New-onset Chest Pain Research Articles

Clinical risk prediction, coronary computed tomography angiography, and cardiovascular events in new-onset chest pain: the PROMISE and SCOT-HEART trials.

Whether index testing using coronary computed tomography angiography (CTA) improves outcomes in stable chest pain is debated. The risk factor weighted clinical likelihood (RF-CL) model provides likelihood estimation of obstructive coronary artery disease. This study investigated the prognostic effect of coronary CTA vs. usual care by RF-CL estimates. Large-scale studies randomized patients (N = 13 748) with stable chest pain to coronary CTA as part of the initial work-up in addition to or instead of usual care including functional testing. Patients were stratified according to RF-CL estimates [RF-CL: very-low (≤5%), low (>5%-15%), and moderate/high (>15%)]. The primary endpoint was myocardial infarction or death at 3 years. The primary endpoint occurred in 313 (2.3%) patients. Event rates were similar in patients allocated to coronary CTA vs. usual care [risk difference (RD) 0.3%, hazard ratio (HR) 0.84 (95% CI 0.67-1.05)]. Overall, 33%, 44%, and 23% patients had very-low, low, and moderate/high RF-CL. Risk was similar in patients with very low and moderate/high RF-CL allocated to coronary CTA vs. usual care [very low: RD 0.3%, HR 1.27 (0.74-2.16); moderate/high: RD 0.5%, HR 0.88 (0.63-1.23)]. Conversely, patients with low RF-CL undergoing coronary CTA had lower event rates [RD 0.7%, HR 0.67 (95% CI 0.47-0.97)]. The number needed to test using coronary CTA to prevent one event within 3 years was 143. Despite an overall good prognosis, low RF-CL patients have reduced risk of myocardial infarction or death when allocated to coronary CTA vs. usual care. Risk is similar in patients with very-low and moderate/high likelihood.

Protocol-based management of acute chest pain to reduce door-to-balloon time: insights from a tertiary care emergency department

Abstract Background: Chest pain is among the most common reasons patients visit the emergency department (ED). Any new onset of chest pain or any change in the pattern, intensity, or duration of pain in patients with preexisting symptoms must be evaluated to rule out acute coronary syndrome (ACS). Materials and Methods: This study was conducted at the ED of a 250-bed tertiary care center in North India. All patients presenting to the ED with acute chest pain were evaluated using a strictly protocolized approach. The study lasted from October 1, 2021, to December 31, 2022. Patients diagnosed with ST-segment elevation myocardial infarction (STEMI) were included in the study. Key timelines recorded included the time of patient arrival, time to electrocardiogram (ECG), time to transfer to the cardiac catheterization laboratory (CCL), and time to catheterization in the CCL. Results: A total of 208 patients presenting to the ED with acute chest pain were diagnosed with STEMI. The mean door-to-ECG time was 2.96 min, door-to-CCL time was 35.02 min, and door-to-balloon (DTB) time was 65.36 min. Additionally, 86.1% of patients had a DTB time of <90 min. Conclusion: STEMI patients are considered the most vulnerable among those with ACS. Nearly three million STEMI cases occur in India each year. Hospitals providing STEMI care can strengthen protocols to meet recommended timelines and ensure better patient care. Utilizing technology and adapting to local needs can help improve STEMI outcomes and contribute to developing an integrated national policy.

Spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support: a case report

BackgroundIntercostal artery bleeding often occurs in a single vessel; in rare cases, it can occur in numerous vessels, making it more difficult to manage.Case presentationA 63-year-old Japanese man was admitted to the emergency department owing to sudden chest and back pain, dizziness, and nausea. Emergency coronary angiography revealed myocardial infarction secondary to right coronary artery occlusion. After intra-aortic balloon pumping, percutaneous coronary intervention was performed in the right coronary artery. At 12 hours following percutaneous coronary intervention, the patient developed new-onset left anterior chest pain and hypotension. Contrast-enhanced computed tomography revealed 15 sites of contrast extravasation within a massive left extrapleural hematoma. Emergency angiography revealed contrast leakage in the left 6th to 11th intercostal arteries; hence, transcatheter arterial embolization was performed. At 2 days after transcatheter arterial embolization, his blood pressure subsequently decreased, and contrast-enhanced computed tomography revealed the re-enlargement of extrapleural hematoma with multiple sites of contrast extravasation. Emergency surgery was performed owing to persistent bleeding. No active arterial hemorrhage was observed intraoperatively. Bleeding was observed in various areas of the chest wall, and an oxidized cellulose membrane was applied following ablation and hemostasis. The postoperative course was uneventful.ConclusionWe report a case of spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support that was difficult to manage. As bleeding from numerous vessels may occur during antithrombotic therapy, even without trauma, appropriate treatments, such as transcatheter arterial embolization and surgery, should be selected in patients with such cases.

Peri-coronary fat attenuation index combined with high-risk plaque characteristics quantified from coronary computed tomography angiography for risk stratification in new-onset chest pain individuals without acute myocardial infarction.

This study aims to evaluate the role of the peri-coronary Fat Attenuation Index (FAI) and High-Risk Plaque Characteristics (HRPC) in the assessment of coronary heart disease risk. By conducting coronary CT angiography and coronary angiography on 217 patients with newly developed chest pain (excluding acute myocardial infarction), their degree of vascular stenosis, FAI, and the presence and quantity of HRPC were assessed. The study results demonstrate a correlation between FAI and HRPC, and the combined use of FAI and HRPC can more accurately predict the risk of major adverse cardiovascular events (MACE). Additionally, the study found that patients with high FAI were more prone to exhibit high-risk plaque characteristics, severe stenosis, and multiple vessel disease. After adjustment, the combination of FAI and HRPC improved the ability to identify and reclassify MACE. Furthermore, the study identified high FAI as an independent predictor of MACE in patients undergoing revascularization, while HRPC served as an independent predictor of MACE in patients not undergoing revascularization. These findings suggest the potential clinical value of FAI and HRPC in the assessment of coronary heart disease risk, particularly in patients with newly developed chest pain excluding acute myocardial infarction.

Serial Electrocardiograms Show Acute Onset of Inverted P Waves in a 62-Year-Old-Male with Chest Pain

Iatrogenic events are common causes of EMS encounters. This report present the case of a 62-year-old male who presented with new-onset chest pain after his primary care provider increased his diltiazem dose to better control atrial fibrillation. The patient presented with nausea, vomiting, diaphoresis, and 8/10 sub-sternal chest pain. Sequential ECGs captured the initiation of a junctional rhythm indicated by negative (inverted) P waves and a shortened PR interval. The patient had also been prescribed dofetilide (Tikosyn), which can raise diltiazem levels. The case emphasizes the importance of recognizing arrhythmias associated with retrograde A/V conduction and raises awareness of potential iatrogenic events as causes for pre-hospital encounters.

Abstract 14921: Right Atrial Paraganglioma

Introduction: Paragangliomas are rare tumors of neural crest cells origin and can be adrenal or extra-adrenal. They can be associated with catecholamine release in some patients and cause systemic symptoms. Cardiac paragangliomas account for less than 1% of all primary cardiac tumors. Case Summary: A 70-year-old woman presented to the emergency department with new-onset chest pain. Vitals were significant for elevated blood pressure but otherwise unremarkable. Physical exam and serum hematology and chemistries were unremarkable. D-Dimer was mildly elevated. Chest CT Angiogram showed a 1.5 cm right lung nodule but no pulmonary embolism. Outpatient Positron Emission Tomography (PET) scan done for further evaluation of the nodule showed no uptake in the lung nodule but a 5cm mass in the right atrium. Cardiac MRI confirmed the atrial mass with suspicion for angiosarcoma. The patient underwent surgery, and the pathology showed paraganglioma. Patient did well after the surgery. Discussion: Cardiac paragangliomas usually present with fatigue, atypical chest pain or heart failure. It can also present with signs of catecholamine excess. Surgery is the preferred treatment for benign paragangliomas. Surgery should be prompt as it has a potential to be malignant. Chemotherapy and radiolabeled agents are additionally used for the malignant types. Conclusions: There should be high clinical suspicion for secondary causes of hypertension in patients presenting with either episodic hypertension or resistant hypertension. Paragangliomas are very rare cardiac tumors and there have been very few reported cases of right atrial paraganglioma. Any suspicion of this rare tumor should prompt aggressive investigation and prompt referral to a center specializing in their removal.

Telehealth Rapid Access Chest Pain Clinic: Initial Experience During COVID-19 Pandemic.

Objectives: Rapid Access Chest Pain Clinics (RACPCs) provide safe and efficient follow-up for outpatients presenting with new-onset chest pain. RACPC delivery by telehealth has not been reported. We sought to evaluate a telehealth RACPC established during the coronavirus disease 2019 (COVID-19) pandemic. There was a need to reduce the frequency of additional testing arranged by the RACPC during this time, and the safety of this approach was also explored. Methods: This was a prospective evaluation of a cohort of RACPC patients reviewed by telehealth during the COVID-19 pandemic compared with a historical control group of face-to-face consultations. The main outcomes included emergency department re-presentation at 30 days and 12 months, major adverse cardiovascular events at 12 months, and patient satisfaction scores. Results: One hundred forty patients seen in the telehealth clinic were compared with 1,479 in-person RACPC controls. Baseline demographics were similar; however, telehealth patients were less likely to have a normal prereferral electrocardiogram than RACPC controls (81.4% vs. 88.1%, p = 0.03). Additional testing was ordered less often for telehealth patients (35.0% vs. 80.7%, p < 0.001). Rates of adverse cardiovascular events were low in both groups. One hundred twenty (85.7%) patients reported being satisfied or highly satisfied with the telehealth clinic service. Conclusions: In the setting of COVID-19, a telehealth RACPC model with reduced use of additional testing facilitated social distancing and achieved clinical outcomes equivalent to a face-to-face RACPC control. Telehealth may have an ongoing role beyond the pandemic, supporting specialist chest pain assessment for rural and remote communities. Pending further study, it may be safe to reduce the frequency of additional testing following RACPC review.

Intracardiac bone cement embolism resulting in ventricular perforation: an unusual cause of sudden chest pain

Leakage of bone cement is a known complication after percutaneous kyphoplasty. In rare cases, bone cement can reach the venous system and cause life-threatening embolism. We present the case of a 73-year-old male, who was admitted to our hospital with new-onset chest pain and dyspnoea. He had a history of percutaneous kyphoplasty. Multimodal imaging showed intracardiac cement embolism in the right ventricle with penetration of the interventricular septum and perforation of the apex. The bone cement was successfully removed during open cardiac surgery.

Early stent thrombosis in Kounis syndrome - a case report

Introduction. Kounis syndrome is a simultaneous manifestation of acute coronary syndrome and conditions associated with mast cell activation, such as allergies or anaphylactic reactions. We present early stent thrombosis in a female with an atopic constitution without previous atherosclerosis of coronary arteries. Case report. A 50-year-old woman with typical anginal pain was admitted to the Clinic for Cardiology, University Clinical Center Nis. A few hours earlier, she had passed by a linden tree in bloom. She immediately felt chest pain, paresthesia and numbness in her left arm throat tightness, heaviness of the tongue, and swelling of the lips. The symptoms disappeared for 60 min after taking 10mg of loratadine, but then they recurred. On the electrocardiographic (ECG) findings, 30 minutes after admission, ST elevation was seen in leads D2, D3, aVF, and V6. She underwent an emergency percutaneous coronary intervention procedure. Occlusive thrombosis was seen in the ostium of the left anterior descending (LAD) coronary artery. A sirolimus-coated stent was placed and thrombolysis in myocardial infarction (TIMI) 3 flow was obtained. A few hours after the intervention, the patient reported a new onset of chest pain followed by ventricular fibrillation (VF), DC shock, and the occurrence of new ST-segment elevation in aVR and V1?V3 on the ECG. Repeated angiography showed acute instent thrombotic occlusion. Balloon angioplasty was performed, which restored TIMI 3 flow in LAD coronary artery. Anticoagulant and corticosteroid therapy was administered. Three days after the intervention, optical coherence tomography imaging was performed, which showed good stent expansion and apposition, without atherosclerosis and thrombosis. Conclusion. Coronary angiography proved type I Kounis syndrome after exposure to an allergen, and type III Kounis syndrome developed shortly after stent placement when acute instent thrombosis occurred. Newly described causes of acute and sub-acute stent thrombosis in type III Kounis syndrome are stent-associated hypersensitivity reactions.

199: GETTING DOWN TO THE HEART OF IT: A CASE REPORT OF SPONTANEOUS CORONARY ARTERY DISSECTION (SCAD)

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare but fatal diagnosis that can often be misdiagnosed in young and middle-aged female patients who present with acute Myocardial Infarction-like symptoms without any classic cardiovascular risk factors. Description: A middle-aged female with no known medical history presented after she acutely became lightheaded, vomited and had new-onset chest pain. Upon arrival she was obtunded, so she was intubated. Her EKG showed 5mm ST elevation in the inferolateral leads, and her chest x-ray showed mediastinal widening. She was taken for a Computed Tomography (CT) scan, and her CT Chest was negative for dissection. She was then taken for a coronary angiogram where she underwent Percutaneous Coronary Intervention (PCI). During her angiogram, she was found to have a Type 1 SCAD. Her angiogram was complicated by her going into Ventricular Fibrillation (VF) for which she underwent Direct Current Cardioversion and returned to Normal Sinus Rhythm. She had 2 Drug Eluting Stents placed to the Ostial Proximal Right Coronary Artery and was started on norepinephrine due to cardiogenic shock. As she started to stabilize, she was weaned off norepinephrine and propofol and extubated. Further workup showed during a CT Angiography Head and Neck there was beading and undulation noted of the left mid-Internal Carotid Artery which could be indicative of Fibromuscular Dysplasia (FMD). Her SCAD was additionally managed with aspirin, ticagrelor, atorvastatin, and metoprolol with plans to closely monitor her FMD in the outpatient setting due to her risk for recurrent dissection. Discussion: This case shows the importance of early treatment and recognition of rare presentations of ACS such as SCAD. Most cases constitute a conservative approach with medical therapy as over time there appears to be spontaneous healing of the vessel wall, but when the patient is unstable such as in cardiogenic shock, VF, or has ongoing chest pain it warrants a more invasive approach with PCI and medical therapy. This case also shows that there may be an association between SCAD and FMD, such that emerging guidelines recommend after a SCAD event, patients should be screened for FMD with imaging of the renal, cerebrovascular and iliac arteries.

Electrocardiography Diagnostic performance in the assessment of significant coronary artery disease and its anatomical site in comparison with coronary angiography among Nigerians: A pilot study

Introduction: Coronary angiography (CAG) is a useful diagnostic tool in patients with suspected CAD especially in patients that are at high risk. CAG is the gold standard for diagnosis of significant coronary stenosis. However, it can be associated with certain risks. The use of noninvasive assessment tools for predicting CAD is considered because it offers safety, patient convenience, and faster performance. The aim of the study was to assess the predictive value of 12-lead electrocardiogram (ECG) in patients with suspected coronary artery disease (CAD). Methods: 59 consecutive patients aged 40 to 98 years with new onset of chest pain that were referred to the cardiac catheterization laboratory of Bayelsa Specialist Hospital, Yenagoa October 2017 and November, 2018. At admission, a resting standard 12-lead ECG was recorded and the ECG changes were interpreted by the cardiologist. The ECG was recorded as normal or abnormal depending on regional changes in ST segment (ischemic-appearing ST depression or elevation), T-wave inversion (≥ 1 mm) and Q-wave appearance (≥ 0.04 s or ≥ 25% of R-wave amplitude). The III, aVF and II leads were used to detect RCA involvement; V2 or V3 and aVL to detect LCx involvement, and V2 or V3, V1, and V4 were used to detect LAD involvement. ECGs were taken at a paper speed of 25 mm/s and calibration of 10 mm. Results: ECG correctly detected significant stenosis in 21 out of 59 patients with an overall sensitivity per patient of 59.5% and specificity per patient of 59.1%. ECG had the highest sensitivity with LAD involvement LAD (37.3%) and RCA (25.8%), respectively. ECG had a probability of indicating coronary vessel disease in persons with the disease (positive predictive value) 71%, whereas, negative ECG findings were less likely to indicate the absence of disease (a negative predictive value = 46.4%. Similarly, ECG correctly classifying patients as having LAD, RCA, and LCx diseases (66.7%, 70%, and 66.7% respectively) as compared to its ability to correctly classify persons without the respective vessel disease (33.3%, 55.6%, and 55.6%). Among the patients, 59.3% were correctly identified Conclusions: ECG has low sensitivity and specificity for predicting coronary artery stenosis with accuracy ranged 59.5% and 59.1% based on coronary artery analysis.

Clinical Case 31—Active gastrointestinal bleeding during STEMI: a management dilemma

Abstract A man in his 40s presented to the emergency department with chest pain for 8 hours. ECG showed an anterior wall ST-segment elevation myocardial infarction (MI). He received a loading dose of both aspirin and ticagrelor. Coronary angiography demonstrated occlusion of the proximal left anterior descending artery, and primary percutaneous coronary intervention (PCI) with one drug-eluting stent was performed. The patient also presented melena for 5 days. At admission, his hemoglobin was 6.3 g/dL and he was stable. He received a blood transfusion and was started on IV pantoprazole. Endoscopic study was postponed due to concerns related to performing such exam in the setting of a recent MI. The day after PCI, the patient presented major bleeding and hypotension, leading to interruption of the P2Y12 inhibitor. On day 3 of hospitalization, while on single antiplatelet therapy with aspirin, the patient presented new onset of chest pain. He was diagnosed with subacute stent thrombosis (type 4b MI), and thrombus aspiration and balloon angioplasty were performed (Figure 1A, and B). Dual antiplatelet therapy was immediately restarted. Echocardiography revealed worsened left ventricular disfunction (LVEF of 20%). Endoscopy showed tears in the esophagogastric junction (Mallory-Weiss syndrome). This case challenged clinical decision-making, especially the antithrombotic strategy after primary PCI in a patient with major bleeding. Learning points Management of a bleeding patient with acute MI should be individualized. The decision to withhold antithrombotic treatment should weigh the risks related to ongoing bleeding and stent thrombosis. Early endoscopy for acute gastrointestinal bleed in recent MI appears to be a safe procedure for hemorrhage control, although evidence is lacking. Figure 1 Coronary angiography. A—Total occlusion with in-stent thrombus in the proximal left anterior descending artery. B—After thrombus aspiration and angioplasty with paclitaxel-coated balloon of stent thrombosis in the proximal left anterior descending artery, remaining a residual lesion of 50–70%, and distal flow TIMI grade 3.

ALL OVER THE PLACE: A CASE OF MULTIVALVULAR INFECTIVE ENDOCARDITIS

ALL OVER THE PLACE: A CASE OF MULTIVALVULAR INFECTIVE ENDOCARDITIS

Rosai-Dorfman Disease Presenting as Massive Mediastinal Lymphadenopathy in an Elderly Man.

We present a patient case of a 73-year-old man with new-onset substernal chest pain and B symptoms, found on computed tomography imaging to have massive mediastinal lymphadenopathy of more than 6 cm. Positron emission tomography imaging revealed fluorodeoxyglucose-avid nodes further extending to the axillary, abdominal, and inguinal regions. After a broad patient work-up for infectious, malignant, and rheumatic causes, he was ultimately diagnosed with Rosai-Dorfman disease, a rare histiocytic neoplasm, by excisional lymph node biopsy.

Immunological response and temporal associations in myocarditis after COVID-19 vaccination using cardiac magnetic resonance imaging: An amplified T-cell response at the heart of it?

IntroductionAlthough myocarditis after anti-SARS-CoV-2 vaccination is increasingly recognized, we have little data regarding the course of the disease and, consequently, the imaging findings, including the tissue-specific features. The purpose of this study is to describe the clinical, immunological, and cardiac magnetic resonance (CMR) features of myocarditis after COVID-19 immunization in the acute phase and during follow-up. We aimed to compare the trajectory of the disease to myocarditis cases unrelated to COVID-19.MethodsWe assembled a CMR-based registry of potentially COVID-19 vaccination-related myocarditis cases. All patients who experienced new-onset chest pain and troponin elevation after COVID-19 vaccination and imaging confirming the clinical suspicion of acute myocarditis were enrolled in our study. Participants underwent routine laboratory testing and testing of their humoral and cellular immune response to COVID-19 vaccination. Clinical and CMR follow-up was performed after 3–6 months. We included two separate, sex- and age-matched control groups: (1) individuals with myocarditis unrelated to COVID-19 infection or vaccination confirmed by CMR and (2) volunteers with similar immunological exposure to SARS-CoV-2 compared to our group of interest (no difference in the number of doses, types and the time since anti-SARS-CoV-2 vaccination and no difference in anti-nucleocapsid levels).ResultsWe report 16 CMR-confirmed cases of myocarditis presenting (mean ± SD) 4 ± 2 days after administration of the anti-SARS-CoV-2 vaccine (male patients, 22 ± 7 years), frequently with predisposing factors such as immune-mediated disease and previous myocarditis. We found that 75% received mRNA vaccines, and 25% received vector vaccines. During follow-up, CMR metrics depicting myocardial injury, including oedema and necrosis, decreased or completely disappeared. There was no difference regarding the CMR metrics between myocarditis after immunization and myocarditis unrelated to COVID-19. We found an increased T-cell response among myocarditis patients compared to matched controls (p < 0.01), while there was no difference in the humoral immune response.ConclusionIn our cohort, myocarditis occurred after both mRNA and vector anti-SARS-CoV-2 vaccination, frequently in individuals with predisposing factors. Upon follow-up, the myocardial injury had healed. Notably, an amplified cellular immune response was found in acute myocarditis cases occurring 4 days after COVID-19 vaccination.

A Rare Case of Tumefactive Endomyometriosis of the Liver

A 40-year-old woman presented to the emergency department with new-onset chest pain. Her medical history included laparoscopic supracervical hysterectomy involving morcellation of uterine myomas performed 8 years ago and biopsy-proven “disseminated peritoneal leiomyomatosis” involving the liver. Computed tomography revealed known hepatic and omental masses that increased in size (Fig. 1). The patient underwent multiteam surgery for removal of the hepatic and the omental masses, with bilateral salpingectomy and cervix trachelectomy.

A Novel Clinical Score for Differential Diagnosis Between Acute Myocarditis and Acute Coronary Syndrome - The SAlzburg MYocarditis (SAMY) Score.

BackgroundAcute myocarditis and acute coronary syndrome (ACS) are important differential diagnoses in patients with new-onset chest pain. To date, no clinical score exists to support the differentiation between these two diseases. The aim of this study was to develop such a score to aid the physician in scenarios where discrimination between myocarditis and ACS appears difficult.Materials and MethodsPatients with ACS (n = 233) and acute myocarditis (n = 123) were retrospectively enrolled. Least absolute shrinkage and selection operator (LASSO) regression was conducted to identify parameters associated with the highest or least probability for acute myocarditis. Logistic regression was conducted using the identified parameters and score points for each level of the predictors were calculated. Cutoffs for the prediction of myocarditis were calculated. Validation was conducted in a separate cohort of 90 patients.ResultsA score for prediction of acute myocarditis was calculated using six parameters [age, previous infection, hyperlipidemia, hypertension, C-reactive protein (CRP), and leukocyte count]. Logistic regression analysis showed a significant association between total score points and the presence of myocarditis (B = 0.9078, p < 0.0001). Cutoff #1 for the prediction of myocarditis was calculated at ≥ 4 (Sens.: 90.3%, Spec.: 93.1%; 46.3% predicted probability for acute myocarditis), cutoff #2 was calculated at ≥ 7 (Sens.: 73.1%, Spec.: > 99.9%; 92.9% pred. prob.). Validation showed good discrimination [area under the curve (AUC) = 0.935] and calibration of the score.ConclusionOur clinical score showed good discrimination and calibration for differentiating patients with acute myocarditis and ACS. Thus, it could support the differential diagnosis between these two disease entities and could facilitate clinical decisions in affected patients.

Prognostic value of exercise stress echocardiography in patients with known coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Exercise stress echocardiography (EE) is useful for diagnosis and risk stratification in patients (pts) with suspected coronary artery disease (CAD). Pts with known CAD carry a high risk of events. Our aim was to assess the utility of EE in predicting outcomes in this population. Methods Single center retrospective study of consecutive pts with known CAD who performed an EE between 2018 and 2019. The primary endpoint was a composite of admission for acute coronary syndrome (ACS), coronary revascularization and cardiovascular death during the follow-up. Results A total of 76 pts were included (mean age 59±9 years; 87% male). Fifty-nine (78%) pts had history of ACS, 51 (67%) of percutaneous coronary intervention (PCI) and 14 (18%) of coronary artery bypass graft. The majority of pts had 2 or more vessel disease (42 pts; 55%). The main reason for performing EE was new onset of chest pain (38 pts; 50%) followed by functional assessment of coronary stenoses after incomplete revascularization (29 pts; 38%). The majority of pts had a preserved left ventricular ejection fraction (67; 88%). The exam was performed under beta-blocker effect in 35 (46%) pts. The results of EE were positive for myocardial ischemia in 7 (9%) pts, negative in 37 (49%) pts and inconclusive in 32 (42%) pts. Mean exercise time was 8±3 minutes and mean METs achieved was 9.4±2.6. ST-segment depression fulfilling electrocardiographic criteria for ischemia occurred in 17 (22%) pts. Eleven (14%) pts complained of chest pain during the exam. During a median follow up of 22 months (IQR 15-26), the primary endpoint occurred in 9 pts (admission for ACS in 5 pts; revascularization for chronic coronary syndrome in 4 pts). No cardiovascular death occurred. The positive predictive value of EE for the primary endpoint was 57.1% and the negative predictive value (NPV) 97.3%. In a survival analysis, the predictors of the primary endpoint were lower exercise time, lower METs achieved, untreated significant coronary lesions and a positive EE (figure). After adjustment in a multivariate analysis, a positive EE was an independent predictor of the primary endpoint (HR 4.6, 95%CI: 1.1-16.7, p=.044). Conclusion In pts with known CAD, EE had a high NPV and a positive result was an independent predictor of future cardiovascular events.

Impact of a rapid access chest pain clinic in Singapore to improve evaluation of new-onset chest pain.

Chest pain (CP) accounts for 5% of emergency department (ED) visits, unplanned hospitalisations and costly admissions. Conversely, outpatient evaluation requires multiple hospital visits and longer time to complete testing. Rapid access chest pain clinics (RACPCS) are established in the UK for timely, cost-effective CP assessment. This study aims to evaluate the feasibility, safety, clinical and economic benefits of a nurse-led RACPC in a multiethnic Asian country. Consecutive CP patients referred from a polyclinic to the local general hospital were recruited. Referring physicians were left to their discretion to refer patients to the ED, RACPC (launched in April 2019) or outpatients. Patient demographics, diagnostic journey, clinical outcomes, costs, HEART (History, ECG, Age, Risk Factors, Troponin) scores and 1-year overall mortality were recorded. 577 CP patients (median HEAR score of 2.0) were referred; 237 before the launch of RACPC. Post RACPC, fewer patients were referred to the ED (46.5% vs 73.9%, p < 0.01), decreased adjusted bed days for CP, more non-invasive tests (46.8 vs 39.2 per 100 referrals, p = 0.07) and fewer invasive coronary angiograms (5.6 vs 12.2 per 100 referrals, p < 0.01) were performed. Time from referral to diagnosis was shortened by 90%, while requiring 66% less visits (p < 0.01). System cost to evaluate CP was reduced by 20.7% and all RACPC patients were alive at 12 months. An Asian nurse-led RACPC expedited specialist evaluation of CP with less visits, reduced ED attendances and invasive testing whilst saving costs. Wider implementation across Asia would significantly improve CP evaluation.

Impact of a rapid access chest pain clinic in Singapore to improve evaluation of new-onset chest pain

BackgroundChest pain (CP) accounts for 5% of emergency department (ED) visits, unplanned hospitalisations and costly admissions. Conversely, outpatient evaluation requires multiple hospital visits and longer time to complete testing. Rapid...