Presence Of Chest Pain Research Articles

Thoracic Endometriosis: A Review Comparing 480 Patients Based on Catamenial and Non-Catamenial Presentation

Study Objective To revisit thoracic endometriosis cases in literature and compare symptoms, diagnosis, pathology, treatment and follow-up based on the catamenial or non-catamenial nature of the disease. Design A PubMed/MEDLINE search was conducted using the key words: diaphragm endometriosis, thoracic endometriosis, thoracic endometriosis syndrome, catamenial pneumothorax. Setting n/a Patients or Participants 480 cases of thoracic endometriosis were included in this review. 61 presented with non-catamenial symptoms and 419 had catamenial symptoms. Patients were compared based on the presence of chest pain, dyspnea, hemoptysis, pneumothorax history, pneumothorax type, use and types of imaging techniques, pre- and postoperative medication, type of surgery, presence of endometriosis in pathological evaluation, location of thoracic endometriosis, follow-up period and recurrence. Interventions Types of surgeries evaluated in this review were laparoscopy (LS), laparotomy (LT), video-assisted thoracoscopic surgery (VATS), thoracotomy. Measurements and Main Results A significantly higher number of patients presented with preoperative chest pain (79.7%), dyspnea (52.2%) and pneumothorax (78.9%) in the catamenial group (p <0.001). Pneumothorax occurred more frequently on the right side in both groups. 285 patients (68%) in the catamenial group received a positive imaging finding whereas this number was significantly less in the non-catamenial group (59%, p = 0.003). Majority of patients in both groups didn't receive any pre-/post-operative medication. VATS was the most common surgery in the catamenial group (56.6%). Whereas LT/LS was more frequently performed in the non-catamenial group (70.5%). Majority of the patients in both groups received a pathological finding of endometriosis Conclusion Catamenial and non-catamenial nature of the disease caused a significant difference in presenting symptoms, preoperative evaluation, surgical and medical treatment and recurrence. Although most of patients presented with catamenial disease, majority of the non-catamenial patients also received a positive pathological finding. Therefore, it is important to keep thoracic endometriosis in mind when dealing with patients with non-catamenial symptoms. To revisit thoracic endometriosis cases in literature and compare symptoms, diagnosis, pathology, treatment and follow-up based on the catamenial or non-catamenial nature of the disease. A PubMed/MEDLINE search was conducted using the key words: diaphragm endometriosis, thoracic endometriosis, thoracic endometriosis syndrome, catamenial pneumothorax. n/a 480 cases of thoracic endometriosis were included in this review. 61 presented with non-catamenial symptoms and 419 had catamenial symptoms. Patients were compared based on the presence of chest pain, dyspnea, hemoptysis, pneumothorax history, pneumothorax type, use and types of imaging techniques, pre- and postoperative medication, type of surgery, presence of endometriosis in pathological evaluation, location of thoracic endometriosis, follow-up period and recurrence. Types of surgeries evaluated in this review were laparoscopy (LS), laparotomy (LT), video-assisted thoracoscopic surgery (VATS), thoracotomy. A significantly higher number of patients presented with preoperative chest pain (79.7%), dyspnea (52.2%) and pneumothorax (78.9%) in the catamenial group (p <0.001). Pneumothorax occurred more frequently on the right side in both groups. 285 patients (68%) in the catamenial group received a positive imaging finding whereas this number was significantly less in the non-catamenial group (59%, p = 0.003). Majority of patients in both groups didn't receive any pre-/post-operative medication. VATS was the most common surgery in the catamenial group (56.6%). Whereas LT/LS was more frequently performed in the non-catamenial group (70.5%). Majority of the patients in both groups received a pathological finding of endometriosis Catamenial and non-catamenial nature of the disease caused a significant difference in presenting symptoms, preoperative evaluation, surgical and medical treatment and recurrence. Although most of patients presented with catamenial disease, majority of the non-catamenial patients also received a positive pathological finding. Therefore, it is important to keep thoracic endometriosis in mind when dealing with patients with non-catamenial symptoms.

ACHY BREAKY HEART

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Acute pericarditis accounts for about 5% of presentations of acute chest pain. Of those cases of pericarditis an etiology is found in about 22% of cases. Etiologies commonly include neoplasms, tuberculosis, infections, collagen diseases and thyroid disorders. CASE PRESENTATION: Our patient is a 16 year old healthy female that presented to the hospital with six days of fever, sore throat, cough, pleuritic chest pain and progressive dyspnea. She was sent to the emergency department (ED) by her pediatrician due hypotension. Upon arrival her blood pressure (BP) while supine was 70/40 and 50/30 with standing, with a heart rate (HR) of 121 bpm. In the ED she received 3 liters of normal saline. On admission BP was 107/63, HR 90, respiratory rate 33 and oxygen saturation was 80% on room air. The patient appeared drowsy. Her hands were cold and her lower extremities were warm; capillary refill was 4 seconds. Cardiovascular exam was normal with no pericardial friction rub. Lung exam was significant for diffuse inspiratory and expiratory crackles and decreased breath sounds at the left lung base. Initial laboratory work was significant for hemoglobin 10.5 g/dl, Sodium 128 mEq/L, creatinine 1.3 mg/dl, AST 129 U/L, ALT 72 U/L and Albumin 2.7 gm/dl. Troponin peaked at 0.682 ng/ml. BNP 141 pg/ml. Electrocardiogram showed nonspecific T wave abnormalities. Respiratory viral panel and rapid strep were negative. Chest radiograph showed patchy left lower lobe airspace disease that progressed bilaterally within 24 hours. Initial echo showed normal biventricular function with trivial pericardial effusion. She was diagnosed with acute perimyocarditis and treated with Ketorolac and IV Furosemide. Over her hospital course her respiratory distress worsened and she developed a moderate to large pericardial effusion 2 days after her initial echo. Work up included positive ANA (1:5120, speckled pattern), positive lupus anticoagulant, smith antibody and RNP antibody. Our patient was diagnosed with lupus (SLE) pericarditis and she was treated with high dose Methylprednisolone and Hydroxychloroquine which improved her pericardial effusion. DISCUSSION: This is a case of a female diagnosed with SLE perimyocarditis with pericardial effusion. This patient did not initially meet criteria for lupus, but by the end of her hospital course she met 4/11 criteria. Cardiac disease is rarely a presenting manifestation of SLE and only 1% of cases of SLE, in children and adults, present with pericarditis. While it is rare to present with cardiac symptoms, most patient with SLE develop cardiovascular manifestations at some point. Asymptomatic pericarditis is found in >50% of patients with SLE. Myocarditis, endocarditis and CAD are rare manifestations. CONCLUSIONS: This case highlights the importance of having a high index of suspicion for lupus in a patient that is not responding to initial treatment for viral myocarditis. Reference #1: Ansari, A., Larson, P. H., & Bates, H. D. (1985). Cardiovascular manifestations of systemic lupus erythematosus: Current perspective. Progress in Cardiovascular Diseases, 27(6), 421–434. doi: 10.1016/0033-0620(85)90003-9 Reference #2: Zayas, R., Anguita, M., Torres, F., Gime´nez, D., Bergillos, F., Ruiz, M., … Valle´s, F. (1995). Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. The American Journal of Cardiology, 75(5), 378–382. doi: 10.1016/s0002-9149(99)80558-x Reference #3: Durrance, R. J., Movahedian, M., Haile, W., Teller, K., & Pinsker, R. (2019). Systemic Lupus Erythematosus Presenting as Myopericarditis with Acute Heart Failure: A Case Report and Literature Review. Case Reports in Rheumatology, 2019, 1–7. doi: 10.1155/2019/6173276 DISCLOSURES: No relevant relationships by Alejandra Grana, source=Web Response

Koroner anjiyografide yavaş akım tespit edilen kararlı anjina pektorisli hastalarda CHA2DS2-VASc skorunun kullanımı

Purpose: Coronary slow flow (CSF) phenomenon is the slow movement of contrast to distal vascular structures during coronary angiography. Eventhough It has a high morbidity due to recurrent chest pain and different ischemic presentations, it is linked to coronary artery diseases (myocardial ischemia symptoms, life-threatening arrhythmias, recurrent acute coronary syndromes and sudden cardiac death). CHA2DS2-VASc score is a total of several risk factors for thromboembolism. Impaired renal function was shown to be a predictor of stroke and systemic embolism. We aimed to evaluate the CHA2DS2-VASc score to predict coronary slow flow.Materials and Methods: Of the 3772 patients who applied to Tokat State Hospital with the diagnosis of stable angina pectoris (SAP) were screened retrospectively. A total of 71 patients with angiographically proven CSF and to meet the age characteristics of the CSF group, 84 patients who were completely normal coronary arteries (NCA) in the control group (n = 84) were screened and total of 155 patients were included in the study.Results: Patients were classified into two groups: the CSF group (n=71) and the NCA group (n=84). When the characteristics of the CSF and control groups were compared, age, body mass index, systolic blood pressure, diastolic blood pressure, gender were similar. According to the results of the multivariate regression analysis, CHA2DS2-VASc score was an independent predictor (odds ratio: 1.872, 95 % CI: 0.849-1.981, p&amp;lt;0.001)Conclusion: CHA2DS2-VASc score can be very useful in this regard as an easily applicable instrument. CHA2DS2-VASc score is independent indicators of CSF and can be used to predict CSF risk.

COVID-19 outbreak: Challenges in pharmacotherapy based on pharmacokinetic and pharmacodynamic aspects of drug therapy in patients with moderate to severe infection

The new coronavirus (COVID-19) was first detected in Wuhan city of China in December 2019. Most patients infected with COVID-19 had clinical presentations of dry cough, fever, dyspnea, chest pain, fatigue and malaise, pneumonia, and bilateral infiltration in chest CT. Soon COVID-19 was spread around the world and became a pandemic. Now many patients around the world are suffering from this disease. Patients with predisposing diseases are highly prone to COVID-19 and manifesting severe infection especially with organ function damage such as acute respiratory distress syndrome, acute kidney injury, septic shock, ventilator-associated pneumonia, and death. Till now many drugs have been considered in the treatment of COVID-19 pneumonia, but pharmacotherapy in elderly patients and patients with pre-existing comorbidities is highly challenging. In this review, different potential drugs which have been considered in COVID-19 treatment have been discussed in detail. Also, challenges in the pharmacotherapy of COVID-19 pneumonia in patients with the underlying disease have been considered based on pharmacokinetic and pharmacodynamic aspects of these drugs.

Cardiac Computed Tomography for Personalized Management of Patients With Type 2 Diabetes Mellitus.

The incidence and prevalence of type 2 diabetes mellitus are increasing in the United States and worldwide. The individual-level risk of atherosclerotic cardiovascular disease events in primary prevention populations with type 2 diabetes mellitus is highly heterogeneous. Accurate risk stratification in this group is paramount to optimize the use of preventive therapies. Herein, we review the use of the coronary artery calcium score as a decision aid in individuals with type 2 diabetes mellitus without clinical atherosclerotic cardiovascular disease to guide the use of preventive pharmacotherapies, such as aspirin, lipid-lowering mediations, and cardiometabolic agents. The magnitude of expected risk reduction for each of these therapies must be weighed against its cost and potential adverse events. Coronary artery calcium has the potential to improve risk stratification in select individuals beyond clinical and laboratory risk factors, thus providing a more granular assessment of the expected net benefit with each therapy. In patients with diabetes mellitus and stable chest pain, coronary computed tomography angiography increases the sensitivity for coronary artery disease diagnoses compared with functional studies because of the detection of nonobstructive atherosclerosis. Most importantly, this anatomic approach may improve cardiovascular outcomes by increasing the use of evidence-based preventive therapies informed by plaque burden. We therefore provide an updated discussion of the pivotal role of coronary computed tomography angiography in the workup of stable chest pain in patients with diabetes mellitus in the context of recent landmark trials, such as PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain), SCOT-HEART trial (Scottish Computed Tomography of the Heart), and ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches). Finally, we also outline the current role of coronary computed tomography angiography in acute chest pain presentations.

Diagnosing acute aortic syndrome: a Canadian clinical practice guideline.

KEY POINTS Acute aortic syndrome (AAS) is a life-threatening emergency, accounting for 1/2000 presentations of acute chest or back pain to the emergency department.[1][1] It is a clinical spectrum of diagnoses including aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer at

Effectiveness of Manchester Triage System in risk prioritisation of patients with pulmonary embolism who present dyspnoea, chest pain or collapse

BackgroundRecognising patients with pulmonary embolism continues to be a clinical challenge. In the Emergency Department, up to 50% of patients with pulmonary embolism can be delayed or even misdiagnosed. The ability of a triage system to correctly prioritise suspected embolism in these patients is fundamental for determining diagnostic-therapeutic procedures. AimTo verify the effectiveness of the Manchester Triage System in risk prioritisation of patients with pulmonary embolism who present with dyspnoea, chest pain, or collapse. MethodsIn this observational, retrospective, study the sensitivity, specificity, and positive and negative predictive values of the Manchester Triage System were calculated using the triage classification for these patients, and their established diagnoses. The analysis included baseline characteristics and triage evaluations. ResultsDuring the two-year study period, 7055 patients were enrolled. Pulmonary embolism episodes were 2.1% of all cases, while severe pulmonary embolisms were 0.8%. The estimated specificity of the Manchester Triage System was 72.5% (CI 95%, 71.5–73.6), and the negative predictive value was 98.1% (CI 95%, 97.7–98.5). The results suggest that clinical characteristics leading to a high Manchester Triage System priority are similar to those characterising a pulmonary embolism episode. ConclusionsAlthough pulmonary embolism is difficult to diagnose, the Manchester Triage System is an effective tool for prioritising patients with symptoms of this disease.

Infarct-Like Spindle Cell Carcinoma of the Lung: Clinicopathologic, Immunohistochemical, and Molecular Analysis of 4 Cases.

Pulmonary spindle cell carcinoma is a rare and aggressive malignancy that often mimics benign conditions. We report 4 cases that simulate a pulmonary infarction, 2 of which were misdiagnosed. Patients were 3 men and 1 woman, smokers, presenting chest pain. All cases appeared as pleural-based, solitary, and rounded nodules. Patients underwent wedge resections followed by adjuvant chemotherapy (3/4) but died of disease. At histology, lesions consisted of widely necrotic nodules surrounded by organizing fibrosis and pleuritis. Examination and immunostains with pan-cytokeratins and epithelial membrane antigen (EMA) revealed atypical spindle cells encircling necrotic tissue and involving the vascular wall. Positive staining with PD-L1 was noted. Molecular analysis showed KRAS (2/4) and TP53 (1/4) mutations, whereas EGFR, ALK, and ROS1 alterations were not detected. Although in a limited series, these cases further evidence the treacherous appearance of spindle cell carcinomas and the need for careful attention when examining pulmonary infarcted tissue, thus requiring extensive sampling, meticulous examination of vascular structures, and immunostaining with cytokeratins.

Chest pain in Brugada syndrome: Prevalence, correlations, and prognosis role

Brugada syndrome (BrS) is sometimes diagnosed because of chest pain. Prevalence and characteristics of such BrS patients are unknown. A total of 200 BrS probands were retrospectively included. BrS diagnosis made because of chest pain (n=34, 17%) was compared to the other ones. BrS probands with diagnosis because of chest pain had significantly more often smoker habits, increased body mass index, and familial history of coronary artery disease but less frequently previous resuscitated sudden death/syncope or atrial fibrillation. Presence of coronary spasm and familial coronary artery disease were independently associated with BrS diagnosed because of chest pain. They presented more often with spontaneous type 1 ST elevation (59%vs 26%, P=.0004) and higher ST elevation during the episode of chest pain compared to other patients or compared to baseline electrocardiogram after chest pain resumption. ST elevation during chest pain was lower compared to ajmaline test. A total of 20% of them had significant coronary artery disease and four (11%) had coronary spasm, and they experienced more often recurrent chest pain episodes (24%vs 5%, P=.0002). Presence of chest pain at BrS diagnosis was not correlated to future arrhythmic events in univariate analysis. Only previous sudden cardiac death (SD)/syncope and familial SD were still significantly associated with outcome in multivariate analysis. Chest pain is a common cause for BrS diagnosis, although major part is not apparently explained by ischemic heart disease. Mechanisms leading to chest main remain unknown in the other ones. ST elevation is higher in this situation but does not seem to carry poor prognosis.

Factors Associated with Family Physician Follow-up 30 Days Post-discharge from a Local Canadian Community Emergency Department.

IntroductionClose outpatient follow-up with a specialist or family physician post-discharge from the emergency department (ED) has been shown to increase adherence to antihypertensive medications, decrease mortality in heart failure, and reduce the odds of myocardial infarction or death after ED presentation for chest pain. A Canadian study demonstrated that 21% of patients who left the ED with a new diagnosis of atrial fibrillation, heart failure, or hypertension were not seen by a physician within 30 days. There is a paucity of research investigating why this follow-up does not occur. This study aimed to elucidate factors that are associated with outpatient follow-up by a family physician clinic following discharge from a local Canadian community emergency department.MethodsA retrospective chart review of patients rostered to a family physician who presented to the community ED in the past two years was conducted. The primary outcome examined was a documented follow-up visit with any physician at the clinic within 30 days of the index ED visit. Patients aged 18 or older at the time of the initial ED visit were eligible for inclusion in the study. Exclusion criteria were the following: patients aged 17 or younger at the time of the initial ED visit, those who were not fully assessed at ED visit (i.e., left against medical advice), those whose charts corresponding to the ED visit were unable to be found, patients who were admitted to any facility within 30 days of ED visit, and patients who died within 30 days of the ED visit. Variables of interest extracted from the ED chart and clinic electronic medical record were the following: Canadian Triage and Acuity Scale (CTAS) score, documented discharge instructions, age, sex, primary residence distance from the clinic, last documented clinic visit before ED visit, and the date of and presenting complaint of the next clinic visit after the ED visit. Data were collected as continuous and categorical variables. Descriptive statistics were used to show the number and percentages of patients who followed up in clinic. Binomial regression analysis was used to determine if a specific variable was associated with patient follow-up. Inter-rater reliability between data abstractors was calculated using Fleiss Κ. An alpha-value of 0.05 was chosen, and SPSS version 25.0 (IBM Corp., Armonk, NY) was used for all statistical analyses.ResultsA total of 234 patients out of 1292 patients met inclusion criteria. 53% of patients were female, and the mean age was 50. Seventy-two (31%) received discharge instructions from the ED physician to follow up with their family doctor. In total, 93 of the 234 patients proceeded to have a documented clinic visit within 30 days (40%). 52% (n = 48) of these were women. Receiving specific discharge instructions increased the adjusted odds of follow-up (OR 3.07, 95% CI: 1.64-5.76; P < 0.05). Patients who followed up also tended to have been seen in clinic in the last three months, but this was not statistically significant.ConclusionReceiving specific discharge instructions to follow-up increased the odds that patients followed up with their family physician after discharge from the ED. ED physicians may consider giving explicit instructions to patients to improve monitoring of ongoing clinical issues. More research needs to be conducted on how to improve transitions of care. Countries with different healthcare models may have other barriers to appropriate follow-up.

Frequency and Significance of Coronary Artery Disease and Myocardial Bridging in Patients With Hypertrophic Cardiomyopathy

The etiology of chest pain in hypertrophic cardiomyopathy (HC) is diverse and includes coronary artery disease (CAD) as well as HC-specific causes. Myocardial bridging (MB) has been associated with HC, chest pain, and accelerated atherosclerosis. We compared HC patients with age-, gender- and CAD pre-test probability-matched outpatients presenting with chest pain to investigate differences in the presence of MB and CAD using coronary computed tomography angiography (CCTA). We studied 84 HC patients who underwent CCTA and compared these with 168 matched controls (age 54 ± 11 years, 70% men, pre-test probability 12% [5% to 32%]). MB, calcium score, plaque morphology and presence and extent of CAD were assessed for each patient. Linear mixed models were used to assess differences between cases and controls. MB was more often seen in HC patients (50% vs 25%, p <0.001). Calcium score and the presence of obstructive CAD were similar in both groups (9 [0 to 225] vs 4 [0 to 82] and 18% vs 19%; p = 0.22 and p = 0.82). In the HC group, MB was associated with pathogenic DNA variants (p = 0.04), but not with the presence of chest pain (74% vs 76%, p = 0.8), nor with worse outcome (log-rank p = 0.30). In conclusion, the prevalence and extent of CAD was equal among patients with and without HC, demonstrating that pre-test risk prediction using the CAD Consortium clinical risk score performs well in HC patients. MB was twice as prevalent in the HC group compared with matched controls, but was not associated with chest pain or decreased event-free survival in these patients.

542 Review of Efficacy and Outcomes of Preventing Hospital Admissions by Use of Quick-Access Chest Pain Clinic for Low-Moderate Risk Chest Pain Presentations

Chest pain clinics have been increasingly utilized around the world as an effective way of assessing patients with low-to-moderate risk chest pain. To review the clinical utility of our outpatient chest pain clinic. Consecutive patients referred to the chest pain clinic over a six-month period in 2019 in a single-centre tertiary hospital were retrospectively reviewed. 507 patients were referred during the six-month period, of which 382 patients were assessed. Of these, 237 patients (62%) had an exercise stress test (EST) and 46 patients (12%) had an alternative functional study. 13 patients (3.4%) were referred for angiogram. Of these, 3 patients were referred directly, whilst 10 were referred after abnormal EST. Of the latter 10, 5 patients (50%) who had strong initial clinical suspicion for CAD had significant disease on angiography requiring intervention. This represents 0.01% of patients reviewed in the chest pain clinic requiring invasive intervention. The other 5 patients with low clinical suspicion had no significant CAD on angiography. 72 of the 382 reviewed patients (19%) were deemed to not need any cardiac investigations. This retrospective analysis confirms the utility of chest pain clinic in preventing hospital admissions for low-moderate risk chest pain patients. However, it also highlights the low-specificity that standard EST has in predicting significant CAD, with high false positivity. Further it demonstrates that initial high clinical suspicion is very important in predicting significant coronary disease.

A031 Non-ACS Diagnosis in Suspected Acute Coronary Syndrome and Regional Variations - An ANZACS-QI Study

Rate of invasive coronary angiography (ICA) has risen over past two decades. Many non-coronary and non-cardiac conditions can mimic acute coronary syndrome (ACS), with less than 30% of chest pain presentations being ACS. There is a potential for inappropriate and unnecessary procedural risks. This study reviews New Zealand regional variation in non-ACS diagnosis in patients suspected of ACS. Consecutive patients ≥18y presenting with their first suspected ACS and underwent coronary angiography in 2015-2019 were identified from the ANZACS-QI registry. Two cohorts were compared: 1) suspected STEMI and 2) suspected NSTEACS. Patient demographics, investigations and discharge diagnosis were obtained from the registry. 30,317 patients were identified. 6059 (20%) suspected STEMI among which the rate of false-positive diagnosis across all district health boards (DHB) was <12% and appears independent of patient volume. In comparison, a wider variation exists for suspected NSTEACS, up to 27.3%, and demonstrates a general trend of higher non-ACS diagnosis in higher volume centres. The non-ACS condition most likely to raise suspicion for ACS on presentation and undergo ICA includes stress cardiomyopathy (11.9%), arrhythmia (10.4%), stable angina (9.3%) and myocarditis (7.9%). Low rates of false-positive diagnosis for patients presenting with suspected STEMI across the nation. Comparatively, non-ACS diagnoses rate is higher particularly in higher volume centres for suspected NSTEACS. However, ICA appears to be appropriately performed as diagnostic tools for common non-ACS conditions that can mimic potentially life-threatening ACS.

480 Does Sex-Specific High-Sensitivity Troponin T Cut-Off Values Alter Clinical Outcomes in Chest Pain Presentations to the Emergency Department?

Despite gender differences in cardiovascular disease, data is limited on the utility of sex-specific high-sensitivity cardiac troponin (hs-cTn) cut-off values. We aimed to determine the clinical impact of sex-specific hs-cTnT cut-off values (>14ng/L vs >16.8ng/L for males, >9ng/L vs >14ng/L for females) in evaluating patients with chest pain in emergency department. Patients >18 years old with chest pain and hs-cTnT were studied. We excluded patients with ST-segment elevation myocardial infarction, lacked serial hs-cTnT, on dialysis or had trauma-related chest pain. Data were collected retrospectively on baseline characteristics, serial hs-cTnT, discharge diagnosis, coronary anatomy, functional tests and clinical outcome(s) during admission and at one-year follow-up. 1049 patients were included. Regardless of cut-off value, 69/589 males (11.7%) had at least one abnormal troponin with >20% change and were judged to have an ischaemic event. In females, using gender specific cut-off, 13 (2.8%) additional subjects had at least one abnormal troponin with >20% change. 6 were judged to have an ischaemic event and cardiac stress testing (CST) was recommended. 1/2 who did not undergo CST had recurrent admissions for congestive heart failure. 1/4 had positive CST. 7/13 were judged to have a non-ischaemic event and had no further cardiac presentations. Our data showed no change in males, but more false positives in females. However, as only one of the additional 13 females who were identified using the new cut-off had a further cardiac presentation, further investigation is warranted to establish whether sex specific cut-offs improve outcomes for females.

IFN Regulatory Factor 1 Mediates Macrophage Pyroptosis Induced by Oxidized Low-Density Lipoprotein in Patients with Acute Coronary Syndrome.

Background Atherosclerosis (AS) is recognized as a chronic inflammatory disease. It is caused by the interaction between inflammatory cells such as macrophages, dendritic cells, and lipoproteins. Evidence has revealed that macrophage pyroptosis in lesion contributes to the formation of the necrotic core and thinning of the fibrous cap, which plays crucial roles in the onset of acute coronary syndrome (ACS). IFN regulatory factor 1 (IRF-1) is a pleiotropic transcription factor involved in various immune processes and cell death. We propose that IRF-1 may be implicated in macrophage pyroptosis in the pathogenesis of AS and ACS. Methods Patients with stable angina, unstable angina, acute myocardial infarction, and clinical presentation of chest pain were enrolled. The expression of IRF-1 in human PBMC-derived macrophages was analyzed. Then, overexpression and inhibition of IRF-1 was performed in macrophages from patients with ACS to explore the possible role and mechanism of IRF-1 involvement in macrophage pyroptosis. Results The expression of IRF-1 in macrophages was upregulated in ACS patients. The overexpression or inhibition of IRF-1 effectively modulated caspase-1 activation, as well as macrophage lysis, expression of gasdermin D-N (GSDMD-N), production of IL-1β and IL-18, and activation of NLRP3-ASC inflammasome, which were all inhibited by caspase-1 inhibitor. Further experiments revealed that pyroptosis and the downstream inflammatory response in AS induced by IRF-1 is a process that is dependent on reactive oxygen species (ROS) generation. Conclusion Our observations suggest that IRF-1 potently activates ox-LDL-induced macrophage pyroptosis and may play an important role in AS and ACS.

Can low intensity cognitive behavioural therapy for non‐cardiac chest pain presentations to an emergency department be efficacious? A pilot study

ObjectiveComplaints of chest pain are one of the most common reasons that people visit emergency departments (EDs). However, more than 50% of patients who present to EDs with chest pain do not have identifiable cardiac disease or other medical conditions. A pilot study was conducted to investigate if using low‐intensity (LI) cognitive behavioural therapy (CBT) in the ED at Flinders Medical Centre, South Australia, reduced the reported levels of anxiety and depression, re‐presentation rates, and the associated cost of patients presenting to the ED with non‐cardiac chest pain.MethodA convenience sample (n = 35) was recruited from people who presented to the ED with non‐cardiac chest pain and screened positive for psychological distress. If eligible, participants were referred to the Improving Access to Psychological Therapies@Flinders (IAPT@Flinders) service and, following completion, hospital medical records were reviewed to investigate the number of presentations to the ED and the subsequent costs of each presentation, in the 3-months prior and 3-months preceding treatment.ResultsThere was a decrease in self‐reported levels of depression and anxiety after the completion of treatment, and a suggested 59% decrease in ED admissions and a 69% cost saving.ConclusionsThe potential health benefits and cost savings as a result of LICBT for patients who present to ED's with non‐cardiac chest pain warrant further investigation utilising a robust and economically validated trial.

P5473Perceived well-being after acute myocardial infarction according to diabetic status and its impact long-term mortality. The FAST-MI programme

Abstract Background Little information is available regarding subjective well-being according to diabetic status in patients surviving an acute myocardial infarction (AMI). Aims and methods A health status questionnaire was sent to all patients participating in the nationwide French FAST-MI cohorts (2005, 2010 and 2015) one year after the acute episode of AMI, with a specific question on overall health condition (how do you feel: very well, well, fair, poor) (n=6082), and additional questions on the presence of any chest pain (n=4590), presence nuisance bleedings (n=3968), and reporting of perceived medication side-effects (n=2220). Answers were analysed according to diabetic status. We also analysed in the 2005 and 2010 cohorts whether subjective health status at one year was a correlate of 5-year mortality. Results Compared with non-diabetic patients (n=4692), those with diabetes (n=1390) had a poorer perceived health status (poor/fair health status: 40% vs 30%, P&lt;0.001), more presence of chest pain (31% vs 23%, P&lt;0.001), but less nuisance bleedings (47% vs 56%, P&lt;0.001) and similar reported medication side-effects (37% vs 41%, P=0.12). Using logistic regression analysis, diabetes was an independent correlate of poorer health status (any diabetes OR vs non-diabetic 1.29, 1.13–1.49, P&lt;0.001; non-insulin-treated: 1.17, 1.00–1.36, P=0.05, insulin-treated: 1.58, 1.29–1.94, P&lt;0.001). In diabetic patients, perceived health condition at one year was an independent correlate of 5-year death (Cox multivariate analysis): compared with patients reporting very good health, HR (95% CI) 2.16 (1.08–4.32) for good health, 3.06 (1.53–6.11) for fair health, and 3.63 (1.55–8.55) for poor health; in non-diabetic patients, 5-year survival was similar in those reporting good or very good health status, but lower in those reporting fair or poor health status (Figure). Figure 1. 5-year survival by health status Conclusion Compared with non-diabetic patients, patients with diabetes described a poorer general health and more residual chest pain after AMI, but had less nuisance bleedings. Health condition reported one year after AMI was an independent correlate of subsequent long-term mortality, particularly for diabetic patients. Acknowledgement/Funding Amgen, AstraZeneca, Bayer, Daiichi-Sankyo, Eli-Lilly, GSK, MSD, Novartis, Pfizer, Sanofi, Servier

P3675Prognostic implications of early detection and treatment of left main coronary artery compression by a pulmonary artery among pulmonary arterial hypertension patients

Abstract Introduction Pulmonary artery aneurysm (PAA) is a common condition among pulmonary arterial hypertension (PAH) patients (38%). A pulmonary artery diameter ≥48 mm is an independent risk factor for sudden cardiac death in PAH patients. In the past years, the diagnosis of potentially lethal complications related to PAA is increasing. These complications include pulmonary artery dissection, bronchial compression and left main coronary artery compression (LMCAC). Our aim is to compare the survival and cause of death between PAA patients with a diagnosed and treated LMCAC and the rest of our PAA population. Methods Among our PAH population, we selected those patients who had a PAA diagnosis, defined as main pulmonary artery dilatation &gt;40 mm. All the information was gathered from our institutional database. Patients with a suspected LMCAC based on computed tomography findings were evaluated with coronary angiography and treated surgically or percutaneously when LMCAC was confirmed. Survival from PAH diagnosis was estimated by the Kaplan–Meier method and compared by log-rank test between groups. Results 86 patients in our cohort were diagnosed with a PAA (24% male, 49.8±12.5 years). In 10 (12%) patients, a LMCAC was diagnosed, 9 of them were treated with a percutaneous coronary intervention and the remaining one underwent PAA resection surgery due to severe pulmonary regurgitation. Among patients with LMCAC, only 3 presented chest pain and 2 had signs of ischemia in cardiopulmonary stress testing. In the other 5 patients, LMCAC was suspected after performing a thoracic computed tomography for different reasons: chronic cough in 1 patient, congenital heart disease evaluation in 2 patients and asymptomatic PAA follow-up in 2 patients. None of the patients presented complications secondary to revascularization. There were no differences between patients with and without LMCAC neither in age (49.5±12.9 vs. 49.6±12.4 years; p=0.982) nor in PAH hemodynamic severity (mean pulmonary artery pressure: 63.1±27.6 vs. 56.6±15.0 mmHg; p=0.486). Patients with LMCAC had larger median pulmonary artery diameter (52.5 [47–60.3] vs 43 [46–50] mm; p=0.024). Among LMCAC patients, 1 (10%) died during follow-up due to neoplastic disease. Among patients without LMCAC, 18 (24%) died (5 [6%] sudden cardiac death; 8 [11%] heart failure; 5 [6%] neoplastic or infectious diseases). Despite LMCAC diagnosis, there were no differences between both groups in time from PAH diagnosis to death (log rank test p=0.38). Conclusion LMCAC is a common complication among PAH patients with a PAA. Its early identification and treatment might reduce the rate of sudden cardiac death among PAH patients. Since LMCAC is often asymptomatic regular screening with non-invasive tests should be incorporated to PAH follow-up protocols.

Sex disparities in the assessment and outcomes of chest pain presentations in emergency departments

ObjectiveTo determine whether sex differences exist in the triage, management and outcomes associated with non-traumatic chest pain presentations in the emergency department (ED).MethodsAll adults (≥18 years) with non-traumatic chest pain...

The Unusual Suspect: Gadobenate-Dimeglumine Induced Kounis Syndrome

A myocardial bridge has traditionally been considered a benign condition characterized by an atypical intramyocardial route of a segment of one of the major coronary arteries. However, the clinical complications of myocardial bridges can be dangerous. These potential complications include acute coronary syndromes, arrhythmias, ventricular dysfunction, and sudden death. Myocardial bridges are suspected to be adjuvant of Kounis syndrome, which is defined as an acute coronary syndrome caused by an allergic reaction. Due to high epidemiologic prevalence, clinical suspicion of a myocardial bridge should be considered in atypical and typical presentations of chest pain, especially in patients with low-risk factors for atherosclerotic disease. A male in their late 30’s presented with non-ST elevation myocardial infarction suspected to be secondary to Kounis syndrome after gadobenate dimeglumine contrast media was used for an imaging study. His clinical presentation was further complicated when he was found to have a mid-left anterior descending coronary artery myocardial bridge.