Low Risk For Acute Coronary Syndrome Research Articles

Can a chest pain virtual ward be used to safely manage patients with low-risk acute coronary syndrome?

Abstract Background Acute coronary syndrome (ACS) accounts for approximately 2-6% of emergency department (ED) presentations and contributes at least 20% of the overall acute hospital admissions(1-3). Patients presenting with low-risk ACS may be suitable for remote monitoring(4) while awaiting angiogram in chest pain virtual ward(CPVW) thereby improving patient flow and resource utilisation. Purpose We aimed to assess outcomes for patients with low-risk ACS admitted in a district general hospital with a view to establish an onboarding pathway for CPVW whilst ensuring a safe monitoring without effecting the readmission rate or all-cause mortality. Methods We retrospectively analysed the Myocardial Ischaemia National Audit Project (MINAP) registry of from March 2022 to April 2023 for patients who presented to ED with a diagnosis of confirmed ACS. Patients were stratified into low-risk (GRACE score <140, HEART score <4, non-dynamic ECG, non-dynamic troponin, without ongoing chest pain), all other patients were deemed intermediate-to-high-risk ACS. Baseline demographics, the total length of acute admission days, waiting time before and after coronary investigation ,adverse events (escalation of therapy, death)whilst awaiting for invasive inpatient angiogram were calculated. The primary endpoint was 30-day readmission and all-cause mortality. Results 1077 patients were coded as ACS diagnosis in ED. 561(52.1%) had a confirmed diagnosis of ACS. Data to allow stratification was available for 538 patients, included in final analysis. 377(70.1%) were male with a mean age of 66.8 ± SD 13.1 years. A significant number of patients had other comorbidities, including hypertension (66.1%), diabetes (45.3%), hyperlipidaemia (51.3%), and previous history of IHD (46.5%). Total number of patients stratified into low-risk ACS was 55(10.2%), intermediate-to-high-risk group contained 483(89.8%) patients. The median total-length-of-stay (LOS) for low-risk ACS patients was 4 days(IQR 2-7), waiting time to have an inpatient angiogram was 3 days(IQR 0-5), and discharge time post-angiogram was 1 day(IQR 0-2). 4 patients(7.3%) in low-risk cohort required CCU admission for GTN infusion due to ongoing chest pain, among them 3 patients(5.5%) had abnormal coronary angiogram. 5 patients(9.1%) in low-risk cohort were readmitted due to chest pain post-angiogram and no patients had 30-days or 1-year all-cause mortality. The result depicts 51 patients from low-risk cohort would have been eligible for CPVW reducing the LOS from median 4 days to 1-2 days, this is a saving of 102-153 acute bed days per year. Assuming the costing of a bed day is £320 this equates to £32,640 - £48,960 cost saving without any adverse outcomes. Conclusion Our data suggests that there is a large cost saving with minimal risk in managing patients with low-risk ACS via a CPVW. This pathway of management is likely to have benefit in patient flow and resource utilisation in our district general hospital trust.Comparison of different ACS cohortsCPVW flow-diagram

Is having a moderate or low history, electrocardiogram, age, risk factors, troponin risk score a handicap for long-term mortality?

History, electrocardiogram, age, risk factors, troponin risk score and troponin level follow-up are used to safely discharge low-risk patients with suspected non-ST elevation acute coronary syndrome from the emergency department for a 1-month period. We aimed to comprehensively investigate the 6-month mortality of patients with the history, electrocardiogram, age, risk factors, troponin risk score. A total of 949 non-ST elevation acute coronary syndrome patients admitted to the emergency department from 01.01.2019 to 01.10.2019 were included in this retrospective study. History, electrocardiogram, age, risk factors, troponin scores of all patients were calculated by two emergency clinicians and a cardiologist. We compared the 6-month mortality of the groups. The mean age of the patients was 67.9 (56.4-79) years; 57.3% were male and 42.7% were female. Six-month mortality was significantly lower in the high-risk history, electrocardiogram, age, risk factors, troponin score group than in the low- and moderate-risk groups: 11/80 (12.1%), 58/206 (22%), and 150/444 (25.3%), respectively (p=0.019). Patients with high history, electrocardiogram, age, risk factors, troponin risk scores are generally treated with coronary angioplasty as soon as possible. We found that the mortality rate of this group of patients was lower in the long term compared with others. Efforts are also needed to reduce the mortality of moderate and low-risk patients. Further studies are needed on the factors affecting the 6-month mortality of moderate and low-risk acute coronary syndrome patients.

Detection of cardiac arrhythmias following acute coronary syndrome using a connected continuous rhythm monitoring device

Abstract Background The incidence of cardiac arrhythmias following acute coronary syndrome (ACS) is not well-known. Purpose To describe the incidence of clinically relevant cardiac arrhythmias following low-risk ACS, using a connected continuous rhythm monitoring device. Methods In a prospective, single arm and open label, observational study, patients in sinus rhythm and with a left ventricular ejection fraction > 40% discharged home after an ACS were equipped with a rhythm monitoring tee-shirt, providing a high-quality continuous 15-lead electrocardiogram signals. Patients were prompted to wear the device as much as possible, for a maximum length of 30 days. Recorded data were reviewed by two independent cardiologists. The primary endpoint was the occurrence of clinically relevant arrhythmias – defined as either new atrial fibrillation, ventricular tachycardia, accelerated idioventricular rhythm or frequent premature ventricular contractions (≥ 500/day) – detected by the device over the first 30 days after hospital discharge following the ACS. Results From January 2020 to August 2022, 99 patients were discharged home with a functional rhythm monitoring device, among whom 45 (55%) were ST-segment elevation myocardial infarction. The median recording duration was 13 days (range: 1-30), with a median workable signal of 9 days. Recorded data were interpretable in 82 patients. At least one clinically relevant arrhythmia occurred in 10 patients (12.2%) during follow-up. Median time to first arrhythmia was 16,5 days (IQR: 8,5-23). Paroxysmal atrial fibrillation was detected in 3 patients (3.7%), non-sustained ventricular tachycardia in 4 patients (4.9%), accelerated idioventricular rhythm in 3 patients (3.7%) and frequent premature ventricular contractions in 5 patients (6.1%) (Figure 1). None of these arrhythmias were symptomatic. No sustained ventricular tachycardia was detected. Conclusions Asymptomatic cardiac arrhythmias were frequent after ACS in patients considered at low risk for further events. The long-term clinical risk of these arrhythmias remains to be studied.

Impact of Glycemic Control on Coronary Inflammation Evaluated by Computed Tomography Pericoronary Fat Attenuation Index in Patients with Acute Coronary Syndrome.

Coronary inflammation causes significantly increased risk of cardiovascular disease (CVD) in diabetic patients. This study investigated the relationship between coronary local inflammation, detected by pericoronary fat attenuation index (FAI), and different blood glucose control levels in low-risk acute coronary syndrome (ACS) patients with or without diabetes. A total of 309 patients with low-risk ACS were classified into three groups: non-diabetes, well-regulated diabetes, and poorly regulated diabetes. Pericoronary FAI around the proximal or left anterior descending artery (LAD), left circumflex artery (LCX), and right coronary artery (RCA), were evaluated by coronary computed tomography angiography (CCTA), and systemic inflammatory variables and other biochemical indicators were detected by flow cytometry. Pericoronary FAI values around the proximal LAD, LCX, and RCA in poorly regulated diabetes were significantly higher than those in well-regulated diabetes and non-diabetes, whereas those in well-regulated diabetes were not statistically different from those in non-diabetes. Further, plasma glycated hemoglobin (HbA1c) level was positively correlated with the pericoronary FAI values in LAD, LCX, and RCA. However, no significantly increased systemic inflammatory mediators were found in diabetic patients with poor glycemic control. Diabetic patients with poor glycemic control may have higher coronary local inflammation as detected by pericoronary FAI surrounding the three major coronary arteries. NCT05590858.

ABO gene polymorphisms are associated with acute coronary syndrome and with plasma concentration of HDL-cholesterol and triglycerides.

The role of ABO gene polymorphisms in acute coronary syndrome (ACS) and lipid metabolism is increasingly recognized. We investigated whetherABO gene polymorphisms are significantly associated with ACS and the plasma lipid profile. SixABOgene polymorphisms (rs651007T/C, rs579459T/C, rs495928T/C, rs8176746T/G, rs8176740A/T, and rs512770T/C) were determined by 5'exonuclease TaqMan assays in 611 patients with ACS and 676 healthy controls. The results demonstrated that the rs8176746Tallele was associated with a lower risk of ACS under the co-dominant, dominant, recessive, over-dominant, and additive models (P= 0.0004,P= 0.0002,P= 0.039, P= 0.0009, andP= 0.0001, respectively). Furthermore, under co-dominant, dominant, and additive models, the rs8176740Aallele was associated with a lower risk of ACS(P= 0.041,P= 0.022, andP= 0.039, respectively). On the other hand, the rs579459Callele was associated with a lower risk of ACS under the dominant, over-dominant, and additive models (P= 0.025,P= 0.035, andP= 0.037, respectively). In a subanalysis performed with the control group, rs8176746Tand rs8176740Aalleles were associated with low systolic blood pressure and with both high high-density lipoprotein-cholesterol (HDL-C) and low triglyceride plasma concentrations, respectively. In conclusion, ABOgene polymorphisms were associated with a lower risk of ACS, and lower systolic blood pressure and plasma lipid levels, suggesting a causal relationship between ABO blood groups and the incidence of ACS.

Evaluation of a Hybrid Cardiovascular Rehabilitation Program in Acute Coronary Syndrome Low-Risk Patients Organised in Both Cardiac Rehabilitation and Sport Centres: A Model Feasibility Study.

The aim of the study was to investigate the efficiency, the feasibility, and the safety of a hybrid cardiovascular rehabilitation program in low-risk acute coronary syndrome (ACS) patients. Sixty low-risk patients with stable clinical status who experienced an ACS in the previous 3 months were included in a 3-week rehabilitation program. The patients were randomized either to a group performing the rehabilitation totally in a rehabilitation centre or partially (only the first 5 days) and then in sport centres equipped for supervised adapted physical activities. The sport centres were located in the vicinity of the patient’s home. Both rehabilitation programs entailed endurance and resistance training and educational therapy. Before and after rehabilitation, cardiorespiratory functions were measured. Similar and significant improvements in peak O2 and power output were seen in patients after both types of rehabilitation (p < 0.05). No particular complications were associated with both of our programs. We conclude that a hybrid rehabilitation program in low-risk ACS patients is feasible, safe, and as beneficial as a traditional program organised in a rehabilitation centre, at least in a short-term. A longitudinal follow-up should nevertheless be organised to examine the long-term impacts of this hybrid rehabilitation program.

Predictors allowing early discharge after interventional treatment of acute coronary syndrome patients.

Many scoring systems for predicting the outcomes of patients with acute coronary syndrome (ACS) have been proposed. In some populations, a significant reduction in length of hospital stay may be achieved without compromising patient prognoses. However, the use of such scoring systems in clinical practice is limited. The aim of this study was to propose a universal list of predictors that can identify low-risk ACS patients who may be eligible for an earlier hospital discharge without increased short-term risk for major adverse cardiac events. A cohort of 1420 patients diagnosed with ACS were enrolled into a single-centre registry between October 2018 and December 2020. Clinical, laboratory, echocardiographic, and angiographic measurements were taken for each patient and entered into the study database. Using retrospective univariant analyses of patients treated with percutaneous coronary intervention (PCI) (n = 932), we compared each predictor to 30-day mortality rate using the Czech national registry of dead people. Eleven predictors correlate significantly with 30-day survival: age <80 years, ejection fraction >50%, no cardiopulmonary resuscitation, no mechanical ventilation needed, Killip class I at admission, haemoglobin levels >110 g/L while hospitalized, successful PCI procedure(s), no residual stenosis over 90%, Thrombolysis in Myocardial Infarction 3 flow after PCI, no left main stem disease, and no triple-vessel coronary artery disease. In all, presence of all predictors applies to 328 patients (35.2% of the cohort), who maintained a 100% survival rate at 30 days. A combination of clinical, echocardiographic, and angiographic findings provides valuable information for predicting the outcomes of patients with all types of ACS. We created a simple, useful tool for selecting low-risk patients eligible for early discharge.

Analysis of Predictive Model of Coronary Vulnerable Plaque under Hemodynamic Numerical Simulation.

Objective Vulnerable plaque is considered to be the cause of most clinical coronary arteries, and linear cytokines are an important factor causing plaque instability. Early prediction of vulnerable plaque is of great significance in the treatment of cardiovascular diseases. Methods Computational fluid dynamics (CFD) was used to simulate the hemodynamics around plaques, and the serum biochemical markers in 224 patients with low-risk acute coronary syndrome (ACS) were analyzed. Vulnerable plaques were predicted according to the distribution of biochemical markers in serum. Results CFD can accurately capture the hemodynamic characteristics around the plaque. The patient's age, history of hyperlipidemia, apolipoprotein B (apoB), adiponectin (ADP), and sE-Selection were risk factors for vulnerable plaque. Area under curve (AUC) values corresponding to the five biochemical markers were 0.601, 0.523, 0.562, 0.519, 0.539, and the AUC value after the combination of the five indicators was 0.826. Conclusion The combination of multiple biochemical markers to predict vulnerable plaque was of high diagnostic value, and this method was convenient and noninvasive, which was worthy of clinical promotion.

ROB-MEN: a tool to assess risk of bias due to missing evidence in network meta-analysis

BackgroundSelective outcome reporting and publication bias threaten the validity of systematic reviews and meta-analyses and can affect clinical decision-making. A rigorous method to evaluate the impact of this bias on the results of network meta-analyses of interventions is lacking. We present a tool to assess the Risk Of Bias due to Missing Evidence in Network meta-analysis (ROB-MEN).MethodsROB-MEN first evaluates the risk of bias due to missing evidence for each of the possible pairwise comparison that can be made between the interventions in the network. This step considers possible bias due to the presence of studies with unavailable results (within-study assessment of bias) and the potential for unpublished studies (across-study assessment of bias). The second step combines the judgements about the risk of bias due to missing evidence in pairwise comparisons with (i) the contribution of direct comparisons to the network meta-analysis estimates, (ii) possible small-study effects evaluated by network meta-regression, and (iii) any bias from unobserved comparisons. Then, a level of “low risk”, “some concerns”, or “high risk” for the bias due to missing evidence is assigned to each estimate, which is our tool’s final output.ResultsWe describe the methodology of ROB-MEN step-by-step using an illustrative example from a published NMA of non-diagnostic modalities for the detection of coronary artery disease in patients with low risk acute coronary syndrome. We also report a full application of the tool on a larger and more complex published network of 18 drugs from head-to-head studies for the acute treatment of adults with major depressive disorder.ConclusionsROB-MEN is the first tool for evaluating the risk of bias due to missing evidence in network meta-analysis and applies to networks of all sizes and geometry. The use of ROB-MEN is facilitated by an R Shiny web application that produces the Pairwise Comparisons and ROB-MEN Table and is incorporated in the reporting bias domain of the CINeMA framework and software.

Predictive value of HEART score in the outcome of acute coronary syndrome and disposition

Objective: Disposition in acute coronary syndrome (ACS) is pivotal in an emergency department (ED). HEART score is a recent scoring system for finding primary endpoints in undetermined ACS. This study aimed at evaluating the predictive value of HEART score in ACS outcome and disposition. Methods: In this prospective study, all patients with chest pain presentation compatible with our inclusion criteria referring to ED were enrolled during one year. Demographic data, triage level, hospital length of stay, admission ward, coronary angiography result, HEART score, thrombolysis in myocardial infarction (TIMI) score, 1-month primary ACS endpoints and major adverse cardiac events (MACE) were evaluated. Results: In our studied population (200 cases), 49 patients (24.5%) had at least one score for MACE. Comparing the prognostic values of TIMI vs HEART score in MACE revealed that the HEART had a larger AUC. The best cut-off point of HEART score in MACE prediction was calculated to be ≥5. There was a statistically significant relation between HEART score and hospital length of stay. The higher the HEART score, the more probability of patients being admitted to either hospital cardiac ward or coronary care unit (CCU). There was a significant relationship between the triage level and HEART score. Patients with higher HEART score had more acuity (lower triage level 1 or 2). Conclusion: HEART predicted MACE better than TIMI in low risk ACS. Patients with higher HEART score were more admitted to the hospital with longer hospital stay and patients with lower HEART score had higher triage level with less acuity.

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.

Elevated Glycated Albumin in Serum Is Associated with Adverse Cardiac Outcomes in Patients with Acute Coronary Syndrome Who Underwent Revascularization Therapy.

Aims: The associations between increased glycated albumin (GA) in the serum and diabetic complications and mortality have been revealed in the general population. However, less is known regarding the prognostic value of GA in patients diagnosed with acute coronary syndrome (ACS). Methods: In this study, all patients admitted for ACS who underwent a successful percutaneous coronary intervention (PCI) at our center from January 2018 to February 2019 were retrospectively examined. Clinical characteristics, laboratory results (e.g., serum GA levels), and procedural details were collected. The primary outcome included a composite of major adverse cardio-cerebral events (MACCE), such as death, myocardial infarction, stroke, and unplanned revascularization. The association between serum GA levels and clinical outcomes was tested in three multivariable models using Cox proportional hazard analysis. Subgroup analysis was performed in patients who were diagnosed with diabetes versus patients without diabetes. Results: A total of 1,806 ACS patients (mean age of 59.4 years; 77.8% were men; 44.9% were diagnosed with diabetes) were enrolled in this study, where the majority exhibited unstable angina (81.6%) and showed preserved left ventricular systolic function. Patients in the high GA level group were commonly female and were more likely to have metabolic disorders and to exhibit severe CAD (all p ＜0.05). MACCE occurred in 126 patients (7.0%) during a mean follow-up time of 17.2 months. The cumulative risk of MACCE at the 18-month follow-up visit significantly increased in a stepwise fashion along with increased GA levels (log-rank p =0.018) in the serum. The association between serum GA levels and MACCE was further determined after adjusting traditional risk factors and hemoglobin A1c (HbA1c) (GA, per 1% increase: hazard ratio [HR] 1.09, 95% confidence interval [CI] 1.06–1.13; GA, higher vs. lower tertial: HR 1.92, 95% CI 1.01–3.67). In a subgroup analysis, the prognostic role of serum GA only existed in diabetic patients, even when adjusting for traditional risk factors and HbA1c levels. Conclusions: Elevated GA levels in the serum were associated with poor intermediate-term outcomes in low-risk ACS patients who underwent PCI, especially in patients with preexisting diabetes.

Diagnostic accuracy of Instantaneous Wave-Free Ratio (iFR) for the assessment of myocardial ischaemia: a comparison with non-invasive stress imaging

Abstract Background Instantaneous Wave-Free Ratio (iFR) allows for the assessment of the haemodynamic effects of epicardial coronary stenoses without the need for hyperaemia; iFR is currently recommended as a means to evaluate myocardial ischaemia. Purpose To assess the diagnostic accuracy of iFR with respect to the identification of coronary epicardial stenoses causing ischemia. Therefore, we combined anatomical (% stenosis at invasive coronary angiography, ICA) and functional (non-invasive imaging stress test, NIST) information to obtain a “gold standard” for the identification of stenoses causing ischaemia. Methods We enrolled 71 patients (52 male, 19 female; age mean 68.4±8.1 years) with chronic coronary syndrome or low-risk acute coronary syndrome without ST segment elevation who had at least a NIST and who had at least one vessel with a 50%-85% stenosis at ICA. iFR was measured in all coronary arteries with stenosis &amp;gt;50% and categorised according to the 0.89 threshold for ischaemia. Results iFR was assessed in 122 vessels. In a per-vessel analysis, in 56.7% ischaemia was present both at iFR and NIST, in 21.3% ischaemia was absent in both, while in 23.0% ischaemia was found at NIST but not confirmed by iFR. The overall accuracy of iFR with respect to NIST was 90.1%. However, when considering as the “gold standard” for coronary disease causing ischaemia the contemporary presence of an epicardial stenosis &amp;gt;70% at ICA and a positive NIST, the diagnostic accuracy of iFR greatly improved. The sensibility, specificity, PPV, NPV and accuracy were 96.5%, 75.0%, 73.3%, 96.7% and 84.4%, respectively. In case of discordance between NIST and iFR, revascularization was based on iFR. At a mean follow-up of 23±18 months, the composite endpoint of MACE (major adverse cardiac events, defined as the composite of all-cause death, nonfatal MI and unplanned coronary revascularization) occurred in 16.4%, while death/MI occurred in 11.9%. Stratification according to the per-patient concordance between iFR and NIST showed no significant differences in rates of MACE (p=0.50) and death/MI (p=0.20). Stratification based on iFR showed a higher death/MI rate in iFR-positive patients (11.9% vs. 0%, p=0.047) and a trend to higher MACE rate (11.9% vs. 4.47% p=0.14), Conclusions The diagnostic accuracy of iFR is low when compared with NIST as the reference for myocardial ischaemia, but it is very high when compared with the combined presence of epicardial stenosis and positive NIST. Therefore, iFR can accurately guide the decision to treat or defer revascularization of intermediate coronary stenoses, being most useful in patients with multivessel CAD and when non-invasive functional data are lacking or discordant with anatomy. Funding Acknowledgement Type of funding source: None

The Ser290Asn and Thr715Pro Polymorphisms of the SELP Gene Are Associated with A Lower Risk of Developing Acute Coronary Syndrome and Low Soluble P-Selectin Levels in A Mexican Population ‡.

Recent studies have shown that P-selectin promotes the early formation of atherosclerotic plaque. The aim of the present study was to evaluate whether the SELP gene single nucleotide polymorphisms (SNPs) are associated with presence of acute coronary syndrome (ACS) and with plasma P-selectin levels in a case-control association study. The sample size was estimated for a statistical power of 80%. We genotyped three SELP (SELP Ser290Asn, SELP Leu599Val, and SELP Thr715Pro) SNPs using 5’ exonuclease TaqMan assays in 625 patients with ACS and 700 healthy controls. The associations were evaluated with logistic regressions under the co-dominant, dominant, recessive, over-dominant and additive inheritance models. The genotype contribution to the plasma P-selectin levels was evaluated by a Student’s t-test. Under different models, the SELP Ser290Asn (OR = 0.59, pCCo-Dominant = 0.047; OR = 0.59, pCDominant = 0.014; OR = 0.58, pCOver-Dominant = 0.061, and OR = 0.62, pCAdditive = 0.015) and SELP Thr715Pro (OR = 0.61, pCDominant = 0.028; OR = 0.63, pCOver-Dominant = 0.044, and OR = 0.62, pCAdditive = 0.023) SNPs were associated with a lower risk of ACS. In addition, these SNPs were associated with low plasma P-selectin levels. In summary, this study established that the SELP Ser290Asn and SELP Thr715Pro SNPs are associated with a lower risk of developing ACS and with decreased P-selectin levels in plasma in a Mexican population.

A study of clinical profile of low risk Acute Coronary syndrome in a teaching tertiary care hospital - A prospective observational study

A study of clinical profile of low risk Acute Coronary syndrome in a teaching tertiary care hospital - A prospective observational study

COMPARATIVE ANALYSIS OF VARIOUS RISK ASSESSMENT SCORES FOR LOW RISK ACUTE CORONARY SYNDROME IN AN INDIAN SCENARIO – AN ED BASED OBSERVATIONAL STUDY.

Chest pain is one of the most common presentation to emergency department (ED). The misdiagnosis or over-diagnosis of patients with acute chest pain can be associated with serious clinical events or is time-consuming and this places a heavy burden on overcrowded and resource constraint ED. To help overcome this issue various scores are formed to rule out acute coronary syndrome (ACS) in these patients. Those who do not meet the criteria of high risk ACS like raised cardiac biomarkers, ECG changes, etc are labeled as low risk ACS. These patients form the majority of patients. A multitude of risk score have been formulated to predict the outcome and risk stratify patients with chest pain. Our objective was to evaluate the utility of these score in Indian setting in low risk ACS patients.&#x0D; We studied the various risk prediction score of 100 patients presenting to the ED of tertiary care teaching institute in an urban industrial area with low risk ACS. The scores that were calculated included HEART, TIMI, ADAPT, GRACE, NACPR and EDACS.&#x0D; Of all the scores only the HEART score correlated well with identifying those who required further testing. Taking a score of less than 3 as a marker of low risk ACS we get a sensitivity of 95.83% (95CI - 89.67% to 98.85%) and specificity of 100%. The PPV is 100% and accuracy of 96%. All other scores were either not specific enough or had limited utility.&#x0D; Keywords: Low risk ACS, ACS, HEART, TIMI, ADAPT, GRACE, NACPR, EDACS

Clinical utility of mean platelet volume and immature platelet fraction in acute coronary syndrome

BackgroundPlatelets play an important role in the pathogenesis of acute coronary syndrome (ACS). Patients with ACS have an increased mean platelet volume (MPV) and immature platelet fraction (IPF) resulting in elevation of thrombotic ability. In this study, we evaluated the diagnostic performance of MPV and IPF in identifying suspected ACS patients at emergency department. Moreover, we investigated the correlation between MPV or IPF with initial troponin I (TnI), one of the current ACS biomarkers. MethodsThis was a single-center study recruiting suspected ACS patients who had acute chest pain at the emergency department. Whole blood samples were obtained from all participants and MPV and IPF were measured by Sysmex XE-5000 hematology analyzer within 20 min of blood sampling. The diagnostic values of MPV and IPF in identifying ACS were analyzed retrospectively. ResultIn this study, 63 in 104 suspected ACS patients were diagnosed as ACS (65.3%). MPV and IPF were higher in ACS patients compared to non-ACS patients (MPV: 10.7 ± 0.80 fL vs 10.0 ± 0.64 fL, p < 0.001; IPF: 3.7 ± 2.64% vs 3.1 ± 2.69%, p = 0.030). MPV and IPF were similar in unstable angina and acute myocardial infarction patients. We showed that elevation of MPV could be an independent predictive factor of ACS (odds ratio: 5.038). At the optimal cut-off value of 10.55 fL (AUC 95% CI: 0.637–0.836), the diagnostic performance of MPV in predicting ACS had an area under a receiver operating characteristic curve (AUC) of 0.736 with sensitivity and specificity of 54.2% and 82.8%, respectively. Patients with both of initial TnI and MPV higher than the established cut-off value had increased incidence (3.792 fold) for ACS development compared to patients with TnI below the cut-off value. Furthermore, diagnosing ACS with both MPV and initial TnI increased the positive predictive value from 84.2% to 86.7%. No correlation was observed between MPV or IPF and the mortality rate of ACS patients (MPV: 3.8% vs 11.1%, p = 0.300; IPF: 12.0% vs 37.5%, p = 0.054). ConclusionHere we show that ACS patients have higher MPV and IPF compared to non-ACS patients. We further demonstrate that MPV can be utilized as an independent predictor for early diagnosis of low-risk ACS patients who have acute chest pain.

CARE PATHWAY FOR PATIENTS WITH ACS UNDERGOING PCI: OPPORTUNITIES FOR IMPROVING VALUE

Acute coronary syndrome (ACS) admissions are common and costly, amounting to $7 billion annually in the United States. The association between comprehensive ACS care strategies and outcomes are lacking. We identified 434,172 low-risk ACS patients (STEMI 35%, UA/NSTEMI 65%) enrolled in the Premier

Selective coronary angiography, percutaneous coronary intervention and asymptomatic peri-procedural myocardial injury.

While there have been a number of studies reporting the incidence and implications of elevated troponin levels after percutaneous coronary intervention (PCI), the body of information about the incidence, associations, and implications of elevated troponin levels following coronary angiography (CAG) is limited. A total of 220 consecutive patients with stable coronary artery disease or intermediate or low-risk acute coronary syndrome without persistent ST-segment elevation (NSTE-ACS) were included in our study. High-sensitivity cardiac troponin I (hs-cTnI) levels were measured before and after coronary angiography (CAG) in patients with or without PCI and correlated with a number of clinical variables. Hs-cTnI elevations above the 99th percentile upper reference limit (URL), or above 20% of the initially positive, yet already declining values, were found in 60 (37.2%) patients after CAG and in 45 (76.2%) patients undergoing PCI. Significant correlations of hs-cTnI elevation were found with the following variables: volume of contrast, fluoroscopy time, dose-area product, amount of contrast agent injected directly into the coronary arteries, total time of balloon dilation and the number and total length of implanted stents (P<0.001 for all). While an asymptomatic elevation of hs-cTnI is a common finding after PCI, it does occur, quite surprisingly, also after CAG. Despite contradictory views regarding the clinical relevance of asymptomatic post-procedural elevated hs-cTnI levels, it is generally believed that a mild elevation is not associated with an increased risk. Still, it may pose a diagnostic quandary following a successful interventional procedure and even more so after an uncomplicated CAG. Clinicaltrials.gov - NCT02960321.

Anxiety about anxiety: a survey of emergency department provider beliefs and practices regarding anxiety-associated low risk chest pain.

BackgroundApproximately 80% of patients presenting to emergency departments (ED) with chest pain do not have any true cardiopulmonary emergency such as acute coronary syndrome (ACS). However, psychological contributors such as anxiety are thought to be present in up to 58%, but often remain undiagnosed leading to chronic chest pain and ED recidivism.MethodsTo evaluate ED provider beliefs and their usual practices regarding the approach and disposition of patients with low risk chest pain associated with anxiety, we constructed a 22-item survey using a modified Delphi technique. The survey was administered to a convenience sample of ED providers attending the 2016 American College of Emergency Physicians Scientific Assembly in Las Vegas.ResultsSurveys were completed by 409 emergency medicine providers from 46 states and 7 countries with a wide range of years of experience and primary practice environment (academic versus community centers). Respondents estimated that 30% of patients presenting to the ED with chest pain thought to be low risk for ACS have anxiety or panic as the primary cause but they directly communicate this belief to only 42% of these patients and provide discharge instructions to 48%. Only 39% of respondents reported adequate hospital resources to ensure follow-up. Community-based providers reported more adequate follow-up for these patients than their academic center colleagues (46% vs. 34%; p = 0.015). Most providers (82%) indicated that they wanted to have referral resources available to a specific clinic for further outpatient evaluation.ConclusionEmergency Department providers believe approximately 30% of patients seeking emergency care for chest pain at low risk for ACS have anxiety as a primary problem, yet fewer than half discuss this concern or provide information to help the patient manage anxiety. This highlights an opportunity for patient centered communication.