Noncardiac Chest Pain Patients Research Articles

Nourin miRNAs: novel biomarkers highly expressed in unstable angina patients with normal ECG and negative hs-troponin and dropped post percutaneous coronary intervention

Abstract Background We recently reported that Nourin-dependent miR-137 and miR-106b can identify reversible myocardial ischemia in chest pain patients with a confirmed diagnosis of chronic stable chronic artery disease (CAD) and unstable angina (UA). These patients showed normal resting ECG and hs-cTnI below the clinical decision (<99th of URL). Normal, low-grade, baseline expression levels of Nourin miRNAs were detected in healthy subjects and in non-cardiac chest pain patients with hs-cTnI <99th URL. Purpose 1) To confirm the upregulation of Nourin miRNAs in chest pain patients with normal resting ECG and hs-cTnI < 99th URL, who are suspected of having UA; 2) whether Nourin miRNA expression levels change after relieving myocardial ischemia by PCI; and 3) whether there is an association between severity of chest of pain and Nourin miRNA expression levels prior to PCI. Methods This study enrolled 36 consecutive chest pain patients with normal resting ECGs and hs-cTnI <99th URL, from two large referral centers in Egypt. All enrolled patients had a single vessel disease with significant coronary stenosis (>70%) during diagnostic coronary angiography that was treated by PCI using standard techniques. The gene expression levels of miR-137 and miR-106b were measured in serum samples collected prior to PCI, as well as 12 hours and 24 hours post PCI. The angina class was evaluated at presentation, discharge, and after 4 weeks to verify angina relief. Results All patients (n=36) underwent successful PCI. Gene expression levels of miR-137 and miR-106b were significantly upregulated prior to PCI (mean ± SD: miR-137 = 355±150 and miR-106b =317±122) compared to healthy subjects (n=16) who showed minimal expression levels ranged from 0.615 to 1.05 (P <0.0001). Levels of both biomarkers dropped by 50% (12 hours) and 65% (24 hours) post PCI (P <0.05) (Figure 1). The expression levels of Nourin miRNAs did not associate with the Canadian class levels of angina severity. All patients were asymptomatic at discharge, while 84% remained asymptomatic after 4 weeks. Conclusions This study: 1) confirms that Nourin miR-137 and miR-106b can identify myocardial ischemia in patients presenting with unstable angina; 2) confirms that these two novel molecular biomarkers are elevated during myocardial ischemia, in the absence of myocardial injury; and 3) for the first time, we report a significant drop of Nourin miRNA expression levels post PCI, with myocardial ischemia relief.

Circulating Exosomal CircRNAs as Diagnostic Biomarkers for Chronic Coronary Syndrome.

Circular RNA (circRNA) has been reported to be involved in the pathogenesis of cardiovascular disease; however, it is unclear whether circRNA carried by exosomes (exos) can be used as biomarkers for chronic coronary syndrome (CCS). High-throughput sequencing was carried out in the plasma exosomal RNA of 15 CCS patients and 15 non-cardiac chest pain patients (NCCP, control group) to screen for differentially expressed circRNAs. Selected differentially expressed exo-circRNAs were further verified by real-time polymerase chain reaction in a small-sample cohort and a large-sample cohort. A total of 276 circRNAs were differentially expressed in the plasma exosomes of CCS patients, with 103 up-regulated and 173 down-regulated. Among the 103 up-regulated circRNAs, 5 circRNAs with high expression levels were selected for validation. Real time quantitative PCR of the first and second validation cohort demonstrated that exo-hsa_circ_0075269 and exo-hsa_circ_0000284 were significantly up-regulated in patients with CCS. Circulating exo-hsa_circ_0075269 and exo-hsa_circ_0000284 yielded the area under the curve values of 0.761 (p < 0.001, 95%CI = 0.669, 0.852) and 0.623 (p = 0.015, 95%CI = 0.522, 0.724) for CCS, respectively, by ROC curve analysis. In conclusion, the expression profile of circRNA in plasma exosomes of patients with CCS was significantly different from that of the control group. Plasma exo-hsa_circ_0075269 and exo-hsa_circ_0000284 have the potential to be new biomarkers for CCS.

Establishment of a nomogram model for acute chest pain triage in the chest pain center.

Acute myocardial infarction (AMI) is the leading life-threatening disease in the emergency department (ED), so rapid chest pain triage is important. This study aimed to establish a clinical prediction model for the risk stratification of acute chest pain patients based on the Point-of-care (POC) cardiac troponin (cTn) level and other clinical variables. We conducted a post-hoc analysis of the database from 6,019 consecutive patients (excluding prehospital-diagnosed non-cardiac chest pain patients) attending a local chest pain center (CPC) in China between October 2016 and January 2019. The plasma concentration of cardiac troponin I (cTnI) was measured using a POC cTnI (Cardio Triage, Alere) assay. All the eligible patients were randomly divided into training and validation cohorts by a 7:3 ratio. We performed multivariable logistic regression to select variables and build a nomogram based on the significant predictive factors. We evaluated the model's generalization ability of diagnostic accuracy in the validation cohort. We analyzed data from 5,397 patients that were included in this research. The median turnaround time (TAT) of POC cTnI was 16 min. The model was constructed with 6 variables: ECG ischemia, POC cTnI level, hypotension, chest pain symptom, Killip class, and sex. The area under the ROC curve (AUC) in the training and validation cohorts was 0.924 and 0.894, respectively. The diagnostic performance was superior to the GRACE score (AUC: 0.737). A practical predictive model was created and could be used for rapid and effective triage of acute chest pain patients in the CPC.

Non-Cardiac Chest Pain as a Persistent Physical Symptom: Psychological Distress and Workability.

Non-Cardiac Chest Pain (NCCP) is persistent chest pain in the absence of identifiable cardiac pathology. Some NCCP cases meet criteria for Persistent Physical Symptoms (PPS), where the symptoms are both persistent and distressing/disabling. This study aimed to identify patients that might need specialist treatment for PPS by examining cases of NCCP that meet PPS criteria. We analysed data from 285 chest pain patients that had received an NCCP diagnosis after attending an emergency cardiac department. We compared NCCP patients who did and did not meet the additional criteria for heart-related PPS and hypothesised that the groups would differ in terms of psychological variables and workability. We determined that NCCP patients who meet PPS criteria were more likely than other NCCP patients to be inactive or unable to work, reported more general anxiety and anxiety about their health, were more depressed, ruminated more, and, importantly, had a higher number of other PPS. A high proportion of NCCP patients meet PPS criteria, and they are similar to other PPS patients in terms of comorbidity and disability. This highlights the importance of focusing psychological interventions for this subgroup on the interplay between the range of physical and psychological symptoms present.

Association of Mean Platelet Volume with Acute Coronary Syndrome: A Case–Control Study

Abstract Background: Acute coronary syndrome (ACS) is a group of symptoms associated with acute myocardial ischemia and is one of the major causes of morbidity and mortality across the world. Its primary etiology is atherosclerosis which is crucially dependent on platelets, and hence, mean platelet volume (MPV) could be a new biomarker for predicting or diagnosing ACS. Our study aims to measure the MPV in patients of ACS and compares it with patients of noncardiac chest pain to evaluate its usefulness as a new marker for ACS. Materials and Methods: A case–control study with 50 cases and 50 controls was carried out in SSG Hospital, Vadodara, over a period of 1 year (November 2016–November 2017). ACS patients were identified according to inclusion and exclusion criteria and their MPV was compared to that of noncardiac chest pain patients. Results: The cases had a higher MPV as compared to the control group, with both males and females being affected, but a stronger association was seen in case of males. Conclusions: Raised MPV has shown significant association with ACS and the test has reasonable sensitivity and specificity, which warrants larger scale studies to confirm its utility as a biomarker for ACS.

What Predict Self-rated Health: A Cross-sectional Study Among Men and Women with Non-cardiac Chest Pain.

The study aimed to determine different lifestyle and clinical factors that predict self-rated health (SRH) in non-cardiac chest pain (NCCP) patients. In this cross-sectional study, 360 NCCP patients filled out questionnaires about depression, somatization, body sensation, type D personality, and pain intensity. In addition, participants' lifestyle and socio-demographic data were obtained. Multiple regression analyses revealed that among men, pain intensity (OR 1.07; 95% CI 1.03, 1.12), depression (3.10; 1.38, 9.18), somatization (1.18; 1.08, 1.29) and sleep quality (6.23; 1.42, 27.27) were associated with self-rated health. In women NCCP patients, depression (2.44; 1.05, 6.82) pain intensity (1.05; 1.01, 1.10), and physical activity (2.21; 1.07, 5.55) were associated with SRH. The results on the predicting factors of SRH in NCCP patients provide potential insights for more advanced clinical management of NCCP. In addition, they can be applied to improve health policies and promote healthy behaviors among NCCP patients.

Predictors of long-term symptom burden and quality of life in patients hospitalised with chest pain: a prospective observational study

ObjectiveTo describe the magnitude and predictors of symptom burden (SB) and quality of life (QoL) 3 months after hospital admission for acute chest pain.DesignProspective observational study.SettingSingle centre, outpatient follow-up.Participants1506 patients.OutcomesScores...

Patients with NSTEMI have fewer symptoms and higher quality of life three months after admission for acute chest pain

Abstract Background A substantial proportion of patients admitted for possible non-ST elevation acute coronary syndrome (NSTE-ACS) who are not diagnosed with non-ST elevation myocardial infarction (NSTEMI) suffer from conditions (e.g. chronic myocardial injury [CMI]) that may imply serious cardiac risk and impaired quality of life. It is unknown what predicts quality of life and recurrence of symptoms in chest pain patients. Purpose To investigate which demographic and clinical characteristics, including discharge diagnosis, that predict recurrent symptoms and quality of life three months after hospitalization for acute chest pain. Methods A total of 1506 patients ≥18 years admitted with suspected NSTE-ACS at Haukeland University Hospital, Bergen, Norway, were included in the WESTCOR study. The final diagnosis was adjudicated by two independent cardiologists based on all clinical data including routine cTnT (5th gen, Roche Diagnostics). Three months after discharge patients received questionnaires assessing general health (SF-12v1), angina-related health (SAQ-7) and dyspnea (Rose Dyspnea Scale). In all, 774 (51.3%) patients responded and were included in the analyses. Univariable and multivariable regression models were applied to identify predictors of symptoms and quality of life scores after adjusting for a subset of candidate predictors. A subgroup analysis was undertaken in patients with stable troponin concentrations (N=658). Results Based on the discharge diagnosis the patients were grouped as NSTEMI (14.2%), unstable angina pectoris (UAP) (16.9%), non-coronary cardiac disease (6.6%), non-cardiac disease (6.3%) and non-cardiac chest pain (NCCP) (56.0%). After three months the NSTEMI patients had the highest quality of life scores and the lowest prevalence of symptoms (angina and dyspnea), while the inverse was true for the UAP patients (Fig 1). Revascularized patients had a better quality of life compared to those treated conservatively (P&amp;lt;0.001). Adjusted multivariable analysis also demonstrated that revascularization (β=0.19, P=0.002) and a diagnosis of UAP (β=−0.18, P=0.007) succeeded to predict angina frequency. Additionally, current smoking and hypertension were also associated with worse quality of life outcomes (Table 1). NCCP patients had high median prevalence of symptoms after three months, with 50% of the group reporting chest pain in the last four weeks, and 33% reporting dyspnea. In the subgroup analysis, current smoking predicted worse quality of life in all domains (all P&amp;lt;0.05) except SAQ7-Angina frequency. Conclusions Three months after hospitalization for chest pain revascularized patients had better quality of life and less symptoms compared to other patient groups. A diagnosis of UAP predicted recurrent symptoms and impaired quality of life in patients, suggesting that closer monitoring should be considered in order to minimize re-hospitalization. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): The study is funded by grants from the Western Norway Regional Health Authority, Haukeland and Stavanger University hospitals. Figure 1Table 1

Determinants of depression in non-cardiac chest pain patients: a cross sectional study.

BackgroundNon-cardiac chest pain (NCCP) is a common patient complaint imposing great costs on the healthcare system. It is associated with psychological factors such as depression. The aim of the present study is determining depression predictors in NCCP patients.MethodsThe participants of this cross-sectional study were 361 NCCP patients. Patients filled out questionnaires concerning their sociodemographic, lifestyle, and clinical factors (severity of pain, type D personality, somatization, cardiac anxiety, fear of body sensations, and depression).ResultsBased on multiple ordinal logistic regression, lack of physical activity (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.09-2.87), sleep quality (OR, 2.98; 95% CI, 1.15-7.69), being a smoker (OR, 1.33; 95% CI, 2.41-4.03), present pain intensity (OR, 1.08; 95% CI, 1.05-1.11), type D personality (OR, 2.43; 95% CI, 1.47-4.03), and somatization (OR, 1.22; 95% CI, 1.15-1.3) were significant predictors of depression in NCCP patients. Additionally, multiple linear regression showed that being unmarried (β = 1.51, P = 0.008), lack of physical activity (β = 1.22, P = 0.015), sleep quality (β = 2.26, P = 0.022), present pain intensity (β = 0.07, P = 0.045), type D personality (β = 1.87, P < 0.001), somatization (β = 0.45, P < 0.001), and fear of bodily sensation (β = 0.04, P = 0.032) increased significantly depression scores in NCCP patients.ConclusionsPhysicians should consider the predictors of depression in NCCP patients which can lead to receiving effective psychological consultations and reducing the costs and ineffectual referrals to medical centers.

How is type D personality associated with the major psychological outcomes in noncardiac chest pain patients?

Noncardiac chest pain (NCCP) may lead many problems on the health-care system. Having type D personality has been shown to adversely affect NCCP patients. This study aimed to determine the psychological comorbidities that type D personality is associated with, in patients with NCCP. The participants of this cross-sectional study were 360 patients diagnosed with NCCP. Patients filled out questionnaires about sociodemographic, behavioral, and clinical factors (severity of pain, somatization, cardiac anxiety, fear of body sensations, depression, and type D personality). Type D personality was more prevalent among female (p < 0.005), and those people having this personality showed lower sleep quality (p = 0.001) and sexual life satisfaction (p < 0.001) and more likely to be smoker (p < 0.001). Type D personality is strongly associated with fear of body sensations (β = 5.92, SE = 1.95, p = 0.003), pain intensity (β = 3.53, SE = 0.98, p < 0.001), depression (β = 2.91, SE = 0.62, p < 0.001), and somatization (β = 1.75, SE = 0.55, p < 0.001). Type D personality and major psychological comorbidities were strongly associated. Physicians should consider that having type D personality can be linked to NCCP in an effort to help patients receive effective psychological consultations.

Internet-assisted cognitive behavioural therapy for non-cardiac chest pain: a pilot and feasibility study

Abstract Nearly half of patients with non-cardiac chest pain (NCCP) experience significant complaints after a negative cardiac evaluation, at considerable costs for society. Due to the lack of treatment capacity and low interest for psychological treatment among patients with somatic complaints, only a minority receive effective treatment. The aim of this study was to assess the feasibility and usefulness of internet-assisted cognitive behavioural therapy (I-CBT), including encouragement of physical activity for this condition. Ten patients with NCCP received a six-session I-CBT intervention with minimal support from a therapist. Questionnaires assessing cardiac anxiety, fear of bodily sensations, depression, interpretation of symptoms, frequency of chest pain and impact of chest pain symptoms were collected at baseline, post-treatment and at 3-month follow-up. Semi-structured interviews employing a phenomenological hermeneutic approach assessed the participants’ experience of the intervention. Quantitative results showed clear improvements in several measures both at end of treatment and at 3-month follow-up. The retention rate was 100% and client satisfaction was high. The intervention was feasible to implement in a cardiac setting. This setting made it easier for patients to accept a psychological approach. Qualitative interviews revealed that the participants felt respected and taken care of, and they obtained a better understanding of their chest pain and how to cope with it. This pilot study yielded promising results regarding feasibility, clinical effect and patient satisfaction from a brief I-CBT intervention for NCCP in a cardiac setting. These results indicate that a randomized controlled trial with a larger sample size is warranted. Key learning aims (1) Feasibility of internet-assisted cognitive behavioural therapy (I-CBT) for non-cardiac chest pain (NCCP). (2) How NCCP patients experience I-CBT. (3) Possible effects of I-CBT. (4) How I-CBT can be delivered at the Cardiac Department.

Novel low-delta value troponin algorithms have good precision for rule-out of NSTE-ACS

Abstract Background Rapid rule-out algorithms for non-ST-elevation infarction (NSTEMI) may be beneficial for logistics in the emergency room. Current algorithms are designed to rule-out NSTEMI, but do not differentiate between unstable angina (UAP) in need of revascularization and non-cardiac chest pain patients (NCCP) who could be discharged. Recent improvements in analytical precision of high sensitivity troponin (cTn) assays allow for trialing algorithms with very small delta values. Purpose Could the use of lower delta values produce rule-out algorithms for NSTE-ACS with a false negative rate of ≤5%, and a sufficient high rule-out rate of patients with NCCP. Method 927 patients with suspected NSTE-ACS were consecutively included. Serum samples were collected at 0, 3 and 8–12 hours. The final diagnosis was adjudicated by two independent cardiologists based on all clinical data including routine cTnT. The 0- and 3-hour samples were additionally measured for cTnIand cTnI from Singulex Clarity System (cTnI(sgx)). The diagnostic performance to rule-out NSTE-ACS was compared between one low-delta value algorithm from each assay (cTnT, cTnI and cTnT). Results The prevalence of NSTEMI was 13.4%, UAP 11.4% and NCCP 60%. Median age was 63 years, 60% males. Fig. 1 shows baseline and 3-hour delta cTn values for the UAP and NCCP patients for the three different assays. The baseline cTn value differed significantly between UAP and NCCP for all assays, p value &amp;lt;0.001. The novel low-delta cTnT algorithm (Table 1) ruled out 8 NSTE-ACS patients (3.5%), the cTnI algorithm and cTnI (sgx) algorithm ruled out 11 (4.8%) and 12 (5.2%) patients with NSTE-ACS, respectively. Moreover, the cTnT algorithm allocated 35.3% of the NCCP patients to discharge. Respective numbers for the cTnI(sgx) and cTnI algorithm were 30.6% and 33.5%. Comparing the ROC curves, the cTnT algorithm had significantly higher AUC compared to the cTnI(sgx) algorithm (p value =0.005, DeLong test). Conclusion The low-delta value algorithms correctly ruled in ≥95% of the NSTE-ACS patients whilst &amp;gt;30% of NCCP patients were ruled out. The cTnT algorithm had the best performance with a significant higher AUC compared to the cTnI(sgx) algorithm. Figure 1 Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Western Norway Regional Health Authority, Haukeland and Stavanger University hospital

Adding stress biomarkers to high sensitivity troponin measurements increases precision and efficacy of rapid rule out protocols for NSTEMI

Abstract Background NSTEMI may be ruled out in patients presenting with acute chest pain based on low baseline high sensitivity troponin (cTn) at admission. This procedure is limited by a low expected frequency of ruled out non-cardiac chest pain (NCCP) patients. Purpose To investigate if stress-induced biomarkers (glucose or copeptin) combined with cTn can increase the rate of NCCP ruled out without an unacceptable increase in incorrectly ruled out NSTEMI. Method 971 patients with suspected NSTE-ACS were included. Final diagnosis was adjudicated by two independent cardiologists using clinical data including routine cTnT. Additionally, baseline cTnI, cTnI from Singulex Clarity System (cTnI(sgx)), copeptin and glucose were measured. Diagnostic performance to rule out NSTEMI was compared between the ESC rule out algorithms for cTnT and cTnI(Abbott), a local cTnI(sgx) algorithm and different combinations of cTn with copeptin or glucose Results Median age 61 years, 60% male. 13% had NSTEMI, 12% had UAP and 60% NCCP. Distribution of copeptin and glucose concentrations (NSTEMI and NCCP) is shown in figure 1. Copeptin and cTnT produces an algorithm with lower miss rate for NSTEMI, increased rule out rate for NCCP and significantly higher AUC (DeLong test, p value &amp;lt;0.001) compared to the ESC algorithm (Table 1). cTnI(sgx) and copeptin showed higher rule out for NCCP and higher AUC (p value &amp;lt;0.001), however an increased rule out rate for NSTEMIs. Combining cTnI(Abbott) and glucose gave a similar miss rate for NSTEMI as ESC, but increased rule out rate for NCCP and higher AUC (p value &amp;lt;0.001). Conclusion Combining cTnT or cTnI(sgx) with copeptin; or cTnI with glucose, improves diagnostic precision and efficacy of rule out protocols for NSTEMI in patients presenting with acute chest pain. Figure 1 Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Western Norway Regional Health Authority; Haukeland and Stavanger University Hospitals

Early Diagnosis of Brain Natriuretic Peptide (Pro-BNP) and Ischemia Modified Albumin (IMA) Levels in Acute Coronary Syndrome Patients with ST Segment Elevation Myocardial Infarction (STEMI) and Non ST Segment Elevation Myocardial Infarction (NSTEMI)

Background: Acute coronary syndrome (ACS) can be classified to ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) and unstable angina. The challenging in acute coronary syndrome remains, as it does not detect the myocardial ischemia by cardiac troponin and creatine kinase-MB. Pro brain-type natriuretic peptide (pro-BNP) was released when the heart need to hard works, which leads of retention fluid and expansion of veins and arteries. Therefore, this hormone release in the response of the changes of pressure in the heart especially for patients with ACS, which be benefit to use as an indicator to evaluate health problem that related with heart. Ischemia modified albumin (IMA) is a form of human serum albumin in which the N-terminal amino acids have been modified by ischemia as the result of acidosis, damaging occurs by free radicals, fatty acids releasing, exposures to free copper and iron, and disturbance of calcium pump. The aim of this study was to estimate the brain natriuretic peptide (Pro-BNP) and Ischemia Modified Albumin (IMA) Levels as early diagnostic markers and correlated with conventional cardiac markers at admission to the emergency department in Acute Coronary Syndrome Patients with ST segment elevation myocardial infarction (STEMI) and Non ST segment elevation myocardial infarction (NSTEMI). Methods: Eighty ACS patients who arrived at the emergency department ED within 6h of clinical symptoms divided to STEMI and NSTEMI, and another 40 of noncardiac chest pain patients (NCCP) as control were enrolled in this study. pro-BNP was measured using a Cobas e 411 Roche, Germany, and IMA was measured using enzyme linked immunosorbent assay (ELISA) kits. Tukey HSD Post hoc ANONA test and One-way ANOVA were used to compare differences of mean between groups. Pearson Correlation was calculated to assess the relation between the biomarkers of this study. Receiver Operating Characteristics (ROC) curve was calculated to estimate the sensitivity and specificity for the use of pro-BNP and IMA as biomarker in the diagnosis and discriminatory ability of ACS. Results: pro-BNP and Ischemia modified albumin were significantly higher in acute coronary syndrome patients (STEMI & NSTEMI) compared to NCCP as controls (1359.82± 995.00 and 2698.22±1604.69 vs 180.07±90.24) (p

Proton-pump inhibitor use and the development of new ischemic heart disease in non-cardiac chest pain patients.

The growing reports regarding cardiac-related adverse events of chronic proton-pump inhibitors (PPI) treatment, a mainstay therapy of non-cardiac chest pain (NCCP), have raised concerns about alteration of the natural course in NCCP patients using PPI. We aimed to determine if NCCP patients receiving PPI have a higher risk of developing ischemic heart disease (IHD) compared to those not receiving PPI therapy. Three groups of NCCP patients were included; PPI, histamine-2 receptor antagonist (H2RA), and no antireflux treatment. Diagnosis of NCCP had to precede diagnosis of IHD by at least 30days, and in those receiving antireflux treatment at 30days after starting the medication. Data analysis was corrected for 6 known confounding factors for IHD including hyperlipidemia, hypertension, obesity, smoking status, male gender, and diabetes mellitus. Of the patients on PPI or H2RA, 1280 and 250, respectively, developed IHD. Patients on PPI therapy displayed an increased odd of developing ischemic heart disease compared to patients never placed on therapy (OR 1.14, 95% CI 1.03-1.25, P-value .0093). Patients placed on H2RA therapy did not show a statistically significant change in risk compared to patients who were not placed on therapy (OR 0.90, 95% CI 0.77-1.06, P-value .2049). Number needed to harm in the PPI and H2RA groups was 17 and 45, respectively. PPIs confer a statistically significant, but marginal effect on the risk of IHD development in NCCP patients. Thus, PPI use in NCCP only minimally alters the overall benign natural course of the disease.

512 Management and Outcomes of Patients Presenting With “Not Low Risk” EDACS Chest Pain, With Negative or Static Troponins

Emergency Department (ED) Assessment of Chest pain Score (EDACS) identifies patients with chest pain who are at low risk of Major Adverse Cardiac Event (MACE) and safe to be discharged from ED. However, the management and outcomes of “not low risk” EDACS patients who have negative or static troponins, are unclear. We retrospectively reviewed 100 consecutive patients referred by ED from January 2018 to February 2018 with “not low risk” EDACS chest pain who had negative or static troponins. Of 100 patients, 37 were discharged from ED and 63 were admitted. Twenty-one patients underwent non-invasive testing, and 23 patients underwent coronary angiograms (five had normal coronary arteries (22%), six had coronary artery disease (CAD) for medical management (26%), 12 required revascularisation (52%)). Twenty-five patients were diagnosed with cardiac chest pain (CCP), 15 with possible cardiac chest pain (PCCP), and 60 with non-cardiac chest pain (NCCP). At two years, nine out of 25 CCP patients (36%) re-presented with cardiac chest pain, compared to three out of 15 PCCP patients (20%), and five out of 60 NCCP patients (8%). At 30 days, one patient (NCCP group) had MACE (type II myocardial infarction, who had no flow-limiting disease on angiogram). There is a significant burden of CAD in this patient group, however, the overall MACE at 30 days remains low. The current workup largely differentiates non-cardia and cardiac chest pain, evidenced by the lower rates of re-presentation in the NCCP group with cardiac chest pain.

A033 Management and Outcomes of Patients Presenting With “Not Low Risk” EDACS Chest Pain, With Negative or Static Troponins

Emergency Department (ED) Assessment of Chest pain Score (EDACS) identifies patients with chest pain who are at low risk of major adverse cardiac event (MACE) and safe to be discharged from ED. However, the management and outcomes of “not low risk” EDACS patients who have negative or static troponins, are unclear. We retrospectively reviewed 100 consecutive patients referred by ED from January 2018 to February 2018 with “not low risk” EDACS chest pain who had negative or static troponins. Of 100 patients, 37 were discharged from ED and 63 were admitted. Twenty-one patients underwent non-invasive testing, and 23 patients underwent coronary angiograms (five had normal coronary arteries (22%), six had coronary artery disease (CAD) for medical management (26%), 12 required revascularisation (52%)). Twenty-five patients were diagnosed with cardiac chest pain (CCP), 15 with possible cardiac chest pain (PCCP), and 60 with non-cardiac chest pain (NCCP). At two years, nine out of 25 CCP patients (36%) re-presented with cardiac chest pain, compared to three out of 15 PCCP patients (20%), and five out of 60 NCCP patients (8%). At 30 days, one patient (NCCP group) had MACE (type II myocardial infarction, who had no flow-limiting disease on angiogram). There is a significant burden of CAD in this patient group, however, the overall MACE at 30 days remains low. The current workup largely differentiates non-cardiac and cardiac chest pain, evidenced by the lower rates of re-presentation in the NCCP group with cardiac chest pain.

Diagnosis and Management of Functional Chest Pain in the Rome IV Era

Functional chest pain accounts for about a third of the patients with noncardiac chest pain. It is a very common functional esophageal disorder that remains even today a management challenge to the practicing physician. Based on the definition offered by the Rome IV criteria, diagnosis of functional chest pain requires a negative workup of noncardiac chest pain patients that includes, proton pump inhibitor test or empirical proton pump inhibitor trial, endoscopy with esophageal mucosal biopsies, reflux testing, and esophageal manometry. The mainstay of treatment are neuromodulators that are primarily composed of anti-depressants. Alternative medicine and psychological interventions may be provided alone or in combination with other therapeutic modalities.

389 Are Proton Pump Inhibitors Associated With an Increased Risk in Developing Ischemic Heart Disease in Non-Cardiac Chest Pain Patients?

INTRODUCTION: Non-cardiac chest pain (NCCP) is defined as chest pain that persists after cardiac etiologies have been excluded. Treatment of NCCP is targeted towards the underlying cause, most often GERD, which is commonly treated with proton pump inhibitors (PPI). It has been reported that long term PPI use is associated with increased risk for developing ischemic heart disease (IHD). We aim to determine whether PPI use is associated with an increased risk for IHD in NCCP patients, and thus alter the otherwise benign course of the disease. METHODS: Cohort analysis was performed using the multi-institutional database IBM Explorys. NCCP patients started on a PPI at least 1 day after diagnosis, and who developed IHD at least 30 days following PPI initiation were included. Identical parameters were used to acquire data on patients prescribed histamine H2 receptor antagonists (H2RA). Data analysis was controlled for 6 known confounding factors for IHD including hyperlipidemia, hypertension, obesity, smoking status, male gender, and diabetes mellitus. RESULTS: A total of 13,250 NCCP patients without preexisting IHD received PPI; 1,280 (9.66%) developed new IHD. Of these patients, 740 (57.8%) had ST-elevation MI (STEMI), 340 (26.5%) non-ST elevation MI (NSTEMI), and 200 (15.6%) ischemic cardiomyopathy (ICM). A total of 22,260 NCCP patients without preexisting IHD were never prescribed a PPI; 870 (3.91%) developed new IHD. Of these patients, 490 (56.3%) had STEMI, 210 (24.1%) NSTEMI, and 170 (19.5%) ICM. The unadjusted and adjusted odds ratios of developing IHD in NCCP patients while on PPI compared to not on PPI were 2.63 (95% CI 2.41-2.87), and 1.14 (95% CI 1.03-1.25, P-value 0.0093), respectively. A total of 3,050 NCCP patients without preexisting IHD received H2RA; 250 (8.19%) developed new IHD. Of these patients, 160 (64%) had STEMI, 70 (28%) NSTEMI, and 20 (8%) ICM. Overall, 22,070 NCCP patients without preexisting IHD received H2RA; 1,320 (5.98%) developed new IHD. Of these patients, 790 (59.8%) had STEMI, 350 (26.5%) NSTEMI, and 180 (13.6%) ICM. The unadjusted and adjusted odds ratios of developing IHD while on H2RA compared to not on H2RA were 1.40 (95% CI 1.22-1.62) and 0.90 (95% CI 0.77-1.06, P-value 0.2049), respectively. CONCLUSION: PPI use appears to confer a statistically significant, but marginally increased odds in developing IHD in NCCP patients. Thus, PPI use in NCCP only minimally alters the course of the disease. H2RA use does not statistically increase the risk for IHD in NCCP patients.

Anxiety, depression, and behavioural rating scales in children with non-cardiac chest pain.

Chest pain is the second most common reason for referral to paediatric cardiologists after benign heart murmurs. Aetiology frequently depends on non-cardiac reasons. In addition, individuals may experience non-cardiac chest pain which is idiopathic or of unknown origin. The aim of this study is to examine psychological symptoms in children and adolescents with medically unexplained chest pain. A total of 76 patients (ages 8-18 years) were included in the study, who were referred to the paediatric cardiology department with the complaint of chest pain but did not have any detected cardiac aetiology or any other organic causes of chest pain. The control group was composed of 51 healthy volunteers. Self-evaluation scales were given to both groups which included Beck Anxiety Inventory and Children's Depression Inventory. Also parents of both groups completed the Conner's Parent Rating Scale for assessment of Attention-deficit/hyperactivity disorder. Anxiety scores of the non-cardiac chest pain group were significantly higher compared to controls. No significant differences were found between patients and controls in terms of attention-deficit/hyperactivity disorder and depression scores. In patient group, patterns were similar for boys and girls and for children and adolescents; except girls scored significantly higher than boys in children's depression inventory. In children and adolescents, non-cardiac chest pain is associated with increased levels of anxiety. These results show the importance of psychiatric evaluation in non-cardiac chest pain patients. Larger controlled studies are needed to determine the prevalence and impact of attention-deficit/hyperactivity disorder and depression in children and adolescents with non-cardiac chest pain.