions during ACS evaluation in the emergency department (ED) and upon recall were associated with posttraumatic psychopathology burden due to prior trauma and the suspected ACS.Perceived threat was assessed in the ED, and ED threat recall was assessed upon inpatient transfer/discharge, along with acute stress disorder (ASD) symptoms due to suspected ACS and PTSD symptoms due to prior trauma. The sample comprised 894 participants (mean age = 60.7 ± 13.1 years; 46.8% female; 56.3% Hispanic; 20.5% Black). One-way ANOVAs examined how those with consistent posttraumatic psychopathology (prior PTSD/ASD; 14.8%), prior posttraumatic psychopathology (prior PTSD/no ASD; 6.8%), new-onset posttraumatic psychopathology (no PTSD/ASD; 15.7%), or no posttraumatic psychopathology (no PTSD/no ASD; 62.8%) differed in threat perception, threat recall, and their discrepancy.Threat perception scores ranged from 6 to 24. Participants with consistent posttraumatic psychopathology had higher threat perceptions (M = 14.01) than those with prior posttraumatic psychopathology (M = 12.02) and new-onset posttraumatic psychopathology (M = 12.21) (ps ≤ 0.001); the latter two did not differ significantly but had higher threat perceptions than those with no posttraumatic psychopathology (M = 9.84) (p < .001). Similar results were observed for threat recall (p < .001). The new-onset posttraumatic psychopathology group also had a greater increase in perceived threat versus the no posttraumatic psychopathology group (p = .06). Results were similar adjusting for potential confounders.Assessing threat perceptions during ACS evaluation and hospitalization may help identify those at risk for emotional difficulties post-ACS.

Levels of creatine kinase MB-mass in chronic kidney disease patients on maintenance hemodialysis without coronary complications

Introduction: A triad of clinical evaluation, electrocardiography and biomarkers of acute cardio necrosis are basis for diagnosing acute coronary syndrome (ACS). Evaluation of ACS by electrocardiography can be inconclusive in patients on maintenance hemodialysis; thereby making cardiac biomarkers better indicators. Hemodialysis is known to alter troponin I values with studies suggesting high false positives but not for the values of CKMB mass. Aim: The aim of the study was to estimate the levels of cardiac CKMB-mass in patients with stage IV/stage V renal failure on maintenance hemodialysis (MHD) with no evidence of cardiac disease, and to correlate these values with manufactures guidelines for healthy individuals (cut off of Materials and Methods: The study was conducted on 23 patients between age group 20 to 70 years, diagnosed with stage IV or V Chronic Kidney disease (CKD) (confirmed biochemically and ultrasonographically). These patients were undergoing regular biweekly regime of maintenance hemodialysis for more than 3 months at dialysis unit PESIMSR, Kuppam. CKMB mass levels were measured in these patients. Results and Conclusion: The kidney function tests and electrolyte values were deranged in patients with CKD, however as the patients were on calcium supplementation, mineral levels were within normal range. Liver function tests of these patients were found to be normal. The hemoglobin and RBC levels were lower due to CKD associated anemia. CKMB-mass levels of these patients were done in Biomerieux Vidas analyzer using Enzyme linked fluorescent assay (ELFA) method. The values were within manufacturer’s cutoff range of 5ng/ml with mean value of 3.0±1.69 ng/ml. The patients were followed up either until death or for 24 months for any cardiac related events and follow up rate was 99%. The overall survival rates of the patients were found to be 77% and none of the patients were found to have developed cardiac related events and specifically myocardia

Special Report

Special Report

Abstract 16935: Severity of Congenital Heart Disease, Not Risk of Acute Coronary Syndrome,Drives Extent of Ischemic Evaluation for Chest Pain in the Emergency Department

Introduction: Population growth and increasing complexity of disease among adults with congenital heart disease (ACHD) has led to an increased burden on U.S. emergency services. Assessment of chest pain (CP) within this population poses a challenge to emergency department (ED) providers; and as this population ages, their cardiovascular risk profile continues to change. There is a paucity of literature describing appropriate assessment of CP among ACHD patients within the ED setting. Hypothesis: Despite very low probabilities for acute coronary syndrome (ACS), ACHD patients are likely to undergo extensive evaluations for CP within the ED, possibly correlating with ACHD complexity. Methods: Retrospective review of ED visits for primary complaint of acute CP among ACHD patients aged 18-50 years (n=182) presenting to a single tertiary center between 1/1/1998 and 4/1/2018. CP quality was classified according to Diamond-Forrester criteria and severity of ACHD according to the Bethesda Classification. Results: The mean age of the cohort was 32.8±8.7 years, 88 were women, 102 were Caucasian, 74 had simple CHD, 58 had moderate severity CHD, and 50 had high complexity CHD. Although 94.5% of patients were identified as having a low 30-day risk of major adverse cardiovascular events according to Heart Score, 86.3% had ≥1 set cardiac biomarkers drawn. Only 6 patients (3%) had an initial ECG with changes concerning for possible ischemia. 3 patients (2%) had troponin levels above the upper limit of normal and only 1 case required urgent catheterization. Among ACHD complexity groupings (simple, moderate severity, and high complexity), there were no differences seen with regard to, gender, frequency of ECG changes suggesting ischemia, chest pain quality or coronary disease risk factors (hypertension, hypercholesterolemia, diabetes, smoking, BMI or predefined cardiovascular disease). Despite this fact, complexity of ACHD was associated with increased ED length of stay (p=0.02), likelihood of an urgent echocardiogram being performed (p&lt;0.001), ordering of cardiology consultation (p &lt;0.001) and hospital admission (p =0.009), without concurrent increase in 30-day overall mortality. Conclusion: ACHD patients undergo extensive evaluation for ACS despite having low pre-test probability, with complexity of underlying congenital disease correlating with increased ED resource utilization despite similar clinical outcomes.

Patterns of peritraumatic threat perceptions in patients evaluated for suspected acute coronary syndrome according to prior and current posttraumatic stress symptoms.

Prior posttraumatic stress disorder (PTSD) and elevated threat perceptions predict posttraumatic psychopathology after evaluation for acute coronary syndrome (ACS), but most research has measured threat retrospectively. We investigated how threat perceptions during ACS evaluation in the emergency department (ED) and upon recall were associated with posttraumatic psychopathology burden due to prior trauma and the suspected ACS. Perceived threat was assessed in the ED, and ED threat recall was assessed upon inpatient transfer/discharge, along with acute stress disorder (ASD) symptoms due to suspected ACS and PTSD symptoms due to prior trauma. The sample comprised 894 participants (mean age = 60.7 ± 13.1 years; 46.8% female; 56.3% Hispanic; 20.5% Black). One-way ANOVAs examined how those with consistent posttraumatic psychopathology (prior PTSD/ASD; 14.8%), prior posttraumatic psychopathology (prior PTSD/no ASD; 6.8%), new-onset posttraumatic psychopathology (no PTSD/ASD; 15.7%), or no posttraumatic psychopathology (no PTSD/no ASD; 62.8%) differed in threat perception, threat recall, and their discrepancy. Threat perception scores ranged from 6 to 24. Participants with consistent posttraumatic psychopathology had higher threat perceptions (M = 14.01) than those with prior posttraumatic psychopathology (M = 12.02) and new-onset posttraumatic psychopathology (M = 12.21) (ps ≤ 0.001); the latter two did not differ significantly but had higher threat perceptions than those with no posttraumatic psychopathology (M = 9.84) (p < .001). Similar results were observed for threat recall (p < .001). The new-onset posttraumatic psychopathology group also had a greater increase in perceived threat versus the no posttraumatic psychopathology group (p = .06). Results were similar adjusting for potential confounders. Assessing threat perceptions during ACS evaluation and hospitalization may help identify those at risk for emotional difficulties post-ACS.