Ischemic-type Chest Pain Research Articles

Acute ST elevation myocardial infarction (STEMI) in a patient with leptospirosis; a therapeutical dilemma – A case report

A 45-year-old previously healthy farmer was seen at the Emergency Department with ischemic type chest pain. He had a history of an acute febrile illness for four days. The ECG showed an acute anterior myocardial infarction. His laboratory investigations revealed thrombocytopenia, a raised serum creatinine level and significantly raised high-sensitive cardiac Troponin I. A provisional diagnosis of acute STEMI with co-existing leptospirosis was made. The patient was managed conservatively with antibiotics, statins, and aspirin. Neither thrombolysis nor primary coronary intervention was attempted due to high risk of bleeding. Diagnosis of leptospirosis was confirmed later by markedly elevated leptospira antibodies. After recovery, he underwent coronary angiogram which revealed a totally occluded left anterior descending artery and is awaiting myocardial viability assessment with dobutamine stress echocardiography before PCI. We report this uncommon presentation of acute myocardial infarction in a patient with leptospirosis, as it causes a considerable therapeutic dilemma especially in a resource-poor setting.

Ectatic coronary arteries, a cause for myocardial infarction with non-obstructive coronary arteries

Ectatic coronary arteries are an abnormal dilation of the coronary arteries and can contribute to the development of myocardial infarction with non-obstructive coronary arteries (MINOCA). We present a case of a previously unscreened 27-year-old man who presented with ischaemic type chest pain and was found to have ectatic coronary arteries on coronary angiogram. Despite the absence of significant stenosis, the patient experienced an acute myocardial infarction. The patient was treated with dual antiplatelet therapy and statins, and subsequent assessments showed normal echocardiography findings. Coronary artery ectasia (CAE) is a relatively uncommon condition often associated with coronary artery disease (CAD) and atherosclerosis. While antiplatelet therapy is indicated in CAE patients, the use of anticoagulation remains uncertain. Further research and clinical guidelines are needed to establish standardised management approaches for patients with CAE and MINOCA.

Acute heart failure complicating acute coronary syndromes in patients admitted to Coronary Care Unit - Cardiac Center , Al-Thawra Hospital - Sanaa, Yemen

Background: Heart Failure with all its types and presentation is the end result of acute coronary syndrome. Coronary artery disease and its acute manifestations of ST-segment elevation myocardial infarction (STEMI), non-STEMI, and unstable angina are remarked as acute coronary syndromes (ACS). Yemeni patients usually present themselves to hospital late due to a lack of society awareness of the symptoms of ischemic heart disease, absence of medical insurance, poverty, lack of medical aid and intensive care units (ICU), absence of ambulance services, and long distance to the facilitated hospital with equipped ICUs. Late presentation prevents giving thrombolytic therapy or performing invasive interventions within the right time. These factors in addition to other factors may contribute to the large number of heart failure post ACS. We designed this study to study the heart failure complicating acute coronary syndrome. Results: Out of 637 patients with ACS, 294 (39%) were in heart failure complicating ACS, with a median age of 51 years. Males represent 66% (194 patients) and females 34% (100 patients). Smoking represents 36%, khat chewing 88%, hypertension 53%, dyslipidemia 31%, past history of MI 29%, and diabetes mellitus 40%. Ischemic-type chest pain represents 49% and Dyspnea as primary symptom occurred in 29% with heart failure (HF). Late presentation of more than 12 hours represents 53% (111 patients) among patients with HF complicating STEMI or LBBB MI. These patients did not receive thrombolytic therapy or primary PCI. Patients who received thrombolytic therapy represent 45% (95 patients) of patients with HF-complicating ACS. No patients received primary PCI. Conclusions: Heart failure complicating ACS is common among our patients and associated with high in-hospital death and is mainly among young patients and related to late presentation, management with non-fibrine specific thrombolytic agents (streptokinase), and lack of STEMI catheterization team for 24 hours, seven days a week.

Patterns of Perception of Cardiac Symptoms by Patients Presenting with ST-Segment Elevation Myocardial Infarction and their Knowledge of Coronay Artery Disease Risk Factors.

Proper knowledge regarding Coronary Artery Disease and their risk factors is essential for the early recognition of the disease and its presentation. This study was conducted to identify pattern of clinical symptoms and knowledge regarding Coronary Artery Disease risk factors among ST-Elevation myocardial infarction (STEMI) patients. This cross-sectional, observational study was conducted among 340 ST-Elevation myocardial infarction patients in the inpatient Cardiology Department of Shahid Gangalal National Heart Centre Nepal, from November 2020 to February 2021. Baseline clinical characteristics, knowledge regarding Coronary Artery Disease risk factors, patterns of symptoms, and prehospital delay were collected and evaluated. In our study, 299 (87.9%) had typical ischemic chest pain during the symptom onset, however, only 81 (23.8%) perceived chest pain as cardiac disease, and 311 (91.5%) of the patients presented to the nearby health care center within the recommended time of less than 12 hours for the reperfusion therapy of ST-Elevation myocardial infarction. Perception of symptoms as a cardiac origin and typical chest pain were not significantly associated with earlier presentation. Also, the typical chest pain was not significantly associated with the perception of the symptom as a cardiac origin. The history of Coronary Artery Disease was considered as a Coronary Artery Disease risk factor by 184(54.1%) of the study population and 137(40.3%), 132(38.8%), 110(32.4%), 105(30.9%) and 71(20.9%) considered hypertension, smoking, age, obesity, and diabetes mellitus as a Coronary Artery Disease risk factor respectively. Though most patients presented with typical chest pain, identification of the chest pain as a cardiac origin and the awareness of the Coronary Artery Disease risk factors was low.

Lewis Lead: Reveal the Hidden P Wave

Background. The Lewis lead configuration can help to detect atrial activity and its relationship to ventricular activity, so diagnosis can be achieved more accurately. With Lewis lead ECG, it will make easier to make a diagnosis, especially in identifying electrical activity in the atrium.
 Case Illustration. Case 1. A 61-year-old male with decreased consciousness et causa metabolic. From a standard 12-lead ECG, the P waves are difficult to identify, and at first glance it looks like atrial fibrillation. From the Lewis ECG in lead I, it appears that the QRS wave is always preceded by a P wave, with different morphologies (more than 3 forms), that showed as multifocal atrial tachycardia (MAT) with a heart rate of 120 beats / minute. Case 2. The 58-year-old male patient complained of typical ischemic chest pain and palpitations. A standard 12 lead ECG examination revealed a rhythmic tachycardia with a wide QRS wave at a rate of 210 beats / minute. From the Lewis ECG in lead I, we can see that the P waves that appear are not always followed by QRS. Thus, it can be seen that the AV dissociation is a VT so that VT management can be done immediately. Case 3. A 65-year-old male patient diagnosed with grade 5 CKD on dialysis. From a standard 12 lead ECG examination, a wide QRS wave with a P wave is obtained which is sometimes seen behind the QRS wave, making the diagnosis difficult to establish. From the Lewis ECG in lead I, it appears that the P wave always appears at the end of the QRS wave, so it can be seen that the rhythm from the ECG is derived from accelerated idioventricular rhythm with ventriculoatrial conduction.
 Conclusion. The accuracy of ECG interpretation is needed to determine the next treatment for the patient. Through the ECG examination with the Lewis lead method, the cardiac electrical activity will be more visible, so it will be very helpful in the interpretation of the ECG in cases that are not clear on the standard 12 lead ECG examination.

The additive value of copeptin for early diagnosis and prognosis of acute coronary syndromes.

One promising biomarker that has received substantial interest for the evaluation of suspected acute coronary syndromes (ACS) is copeptin. Therefore, our goal was to assess the additive value of copeptin for early diagnosis and prognosis of Non-ST segment acute coronary syndromes (NSTE-ACS). The study included ninety patients with suspected ACS. Patients with typical ischemic chest pain within six hours of symptom onset and without ST-segment elevation on electrocardiograph (ECG) were included. In addition to cardiac troponin I (cTnI), copeptin was assayed from venous blood samples obtained on admission, followed by serial troponin measurements six and twelve hours later. One year follow-up was performed for any major adverse cardiac events (MACEs) including cardiac death, re-infarction, re- hospitalization for ischemic events, heart failure, stroke and target lesion revascularization (TLR). Of seventy nine patients included in the final analysis, Forty (50.6%) were diagnosed as unstable angina (UA), while thirty nine (49.4%) had a non-ST elevation myocardial infarction (NSTEMI). Copeptin level on admission was significantly higher among NSTEMI patients than those with UA. With regard to the correlation analyses, copeptin was positively correlated with each of, Global Registry of Acute Coronary Events (GRACE), Thrombolysis In Myocardial Infarction (TIMI) and synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) scores. The sensitivity and negative predictive value (NPV) of the combination of admission copeptin and cTn-I were 100% and 100%, respectively, versus 57% and 70%, respectively, with admission of cTn-I alone. The area under curve (AUC) of the combination of copeptin and cTn-I was (0.975, p<0.001) and was significantly higher than the AUC of cTn-I alone (0.888, p<0.001). Admission copeptin was an independent predictor for MACEs by multiple regression analysis (OR: 0.01, 95% CI: 0.0-0.8, P=0.04). High values of copeptin had the highest rate of MACEs and coronary revascularization during one year of follow up. The combination of copeptin and conventional troponin I aids in early rule out of NSTEMI virtually independent of chest pain onset (CPO) with high NPV in patients presenting within three hours from chest pain onset with excellent prognostic value for risk stratification and prediction of MACEs.

Multiparametric miRNAs profiling by polymerization induced fluorescence-off amplification for acute myocardial infarction diagnosis

The prompt diagnosis of acute myocardial infarction (AMI) for patients with acute ischemic-type chest pain is critical for timely AMI treatment and lowering its casualty rate. In this article, we developed a multiparametric detection technique for AMI related microRNAs (miRNAs), which is based on the polymerization induced fluorescence-off (PIFO) signal amplification technique. PIFO can be implemented on a specially designed microfluidic chip equipping a fluorescence sensor, which is able to profile 3 miRNAs simultaneously in 45 min with a detection limit of 6100 miRNAs copies. Comparing with other polymerization-based signal amplification techniques, PIFO is rapid, oxygen-independent, multiparametric, and can be performed in ambient environment. The miniaturized PIFO device can be further applied to analyze AMI related miRNAs in clinical serum samples, and displays excellent performance in distinguishing AMI patients from patients with other cardiovascular diseases. Moreover, PIFO shows a high accuracy for AMI diagnosis among patients with low hypersensitivity troponin I level (< 0.1 ng mL−1) as a result of the early and fast respond to AMI onset by miRNAs.

DIABETIC JEOPARDIZE OF ACUTE MYOCARDIAL INFARCTION CHEST PAIN

Objective: Diabetic neuropathy may mask the typical ischemic chest pain and diabetics may carry longer presentation times in cases of acute STEMI. Diabetics may complain of chest pain less frequently, while atypical clinical presentations of STEMI could be more common compared to non-diabetics. Aim of this study was to assess the potential impact of diabetes on STEMI related chest pain, its severity, characteristics and non-specific clinical features. Methodology: The descriptive, cross-sectional study included 254 patients with first episode of STEMI. Data was acquired regarding feeling of chest pain, its severity, different characters, sites of radiation, and occurrence of associated clinical features. These variables were compared among diabetic and non-diabetic groups by Pearson’s Chi-square test. Results: Diabetics were more likely ‘not to feel’ any STEMI related chest pain compared to non-diabetics (22.2% vs. 2.4% p&lt;0.001), severe chest pain was a less frequent complaint in diabetics compared to non-diabetics (21.1% vs. 89% p&lt;0.001). The characters of “chest tightness”, “strangulating pain” and “squeezing chest pain” were less frequent in diabetics (45.6% vs. 68.3% p&lt;0.001, 8.9% vs. 56.7% p&lt;0.001 and 1.1% vs. 18.3% p&lt;0.001 respectively). Syncope and shortness of breath were observed more frequently in diabetics (37.8% vs. 20.7% p=0.003 and 23.3% vs. 17.1% p=0.001 respectively). Conclusion: Diabetics can frequently present without pain or with less severe chest pain and infrequent typical characters compared to non-diabetics and may have atypical symptoms like syncope and shortness of breath more commonly than non-diabetics.

Inferior ST-elevation myocardial infarction managed with a pharmacoinvasive strategy and conservative management of delayed atrioventricular block: classical case report.

BackgroundThe 2017 ESC guideline on patients with ST-segment elevation myocardial infarction (STEMI) provides guidance regarding the optimal management of these patients. Transient atrioventricular (AV) block is a relatively common complication of inferior STEMI and its management is also addressed in the guidelines.Case summaryA 64-year-old gentleman with multiple cardiovascular risk factors presented to the emergency department with a history of ischaemic type chest pain and evidence of inferior ST-segment elevation on his electrocardiogram (ECG). First-degree AV block was noted on his initial ECG. He was given thrombolytic therapy as part of a pharmacoinvasive strategy of reperfusion. He, however, failed fibrinolytic therapy, and emergency angiography revealed critical disease of the right coronary artery which was successfully stented. Subsequent to reperfusion, he developed complete AV block without evidence of re-infarction, which was managed conservatively with successful resolution of the block after 7 days of expectant management with temporary transvenous pacing.DiscussionWe highlight some of the important management principles from the ESC guideline of STEMI including timing and the management of AV block in these patients. In addition, we highlight the role of a pharmacoinvasive strategy for reperfusion where timeous primary percutaneous coronary intervention cannot be performed. The usefulness of such a strategy within the COVID-19 era is also emphasized.

First 24 h' outcomes of acute coronary syndrome in Iraq

Background: In recent years, there has been a noticeable increase in the frequency of acute coronary syndrome (ACS) in Iraq. Despite the need for the data related to the subject in the area, there is a great paucity of such data that mandated the design and conduct of this study. Methods: This prospective, cross-sectional analysis was performed in the coronary care unit of tertiary Azadi Teaching Hospital in Duhok, Kurdistan, Iraq. All patients consecutively who were hospitalized for ACSs between 2015 and 2016 were included to determine the clinical presentations, short term in-hospital complications, and the first 24 h outcomes of ACSs in Duhok, Iraq. Results: The study comprised 380 (279 men and 101 women) cases with a mean age of 59.54 ± 11.50 years. The final diagnosis was ST-elevation myocardial infarction in 67.4%, non-ST-elevation myocardial infarction in 24.7%, and unstable angina in 7.9%. Al least 50% of patients arrived beyond 6 h of symptoms' onset. Participants within the age group 45–74 years constituted the main bulk of the sample (79%). Typical ischemic chest pain accounted for most of the presentations (80.3%). The most common complications were arrhythmias 44.8%, followed by heart failure 15.5%, cardiogenic shock 5.5%, and mechanical complications 3.4%. Uneventful recovery and recovery with complications constituted 74.5% and 19.7%, respectively. The first 24 h in-hospital death was 5.8%. Conclusions: Our patients presented at a relatively young age. In terms of disease presentations, we observed significant gender differences. In-hospital short-term mortality rate was comparable to neighboring nations. Older age rather than gender impact the outcomes.

Gender Differences among Elderly Patients with Primary Percutaneous Coronary Intervention.

Several epidemiological and clinical studies have shown that females with ST-segment elevation myocardial infarction (STEMI) have a higher mortality than males following primary percutaneous coronary intervention (PPCI). Many analyses of sex-based differences following STEMI have revealed conflicting results. Currently, more and more elderly patients with STEMI have undergone emergency interventional therapy. From January 2014 to December 2016, a total of 337 elderly patients with STEMI were enrolled in this study from two chest pain centers, and all patients underwent PPCI. Patients were divided into two groups: elderly females (n=117, mean age 73.4±9.6 years) and elderly males (n=220, mean age 71.7±8.6 years). The prevalence of diabetes was higher in females than in males (29.1% vs. 19.6%,P<0. 01). Typical ischemic chest pain was lower in females than in males (45.3% vs 57.3%, P<0.01). The number of nonsmokers was also significantly higher in females than in males (5.1% vs. 52.3%,P<0. 01). Serum creatinine (sCr) levels (87.6±17.4 umol/L vs 99.5±20.2 umol/L,P<0.01) and body mass index (23.8±2.7 vs 27.3±3.1, P<0.01) were lower in females than in males. The incidences of major adverse cardiac events (MACE) in-hospital showed no significantly difference (P>0.05) between the two groups. However, the cumulative MACE showed a significant difference between the two groups in the 12-month follow-up (16.8% in male vs 12.8% in female, P = 0.04). Our results suggest that the PPCI is safe and effective in elderly female STEMI patients. The cumulative MACE in females are not higher than in males. PPCI are helpful in elderly STEMI patients.

Outcomes after coronary computed tomography angiography of patients at low to intermediate risk for acute coronary syndrome

Background: Coronary computed tomography angiography (CTA) has recently been shown to enjoy a high negative predictive value for ruling out coronary heart disease and risk stratifying patients with acute coronary syndrome (ACS). Hence, we assessed the 1-year outcome associated with a CTA-guided strategy in patients presenting to the emergency department with low to intermediate risk for ACS graded according to the GRACE score. Methods: In this case-series study, 77 consecutive patients (mean age = 49.7 ± 10.1 and 53.2% female) who presented to the emergency department with ischemic-type chest pain and low to intermediate risk for ACS were evaluated prospectively. The patients underwent coronary CTA after the measurement of troponin I. Those with nonobstructive plaques and mild stenoses ( 70% narrowing) underwent coronary angiography. The discharged patients were contacted and their medical records were reviewed to determine the rates of major adverse cardiovascular events (MACE)—comprising death, myocardial infarction, stroke, hospital admission, and revascularization. Results: A total of 89.6% of the patients were in the low-risk ACS group. There was no significant association between MACE and the subscales and the GRACE score (P > 0.05). There was no relationship between the GRACE score and the severity of coronary stenosis (P > 0.05) and the high-severity plaques (P > 0.05). However, the severity of stenoses in the proximal part of the left anterior descending artery (LAD) (P = 0.00), the mid part of the LAD (P = 0.004), and the first part of the obtuse marginal artery (P = 0.004) was associated with MACE. Furthermore, there were no relationships between MACE and the high-risk plaques and the risk factors (P > 0.05). Conclusions: CTA ruled out significant lesions and optimal treatment was accompanied by good prognoses in our patients. CTA may, therefore, be an optimal cost-benefit modality for the determination of the diagnosis and the therapeutic modality in patients at low to intermediate risk for ACS presenting to the emergency department.

Epicardial potentials computed from the body surface potential map using inverse electrocardiography and an individualised torso model improve sensitivity for acute myocardial infarction diagnosis.

Epicardial potentials (EPs) derived from the body surface potential map (BSPM) improve acute myocardial infarction (AMI) diagnosis. In this study, we compared EPs derived from the 80-lead BSPM using a standard thoracic volume conductor model (TVCM) with those derived using a patient-specific torso model (PSTM) based on body mass index (BMI). Consecutive patients presenting to both the emergency department and pre-hospital coronary care unit between August 2009 and August 2011 with acute ischaemic-type chest pain at rest were enrolled. At first medical contact, 12-lead electrocardiograms and BSPMs were recorded. The BMI for each patient was calculated. Cardiac troponin T (cTnT) was sampled 12 hours after symptom onset. Patients were excluded from analysis if they had any ECG confounders to interpretation of the ST-segment. A cardiologist assessed the 12-lead ECG for ST-segment elevation myocardial infarction by Minnesota criteria and the BSPM. BSPM ST-elevation (STE) was ⩾0.2 mV in anterior, ⩾0.1 mV in lateral, inferior, right ventricular or high right anterior and ⩾0.05 mV in posterior territories. To derive EPs, the BSPM data were interpolated to yield values at 352 nodes of a Dalhousie torso. Using an inverse solution based on the boundary element method, EPs at 98 cardiac nodes positioned within a standard TVCM were derived. The TVCM was then scaled to produce a PSTM using a model developed from computed tomography in 48 patients of varying BMIs, and EPs were recalculated. EPs >0.3 mV defined STE. A cardiologist blinded to both the 12-lead ECG and BSPM interpreted the EP map. AMI was defined as cTnT ⩾0.1 µg/L. Enrolled were 400 patients (age 62 ± 13 years; 57% male); 80 patients had exclusion criteria. Of the remaining 320 patients, the BMI was an average of 27.8 ± 5.6 kg/m2. Of these, 180 (56%) had AMI. Overall, 132 had Minnesota STE on ECG (sensitivity 65%, specificity 89%) and 160 had BSPM STE (sensitivity 81%, specificity 90%). EP STE occurred in 165 patients using TVCM (sensitivity 88%, specificity 95%; p < 0.001) and in 206 patients using PSTM (sensitivity 98%, specificity 79%; p < 0.001). Of those with AMI by cTnT and EPs ⩽0.3 mV using TVCM ( n = 22), 18 (82%) patients had EPs >0.3 mV when an individualised PSTM was used. Among patients presenting with ischaemic-type chest pain at rest, EPs derived from BSPM using a novel PSTM significantly improve sensitivity for AMI diagnosis.

Does the Post-Systolic Shortening of the Left Ventricle by Tissue Doppler Imaging Predict Coronary Artery Disease?

Background: Abnormalities in the velocity and pattern of myocardial shortening on tissue Doppler imaging (TDI) have been pro- posed to aid in the noninvasive diagnosis of coronary artery disease (CAD). Objectives: We investigated the diagnostic value of post-systolic shortening (PSS), a delayed ejection velocity of the myocardium after the closure of the aortic valve, on TDI in the diagnosis of CAD among patients with chest pain and normal resting wall motion on standard 2D echocardiography. Methods: Eighty consecutive patients (49% female) with typical ischemic chest pain but without prior myocardial infarction, coro- nary revascularization, arrhythmia, or heart failure, who had no regional wall motion abnormalities on resting echocardiography and who were scheduled to undergo coronary angiography, were selected. TDI was performed in each patient before coronary an- giography at 2 levels (basal and mid left ventricle (LV)) in each of the 4 LV walls (i.e., septal, anterior, inferior, and lateral). Coronary angiography was performed and interpreted per standard clinical protocols. Results: Compared to the patients with normal coronaries, those with angiographic CAD showed significantly increased myocar- dial isovolumic relaxation time (IVRT) velocity (P 4.0 m/sec, a positive PSS velocity had about 65% sensitivity and 85% specificity with a positive predictive value > 90% in predicting angiographic CAD. Conclusions: Among patients with chest pain and normal LV wall motion on 2D echocardiography, a prominent and prolonged IVRT on TDI may help predict the presence of significant CAD.

IMPROVING THE DIAGNOSIS OF ACUTE MYOCARDIAL INFARCTION BY DERIVING EPICARDIAL POTENTIALS FROM THE BODY SURFACE POTENTIAL MAP USING INVERSE ELECTROCARDIOGRAPHY AND AN INDIVIDUALIZED TORSO MODEL

Epicardial potentials (EP) derived from the body surface potential map (BSPM) improve acute myocardial infarction (AMI) diagnosis. In this study, we compared EP derived from the 80-lead BSPM using a standard thoracic volume conductor model (TVCM) with those derived using a patient-specific torso model (PSTM) based on body mass index (BMI). Patients presenting to ED between August 2009 and August 2011 with acute ischaemic-type chest pain at rest were enrolled. At first medical contact, 12-lead ECG and BSPM were recorded. BMI for each patient was calculated. Cardiac troponin-T (cTnT) was sampled 12h after symptom onset. Patients were excluded from analysis if they had any electrocardiographic confounders to interpretation of the ST-segment. A cardiologist assessed the 12-lead ECG for STEMI by Minnesota criteria and BSPM. BSPM ST-elevation (STE) was ≥0.2mV in anterior, ≥0.1mV in lateral, inferior, RV or high right anterior and ≥0.05mV in posterior territories. To derive EP, the BSPM data were interpolated to yield values at 352-nodes of a Dalhousie torso. Using an inverse solution based on the boundary element method, EP at 98 cardiac nodes positioned within a standard TVCM were derived. The TVCM was then scaled to produce a PSTM, using a model developed from CT in 48 patients of varying BMI, and EP re-calculated. EP ≥0.3mV defined STE. A cardiologist blinded to both the 12-lead ECG and BSPM interpreted the EP map. AMI was defined as cTnT ≥0.1µg/L. Enrolled were 400 patients (age 62 ± 13 yrs; 57% male): 80 patients had exclusion criteria. Of the remaining 320 patients, BMI was 27.8 ± 5.6kg m-2. Of these, 180 (56%) had AMI. Overall, 132 had Minnesota STEMI on ECG (sensitivity 65%, sensitivity 89%) and 160 had BSPM STE (sensitivity 81%, specificity 90%). EP STE occurred in 165 patients using TVCM (sensitivity 88%, specificity 95%, p<0.001) and in 206 patients using PSTM (sensitivity 98%, specificity 79%, p<0.001). Of those with EP <0.3mV using TVCM and AMI (n=22), all had EP ≥0.3mV when an individualised PSTM was used. Among patients presenting with ischaemic-type chest pain at rest, EP derived from BSPM using a novel PSTM significantly improves sensitivity for AMI diagnosis.

Heart-type fatty acid-binding protein detects more patients with non-ST segment elevation myocardial infarction compared to troponin-T

Abstract Objective To assess the value of using heart-type fatty acid-binding protein (H-FABP) as a marker of acute myocardial infarction (AMI) in patients presenting with non-ST segment elevation ACS (NSTE-ACS) in comparison with troponin-T (cTnT). Methods 122 consecutive patients presented with ischemic-type chest pain within the first 4 h of symptom onset with NSTE-ACS. Blood samples were obtained on arrival for H-FABP and cTnT. Patients with cTnT negative test on admission had a repeat analysis 6 h later. Patients with both H-FABP negative and admission cTnT positive had repeat analysis of H-FABP 6 h later. Results On admission, H-FABP was positive in 84 patients (68.9%) versus 36 patients (29.5%) with cTnT (p = 0.032). On repeat analysis after 6 h, total number of cTnT positive patients was 94 (77%) and cTnT negative was 28 (23%). All cTnT negative patients had negative H-FABP. Of cTnT positive patients, 84 (89.4%) had positive H-FABP test while the remaining 10 (10.6%) had “false” negative results. Using the final results of cTnT positive as gold standard, early assessment of cTnT within 4 h of chest pain had sensitivity of 38.3% and specificity of 100% while H-FABP had sensitivity of 89.4% and specificity of 100%. Conclusions For patients presenting with suspected ACS within 4 h of onset of symptoms, H-FABP detects a significantly larger number of patients with NSTEMI compared to troponin-T.

Comparison of Fentanyl and Morphine in the Prehospital Treatment of Ischemic Type Chest Pain

In the treatment of acute coronary syndromes, reduction of sympathetic stress and catecholamine release is an important therapeutic goal. One method used to achieve this goal is pain reduction through the systemic administration of analgesia. Historically, morphine has been the analgesic of choice in ischemic cardiac pain. This randomized double-blind controlled trial seeks to prove the utility of fentanyl as an alternate first-line analgesic for ischemic-type chest pain in the prehospital setting. Successive patients who were treated for suspected ischemic chest pain in the emergency medical services system were considered eligible. Once chest pain was confirmed, patients received oxygen, aspirin, and nitroglycerin therapy. If the ischemic-type chest pain continued the patient was randomized in a double-blinded fashion to treatment with either morphine or fentanyl. Pain scale scores, necessity for additional dosing, and rate of adverse events between the groups were assessed every 5 minutes and were compared using t-testing, Fisher's Exact test, or Analysis of Variance (ANOVA) where appropriate. The primary outcome of the study was incidence of hypotension and the secondary outcome was pain reduction as measured by the visual analog score and numeric rating score. A total of 207 patients were randomized with 187 patients included in the final analysis. Of the 187 patients, 99 were in the morphine group and 88 in the fentanyl group. No statistically significant difference between the two groups with respect to hypotension was found (morphine 5.1% vs. fentanyl 0%, p = 0.06). Baseline characteristics, necessity for additional dosing, and other adverse events between the two groups were not statistically different. There were no significant differences between the changes in visual analog scores and numeric rating scale scores for pain between the two groups (p = 0.16 and p = 0.15, respectively). This study supports that fentanyl and morphine are comparable in providing analgesia for ischemic-type chest pain. Fentanyl appears to be a safe and effective alternative to morphine for the management of chest pain in the prehospital setting.

Serial Measurement of Heart-Type Fatty Acid Binding Protein for the Rapid Diagnosis of Acute Coronary Syndromes in the Emergency Department

Introduction We aimed to investigate the diagnostic accuracy of heart-type fatty acid binding protein (H-FABP) at admission and the third and sixth hour after admission in patients presenting to the emergency department (ED) with chest pain or equivalent symptoms. Methods This prospective study was performed over two months in the ED. Patients presenting with ischaemic-type chest pain or other symptoms suggestive of myocardial ischaemia were included in the study. A bedside, point-of-care, quantitative H-FABP level was measured. If the initial electrocardiography (ECG) was non-diagnostic, the patients were observed for six hours. During the observation period, serial H-FABP measurements were obtained at admission, the third hour and the sixth hour; serial measurements of total creatine kinase (CK), CK-MB, troponin I and myoglobin were recorded at admission and the sixth hour. Results A total of 183 patients were included in the study. Initial H-FABP was measured in a joint group of ST segment elevation myocardial infarction (STEMI) and non ST segment elevation myocardial infarction (NSTEMI) patients, with a sensitivity of 80.9%, specificity of 19.2%, positive predictive value (PPV) of 23% and negative predictive value (NPV) of 77.1%. The third-hour H-FABP was measured in the NSTEMI group, with a sensitivity of 46.7%, specificity of 80.2%, PPV of 42.4% and NPV of 82.6%. The sixth-hour H-FABP had a sensitivity of 33.3%, specificity of 73.9%, PPV of 24.2% and NPV of 81.5%. Conclusion H-FABP is superior to myoglobin for diagnosing myocardial infarction in a joint group of STEMI and NSTEMI patients. The third-hour NPV value for H-FABP indicates that, for safety considerations, the cardiac observation time should not be shortened. (Hong Kong j.emerg.med. 2014;21:213-221)

Long-term Outcome after CT Angiography in Patients with Possible Acute Coronary Syndrome

To assess the long-term outcome and hospital readmission rate associated with a computed tomographic (CT) angiography-guided strategy used to examine patients who present to the emergency department (ED) with symptoms of possible acute coronary syndrome (ACS). The study was approved by the institutional review board, and all patients provided written informed consent. A total of 585 consecutive patients (mean age, 58 years ± 11 [standard deviation]; 58% were male) with ischemic-type chest pain and low to intermediate risk for ACS were evaluated prospectively. Patients underwent coronary CT angiography after single or serial troponin I (TnI) measurement, depending on time of presentation to the ED. Subsequent care was determined with CT angiography findings: Patients without plaque and patients with nonobstructive plaque and at most mild to moderate stenosis (<40% luminal narrowing) were discharged without further investigation. Patients with moderate stenosis (40%-70% narrowing) were discharged and referred for outpatient stress echocardiography. Patients with severe stenosis (>70% narrowing) were admitted. Discharged patients were contacted and their medical records were reviewed to determine rates of death, ACS, revascularization, and hospital admission. By using binomial distribution, Clopper-Pearson confidence intervals (CIs) were calculated for outcome data. Coronary CT angiography findings were as follows: A total of 196 patients (34%) had no coronary plaque or stenosis, 288 (49%) had nonobstructive plaque, 22 (4%) had moderate stenosis, and 79 (13%) had severe stenosis. At median 47.4-month follow-up (range, 24-57 months) of the 506 discharged patients, five (1%; 95% CI: 0.4%, 2.3%) had been readmitted for chest pain; there were no instances of coronary revascularization, ACS, or death (0% for all; 95% CI: 0%, 0.7%). Follow-up was 100% complete. Use of a CT angiography-guided strategy to investigate patients with low to intermediate risk of ACS who present to the ED with chest pain is safe at long-term follow-up, including patients discharged after single TnI measurement.

PREDICTION OF CORONARY ARTERY DISEASE BY DETECTION OF POSITIVE ISOVOLUMIC RELAXATION VELOCITY IN PATIENTS WITH NORMAL RESTING WALL MOTIONS "A Tissue Doppler Echocardiographic Study"

Background: Diagnosis of coronary artery disease (CAD) is of importance in the contemporary society of ever-increasing CAD (1,2). Isovolumic relaxation velocity (VIR), Postsystolic motion or postsystolic shortening (PSS) is a delayed ejection motion of the myocardium occurring after the aortic valve closure during a generally prolonged isovolumic relaxation time, which is related with myocardial ischemia in human(3,4) and in experimental studies(5). Spectral tissue Doppler imaging (TDI) is a simple echocardiographic technique that can provide velocity measurement of the myocardial segments(6). A positive myocardial velocity during isovolumic relaxation phase (VIR) detected by TDI, which corresponds to postsystolic motion or PSS, has been shown to indicate severely ischemic myocardium(8). So, detection of positive VIR by spectral TDI may be used as a noninvasive, nonprovocative method to predict possible CAD; specially for those with coexisting morbidities, such as peripheral artery disease in the lower limb, orthopedic diseases. Aim of the work: Diagnostic value of positive myocardial velocity during isovolumic relaxation phase (VIR) by spectral TDI in prediction of CAD in patients with typical ischemic chest pain and normal resting wall motions. Patients and methods: This study was done in Cardiology department, Zagazig University on 80 patients; 41 females (51%) & 39 males (49%)) with typical ischemic chest pain and no regional wall motion abnormalities detected by resting echocardiography. Patients were divided into 2 groups according to presence of significant coronary artery lesion by coronary angiography; group A (patients with CAD) and group B (patients without CAD). All the following parameters were measured by TDI; 5 peak velocities during; Isovolumic contraction phase (VIC), Systolic ejection phase (S'), Early diastolic relaxation phase (Em), Atrial contraction phase (Am) and Isovolumic relaxation phase (VIR) if present and VIR time. Then coronary angiography was done for all patients. Results: As regard to presence of VIR velocity, there was significant difference (<0.05) between group A and group B at mid septal and anterior walls, highly significant difference (<0.001) at basal septal and anterior walls. There was highly significant difference between group A and B at mid and basal lateral and inferior walls. There was highly significant correlation between coronary angiography and VIR velocity regarding detection of positive and negative cases and also there was highly significant correlation between previous 2 tests by Kappa test p value (<0.001). Conclusion: Positive VIR detected by spectral tissue Doppler imaging is a useful indicator of CAD in patients with apparently normal left ventricular contraction and chest pain. Key words: TDI, VIR velocity, coronary angiofraphy, coronary artery disease.