Probability Of Acute Myocardial Infarction Research Articles

Effect Analysis of Nursing Method Based on Stratified Emergency Knowledge in Emergency Myocardial Infarction.

First aid is to give immediate first aid to patients who have suffered accidental injuries or sudden diseases before the emergency medical personnel arrive at the scene or are sent to the hospital for treatment; myocardial infarction is a severe and emergency of coronary heart disease. It is often because of coronary atherosclerosis, plaque rupture, bleeding, or thrombosis, which leads to the acute and complete occlusion of the coronary arteries and acute necrosis of the myocardium. This article aims to investigate the effectiveness of a stratified emergency care team assisted by multidisciplinary first aid knowledge in acute myocardial infarction first aid, hoping to reduce the probability of acute myocardial infarction through first aid and nursing care. Business process reengineering is a management idea that reached its heyday in the 1990s and is usually defined as achieving workflow and productivity through the reorganization and optimization of corporate strategies, value-added operational processes, and the systems, policies, organizations, and structures that support them. This article first outlines the concepts and steps of medical image registration, analyzes the characteristics of current medical image registration methods, and uses the two most commonly used medical registration methods today; in this study, the BPR theory was used to construct the AMI emergency care process in the hospital, which effectively reduced the emergency delay time of AMI patients, improved the patient's emergency response, and increased the efficiency of emergency nurses' rescue work. The experimental results in this paper show that the sensitivities of the first four groups of ST↑III > II, ST ↓ aVL > I, STV3 ↓ /STIII↑≤1.2, STI ↓ ≥0.05 mV are 82.1%, 80%, 75.3%, and 60.3%, respectively. Their sensitivities are relatively close, both are greater than 50%; among them, ST↑III > II has the highest sensitivity, which is 80%. In terms of specificity, ST↑III > II, ST ↓ aVL > I, STV3 ↓ /STIII↑≤1.2, and STI ↓ ≥0.05 mV were 82.1%, 89.2%, 82.7%, and 65.2%, respectively. ST ↓ ≥0.05 mV has the lowest specificity, and ST ↓ aVL > I has the highest specificity.

Nine-fold higher risk of acute myocardial infarction in subjects with type 1 diabetes compared to controls in Norway 1973\u20132017

BackgroundWe aimed to study the cumulative incidence and risk factors (sex, age, calendar year of diabetes onset, country of origin and educational level) of acute myocardial infarction (AMI) in subjects with type 1 diabetes and matched controls.MethodsA nationwide cohort of subjects with type 1 diabetes diagnosed at age < 15 years in Norway during 1973–2000 was followed until the first AMI event, emigration, death or 31st of December 2017. The Norwegian Childhood Diabetes Registry was linked to five nationwide registries, and up to ten sex- and age-matched controls per case were included.ResultsAmong 7086 subjects with type 1 diabetes, 170 (2.4%) were identified with incident AMI, compared to 193 (0.3%) of 69,356 controls. Mean age and diabetes duration at first AMI was 40.8 years and 30.6 years, respectively. The probability of AMI after 40 years of follow-up was 8.0% in subjects with type 1 diabetes and 1.1% in controls, aHR 9.05 (95% CI 7.18–11.41). In type 1 diabetes, male sex (aHR 1.45), higher age at onset of diabetes and lower education (higher compared to lower, aHR 0.38) were significantly associated with higher risk of AMI. There was no significant time trend in AMI by calendar year of diabetes onset.ConclusionsWe found nine-fold excess risk of AMI in subjects with type 1 diabetes, and three-fold higher risk in subjects with low versus high education. These results highlight a strengthened focus on prevention of cardiovascular disease, and diabetes education tailored to the subjects’ educational background.

The association between cardiac risk factors and the probability of acute myocardial infarction in the emergency department: analysis from a multicentre prospective observational study in the high sensitivity troponin era.

Hypertension, hyperlipidaemia, diabetes mellitus, smoking and family history are established risk factors for coronary artery disease. This study sought to determine the diagnostic value these factors have in patients presenting to an emergency department (ED) with suspected acute myocardial infarction (AMI). This secondary analysis of a prospective diagnostic test accuracy study took place across 14 hospitals in England. A total of 1273 patients, presenting with suspected cardiac chest pain, were included for analysis - 179 (14.1%) had an adjudicated diagnosis of AMI. AMI diagnosis was adjudicated with serial troponin testing conducted on arrival and 3-12 hours later. The presence of any risk factors was documented at the time of initial presentation. The post-test probability of AMI in the absence of risk factors (9.7%) shifts to only 23.5% when 4-5 factors are present. Associations of risk factors with AMI diagnosis were found as follows; hypertension [odds ratio (OR) 1.47, confidence interval (CI) 1.07-2.02], hyperlipidaemia (OR 1.57, CI 1.14-2.16), diabetes mellitus (OR 1.51, CI 1.04-2.20), smoking (OR 1.51, CI 1.05-2.17) and family history (OR 0.98, CI 0.71-1.37). The area under the receiver operating characteristic curve was 0.58. Traditional cardiac risk factors have limited association with AMI in the ED, but an increasing risk factor burden is associated with increasing prevalence of AMI. These findings suggest that future work to refine existing decision aids used in this patient group may be of value.

Application of High-Sensitivity Troponin in Suspected Myocardial Infarction

Chest pain is universally a leading cause of emergency department visits. Technological advancements have led to the development of high-sensitivity troponin assays. The application, interpretation, and appropriate utilization of their results is still under investigation. Furthermore, the increased sensitivity of these assays raises additional challenges such as determination of true myocardial infarction (MI) versus other causes of myocardial injury, appropriate timing of serial troponin sampling (i.e., from 1 to 6 hours), and prognostic implications of persistently elevated troponin levels. This study sought to develop a calculator capable of identifying the probability of acute MI (AMI) and 30-day outcomes, as well as provide prognostic information on patients identified as not having a myocardial infarction.

Derivation of a simple clinical model to categorize the probability of acute myocardial infarction in patients with atrial fibrillation.

Atrial fibrillation (AF) is independently associated with a higher risk of acute myocardial infarction (AMI). The occurrence of AMI in AF patients may lead to dismal prognosis. Risk assessment is a fundamental component of prevention for AMI. 2419 consecutive patients with nonvalvular AF were enrolled in this retrospective study. A logistic regression analysis was performed on clinical variables to create a simple clinical prediction rule. The following nine variables and assigned scores (in brackets) were included in the prediction rule: age ≥65 years (1.0), heart failure (1.0), hypertension (1.0), diabetes mellitus (1.0), hyperlipidemia (0.5), history of stroke/TIA (0.5), vascular disease (1.0), current smoking (0.5), and resting heart rate >90 beats/min (1.0). Patients were considered to have a low probability if the score was ≤2.5, moderate if the score was 3.0 to 4.0, and high if the score was ≥4.5. The AMI unlikely was assigned to patients with scores <3.5 and AMI likely if the score was ≥3.5. To evaluate the score, we included an external validation cohort of 1810 nonvalvular AF patients from the Cardiology Center, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China. The score showed a good ability in discriminating AF patients experiencing AMI both in the internal derivation cohort, with a c-index of 0.80 [95% Confidence Interval (CI) 0.77-0.83, p<0.001] and in the external validation cohort (c-index 0.73, 95% CI 0.69-0.77, p<0.001). Our scoring system offered significantly better predictive performance than the CHA2DS2-VASc score (c-index 0.80 vs 0.71, p<0.001). Our scoring system is a simple and accurate way of predicting the risk of AMI in AF patients. Therefore, more accurate targeting of preventive therapy will be allowed.

The Use of Very Low Concentrations of High-sensitivity Troponin T to Rule Out Acute Myocardial Infarction Using a Single Blood Test.

Recent single-center and retrospective studies suggest that acute myocardial infarction (AMI) could be immediately excluded without serial sampling in patients with initial high-sensitivity cardiac troponin T (hs-cTnT) levels below the limit of detection (LoD) of the assay and no electrocardiogram (ECG) ischemia. We aimed to determine the external validity of those findings in a multicenter study at 12 sites in nine countries. TRAPID-AMI was a prospective diagnostic cohort study including patients with suspected cardiac chest pain within 6 hours of peak symptoms. Blood drawn on arrival was centrally tested for hs-cTnT (Roche; 99th percentile = 14 ng/L, LoD = 5 ng/L). All patients underwent serial troponin sampling over 4-14 hours. The primary outcome, prevalent AMI, was adjudicated based on sensitive troponin I (Siemens Ultra) levels. Major adverse cardiac events (MACE) including AMI, death, or rehospitalization for acute coronary syndrome with coronary revascularization were determined after 30 days. We included 1,282 patients, of whom 213 (16.6%) had AMI and 231 (18.0%) developed MACE. Of 560 (43.7%) patients with initial hs-cTnT levels below the LoD, four (0.7%) had AMI. In total, 471 (36.7%) patients had both initial hs-cTnT levels below the LoD and no ECG ischemia. These patients had a 0.4% (n = 2) probability of AMI, giving 99.1% (95% confidence interval [CI] = 96.7% to 99.9%) sensitivity and 99.6% (95% CI = 98.5% to 100.0%) negative predictive value. The incidence of MACE in this group was 1.3% (95% CI = 0.5% to 2.8%). In the absence of ECG ischemia, the detection of very low concentrations of hs-cTnT at admission seems to allow rapid, safe exclusion of AMI in one-third of patients without serial sampling. This could be used alongside careful clinical assessment to help reduce unnecessary hospital admissions.

Point-of-care testing for sensitive cardiac troponin I in early diagnosis of acute myocardial infarction

Objective To evaluate the diagnostic performance of a point-of-care testing for sensitive cardiac troponin I(POCT-cTnI)in early diagnosis of chest pain patients who had a high pretest probability of acute myocardial infarction(AMI). Methods Total of 127 patients with new-onset chest pain at the emergency department were enrolled. Blood samples were drawn for the routine blood test, and determined POCT-cTnI and central laboratory testing for high sensitive cardiac troponin T(CLT-hscTnT) at admission, three and then at six hours after admission. All patients were divided into AMI group and non-AMI group according to the final diagnosis, which was adjudicated independently by two physicians who reviewed all available medical records for the 90-day follow-up period, and they were unaware of the results of the investigational assays of cardiac troponins. The receiver operating characteristic(ROC)curves were constructed to assess and compare the diagnostic performance of AMI of two cardiac troponin assays. The comparison of areas under the ROC curves(AUC)was performed by DeLong test, and the sensitivity, specificity, negative predictive values(NPV)and positive predictive values(PPV)for the target markers were calculated by applying a maker-specific cutoff value. Results The final diagnosis of AMI was made in 40 of 127 patients(31.5%). The diagnostic accuracy of the two assays oBtained at presentation, as quantified by AUC, was no statistically differences(AUC for POCT-cTnI, 0.901, 95%CI, 0.901 to 0.947; and for CLT-hscTnT, 0.907, 95%CI, 0.842 to 0.951; Z=0.235, P=0.745). The AUC for POCT-cTnI at 3 hours after admission was significantly higher than that on admission(0.931 vs. 0.858; Z=-2.038, P=0.042), while there was on further improvement at 6 hours after admission(0.931 vs. 0.949; Z=-1.435, P=0.151). With use of POCT-cTnI (cutoff value 0.023 ng/mL, which was the 99th percentile upper reference limit)on adimission, the clinical sensitivity was 77.5%, and the specificity was 94.2%. A single sample of POCT-cTnI at 3 hours after admission improved the diagnostic accuracy, with a sensitivity of 96.4%, a specificity of 92.0%, and a NPV of 98.6%, a PPV of 81.8%. While, with use of CLT-hscTnT(cutoff value 0.014 ng/mL, was the 99th percentile upper reference limit)at 3 hours after admission, the NPV reached to 100%. Conclusions The use of a POCT-cTnI assay in chest pain patients can identify and exclude the AMI rapidly and exactly at three hours after admission, and the diagnostic performance is equivalent to CLT-hscTnT. Key words: Chest pain; Acute myocardial infarction; Point-of-care testing; Cardiac troponin; Early diagnosis; Receiver operating characteristic curve; Diagnostic performance; Cutoff value

Aplicación de la terminología nanda-noc-nic en un paciente trasplantado de páncreas riñón

La Diabetes Mellitus (DM), es una epidemia mundial que se cifra en 190.000.000 de casos, 330.000.000 se prevén en 2025, produce 3.200.000 muertes al año o lo que es lo mismo 6 muertos por minuto. En España hay 3.400.000 diabéticos, y esta cifra aumenta a un ritmo del 5% al año, y en nuestra comunidad de Castilla y León se contabilizan 200.000 pacientes con esta patología. La DM es la principal causa de ceguera y de insuficiencia renal crónica (IRC) en el mundo desarrollado, el 21% en España, y en Castilla y León es del 6-8 %, y aumenta la probabilidad de infarto agudo de miocardio y/o hemorragia cerebral y amputaciones1. A largo plazo puede tener numerosas complicaciones, entre ellas la nefropatía diabética, la cual suele aparecer en el 50% de los pacientes a los 20 años de comienzo de la diabetes. La nefropatía diabética es completamente asintomática hasta que se produce un daño grave, y es responsable de que cerca del 30% de los enfermos entre en diálisis periódica y primera causa de trasplante renal en países occidentales2. Actualmente el trasplante de páncreas riñón es la mejor opción terapéutica para el paciente diabético en diálisis, pero la intervención quirúrgica y la fase postquirúrgica pueden presentar diferentes complicaciones. Aplicamos el proceso enfermero, que es un método sistematizado de brindar cuidados centrados en el logro de objetivos (NOC), el uso del proceso enfermero complementa el trabajo de los profesionales de otras disciplinas.

Acute cardiac injury events ≤30days after laboratory-confirmed influenza virus infection among U.S. veterans, 2010-2012.

BackgroundCardiac injury is a known potential complication of influenza infection. Because U.S. veterans cared for at the U.S. Department of Veterans Affairs are older and have more cardiovascular disease (CVD) risk factors than the general U.S. population, veterans are at risk for cardiac complications of influenza infection. We investigated biomarkers of cardiac injury characteristics and associated cardiac events among veterans who received cardiac biomarker testing ≤30 days after laboratory-confirmed influenza virus infection.MethodsLaboratory-confirmed influenza cases among veterans cared for at U.S. Department of Veterans Affairs’ facilities for October 2010–December 2012 were identified using electronic medical records (EMRs). Influenza confirmation was based on respiratory specimen viral culture or antigen or nucleic acid detection. Acute cardiac injury (ACI) was defined as an elevated cardiac biomarker (troponin I or creatinine kinase isoenzyme MB) >99 % of the upper reference limit occurring ≤30 days after influenza specimen collection. EMRs were reviewed for demographics, CVD history and risk factors, and ACI-associated cardiac events.ResultsAmong 38,197 patients with influenza testing results, 4,469 (12 %) had a positive result; 600 of those patients had cardiac biomarker testing performed ≤30 days after influenza testing, and 143 (24 %) had one or more elevated cardiac biomarkers. Among these 143, median age was 73 years (range 44–98 years), and 98 (69 %) were non-Hispanic white. All patients had one or more CVD risk factors, and 98 (69 %) had a history of CVD. Eighty-six percent of ACI-associated events occurred within 3 days of influenza specimen collection date. Seventy patients (49 %) had documented or probable acute myocardial infarction, 8 (6 %) acute congestive heart failure, 6 (4 %) myocarditis, and 4 (3 %) atrial fibrillation. Eleven (8 %) had non-cardiac explanations for elevated cardiac biomarkers, and 44 (31 %) had no documented explanation. Sixty-eight (48 %) patients had received influenza vaccination during the related influenza season.ConclusionAmong veterans with laboratory-confirmed influenza infection and cardiac biomarker testing ≤30 days after influenza testing, approximately 25 % had evidence of ACI, the majority within 3 days. Approximately half were myocardial infarctions. Our findings emphasize the importance of considering ACI associated with influenza infection among patients at high risk, including this older population with prevalent CVD risk factors.

Abstract T MP48: Androgen Suppression in Patients with Prostate Cancer Increases Incidence of Combined Cardiovascular Outcomes

Introduction: Androgen suppression therapy for prostate cancer is controversial due to adverse fatal and non-fatal cardiovascular outcomes reported in some studies. However, effects of androgen suppression on stroke have not been fully assessed in the elderly. Methods: Patients diagnosed with prostate cancer during 2007-2013 in a large community-based healthcare system were identified from the Cancer Registry, electronic records, and billing codes. Those who underwent androgen suppression therapy with Gonadotropin-releasing hormone agonist (GnRH) were propensity-matched to patients treated without androgen suppression therapy by age at cancer diagnosis, race/ethnicity, disease stage and outcome, body mass index and use of surgery, radiation, and chemotherapy. Tests of independence and Cox proportional hazards models were used to examine effects of hormone therapy on acute myocardial infarction (AMI), stroke, and mortality outcomes. Models also adjusted for patient comorbidities. Results: A total of 1282 patients and 641 matched-pairs were identified, with mean diagnosis age of 69 yr and follow-up period of 3.05 yr. Effects of androgen suppression therapy on AMI (P=0.051) and stroke (P=0.062) were of marginal to non-significance, but adjusted-odds of death and combined AMI, stroke, and death were 1.61 times (P=0.002; odds ratio [OR] 95% CI: 1.19-2.18) and 1.70 times (P&lt;0.001; OR 95% CI: 1.26-2.28) greater, respectively, for men with than without androgen suppression. An interaction of androgen suppression and age-group (&lt;65 yr, 65-74 yr, &gt;74 yr) was discovered for combined outcomes, suggesting increased probability of AMI, stroke, and/or death with age (8.6-20.0%; P=0.003) for patients without androgen suppression but elevated risk of outcomes across all age groups (18.3-22.4%; P=0.546) for men treated with androgen suppression therapy. Conclusion: Endogenous androgen suppression presents elevated risk of combined cardiovascular and death outcomes, especially for men &lt;65 yr.

Abstract 56: Prognosis of Patients with Acute Myocardial Infarction by Hospital Discharge Diagnosis

Background: Research on acute myocardial infarction (AMI) in medical claims largely focuses on hospitalizations where AMI is the primary discharge diagnosis (dx). Limited data are available on AMIs occurring as a secondary dx during hospitalization. Hypothesis: We hypothesized that mortality following AMI is higher when the primary dx is not AMI. Methods: We examined REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants with definite or probable AMIs adjudicated using published guidelines. Participants were categorized by hospital discharge dx from the discharge summary: primary dx, secondary dx, or no dx of AMI. All-cause and cardiovascular mortality after AMI, detected though active follow-up and the National Death Index, were compared using Kaplan-Meier curves with log-rank tests and Cox proportional hazard models adjusted for sociodemographics, medical history, and characteristics of the AMI (clinical evidence of ischemia, peak troponin, and heart failure during hospitalization). Results: Of 877 participants with AMI, 37% had AMI as primary dx, 12% had AMI as a secondary dx, and 51% had no dx of AMI. All-cause mortality (n = 284) was higher among participants with AMI as a secondary dx or without a dx of AMI than among participants with AMI as primary dx, but cardiovascular mortality (n = 150) was similar across groups ( Figure ). Compared to participants with AMI as primary dx, adjusted hazard ratios for all-cause mortality were 1.03 (95% CI 0.68-1.57) and 1.17 (95% CI 0.84-1.62) and for cardiovascular mortality were 0.79 (95% CI 0.46-1.37) and 0.91 (95% CI 0.60-1.38) for participants with AMI as a secondary dx and without a dx of AMI, respectively. Conclusions: Studies of AMI based on primary discharge dx likely under count the number of AMIs and exclude a population with similar prognosis in terms of all-cause and CVD mortality, once clinical differences considered. Further study into the characteristics, in-hospital and post-discharge management of these patients may be warranted.

Incidence of acute myocardial infarction resulting in sudden death outside the hospital

ObjectiveTo prospectively determine the percentage of cases of acute myocardial infarction (AMI) resulting in sudden death outside the hospital.MethodsTwo groups of patients were defined by the emergency medical services. Group...

Neighborhood Income, Health Insurance, and Prehospital Delay for Myocardial Infarction

Outcomes following an acute myocardial infarction (AMI) are generally more favorable if prehospital delay time is minimized. We examined the association of neighborhood household income (nINC) and health insurance status with prehospital delay among a weighted sample of 9700 men and women with a validated, definite, or probable AMI in the Atherosclerosis Risk in Communities (ARIC) community surveillance study (1993-2002). Weighted multinomial regression with generalized estimation equations was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) and to account for the clustering of patients within census tracts. Low nINC was associated with a higher odds of long vs short delay (OR, 1.46; 95% CI, 1.09-1.96) and medium vs short delay (OR, 1.43; 95% CI, 1.12-1.81) compared with high nINC in a model including age, sex, race, diabetes, hypertension, presence of chest pain, arrival at the hospital via emergency medical service, distance from residence to hospital, study community, and year of AMI event. Meanwhile, compared with patients with prepaid insurance or prepaid plus Medicare, patients with Medicaid were more likely to have a long vs short delay (OR, 1.87; 95% CI, 1.10-3.19) and a medium vs short delay (OR, 1.76; 95% CI, 1.13-2.74). Both low nINC and being a Medicaid recipient are associated with longer prehospital delay. Reducing socioeconomic and insurance disparities in prehospital delay is critical because excess delay time may hinder effective care for AMI.

Probabilistic classification of acute myocardial infarction from multiple cardiac markers

Logistic regression and Gaussian mixture model (GMM) classifiers have been trained to estimate the probability of acute myocardial infarction (AMI) in patients based upon the concentrations of a panel of cardiac markers. The panel consists of two new markers, fatty acid binding protein (FABP) and glycogen phosphorylase BB (GPBB), in addition to the traditional cardiac troponin I (cTnI), creatine kinase MB (CKMB) and myoglobin. The effect of using principal component analysis (PCA) and Fisher discriminant analysis (FDA) to preprocess the marker concentrations was also investigated. The need for classifiers to give an accurate estimate of the probability of AMI is argued and three categories of performance measure are described, namely discriminatory ability, sharpness, and reliability. Numerical performance measures for each category are given and applied. The optimum classifier, based solely upon the samples take on admission, was the logistic regression classifier using FDA preprocessing. This gave an accuracy of 0.85 (95% confidence interval: 0.78–0.91) and a normalised Brier score of 0.89. When samples at both admission and a further time, 1–6 h later, were included, the performance increased significantly, showing that logistic regression classifiers can indeed use the information from the five cardiac markers to accurately and reliably estimate the probability AMI.

Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes

The chest pain history, physical examination, determination of coronary artery disease (CAD) risk factors, and the initial electrocardiogram compose the information immediately available to clinicians to help determine the probability of acute myocardial infarction (AMI) or acute coronary syndrome (ACS) in patients with chest pain. However, conflicting data exist about the usefulness of the chest pain history and which components are most useful. To identify the elements of the chest pain history that may be most helpful to the clinician in identifying ACS in patients presenting with chest pain. MEDLINE and Ovid were searched from 1970 to September 2005 by using specific key words and Medical Subject Heading terms. Reference lists of these articles and current cardiology textbooks were also consulted. Certain chest pain characteristics decrease the likelihood of ACS or AMI, namely, pain that is stabbing, pleuritic, positional, or reproducible by palpation (likelihood ratios [LRs] 0.2-0.3). Conversely, chest pain that radiates to one shoulder or both shoulders or arms or is precipitated by exertion is associated with LRs (2.3-4.7) that increase the likelihood of ACS. The chest pain history itself has not proven to be a powerful enough predictive tool to obviate the need for at least some diagnostic testing. Combinations of elements of the chest pain history with other initially available information, such as a history of CAD, have identified certain groups that may be safe for discharge without further evaluation, but further study is needed before such a recommendation can be considered reasonable. Although certain elements of the chest pain history are associated with increased or decreased likelihoods of a diagnosis of ACS or AMI, none of them alone or in combination identify a group of patients that can be safely discharged without further diagnostic testing.

PRIME ECG improves emergency department diagnosis and management in moderate- to high-risk unstable angina/non–ST elevation myocardial infarction patients

Study objectives: The 12-lead ECG is the current criterion standard for the diagnosis and early evaluation of patients with chest pain. A significant proportion of patients with unstable angina (UA) or non–ST elevation myocardial infarction (NSTEMI) do not manifest ischemic changes on the 12-lead ECG. The recently developed PRIME 80-lead ECG Body Surface Mapping System (Meridian) may be clinically useful in the diagnosis and management of UA/NSTEMI. Recent studies have looked at this 80-lead ECG to see if sensitivity and specificity for acute coronary syndromes could improve with this instrument. Some researchers have shown in 53 patients with enzymatically confirmed acute myocardial infarction (AMI) that the 80-lead ECG doubled the diagnostic sensitivity of AMI compared with 12-lead ECG. Other researchers compared 18 patients with left bundle-branch block and enzymatically confirmed AMI and showed that the sensitivity of 80-lead ECG for early detection of AMI was double that of the 12-lead ECG. The objective of this study is to determine whether 80-lead ECG can improve early detection of ischemic changes in emergency department (ED) patients with UA/NSTEMI over 12-lead ECG. Our hypothesis is that the PRIME ECG body map compared with the 12-lead ECG improves the diagnosis and management of ED patients with acute coronary syndromes. Methods: This is a prospective study performed on a convenience sample of suspected moderate- to high-risk UA/NSTEMI ED patients, defined as a Thrombolysis in Myocardial Infarction (TIMI) risk score of 3 or greater, positive biomarkers, or new (or not known to be old) ischemic ECG changes, who present within 12 hours of the most recent ischemic symptom. Enrolled patients had a 12-lead ECG and also a PRIME 80-lead ECG performed oof 4), blinded to patient data other than medical history and physical examination, interpreted the ECG and PRIME for their effect on patient disposition and therapy including the probability of AMI and cardiac care unit or cardiac step-down admission. The physicians recorded whether the PRIME ECG after evaluation of the 12-lead ECG changed either the patient therapy or disposition. Outcomes were 1-month major adverse coronary events (MACEs), defined as death, AMI, percutaneous transluminal coronary angioplasty or stent, coronary artery bypass graft surgery (CABG), or coronary stenosis greater than 50%. Data were analyzed using descriptive statistics. Results: Thirty-four patients have been enrolled to date. Sixty-eight percent of those enrolled had 1 of the prespecific MACEs, (32% NSTEMI, 41% PCI, 18% CABG, 17% >50% stenosis). The PRIME ECG added additional information to the 12-lead ECG in 59% (20/34) of patients. The PRIME ECG changed ED disposition or therapy in 21% (7/34) of patients. Of the 13 patients for whom the PRIME ECG added additional data without changing management, 62% (8/13) had a MACE. Of the 7 patients for whom the PRIME ECG changed management, 86% (6/7) had a MACE. The 1 patient of the 7 without a MACE was post-CABG, had significant stenosis (80% to 100%) thought to be old, and was treated with aggressive therapy. Conclusion: The use of the PRIME ECG in moderate- to high-risk UA/NSTEMI patients improved the ED diagnosis and management.

Prehospital recognition of acute myocardial infarction

Paramedics often provide advance notice of patients with suspected acute myocardial infarction (AMI) so that emergency department (ED) staff can prepare for early aggressive management and expeditious thrombolysis, but the validity of this practice is unclear. Our objective was to determine the accuracy of prehospital AMI diagnosis by Paramedic Level III (ALS) attendants. ALS paramedics serving a busy community hospital were instructed regarding the clinical diagnosis of chest pain and the value of early thrombolysis. For all patients transported with a chief complaint of chest pain, they were asked to record an explicit diagnosis of "probable AMI" or "chest pain, other." Prehospital diagnoses were subsequently compared to ED diagnoses. Sensitivity, specificity and predictive values of the prehospital diagnosis for AMI were determined. During the 5-year study period, 1305 patients were studied. Based on clinical features alone, ALS paramedics were 77.8% sensitive and 82.2% specific for the diagnosis of AMI. ALS paramedics can accurately identify patients likely to benefit from early aggressive AMI management. These data have implications with respect to prehospital triage of chest pain patients, "early notification" protocols and future prehospital thrombolytic strategies.

Impact of technetium-99m sestamibi imaging on the emergency department management and costs in the evaluation of low-risk chest pain.

To assess the impact of rest sestamibi scanning on emergency physicians' (EPs') diagnostic certainty and decision making (as assessed by the hypothetical disposition of patients) for 69 consenting stable patients with suspected acute cardiac ischemia and nondiagnostic electrocardiograms. The resultant impact on costs was examined as a secondary outcome. Patients with suspected acute cardiac ischemia were injected with 25 mCi of sestamibi within two hours of active pain in one of three emergency department study sites. The probability of acute myocardial infarction (AMI) and unstable angina (UA), and hypothetical disposition decisions were recorded immediately before and after physicians were notified of scan results. Changes in disposition were classified as optimal or suboptimal. For the cost determinations, a cost-based decision support program was used. For the subgroup found to be free of acute cardiac events (ACEs) (n = 62), the EPs' post-sestamibi scan probabilities for AMI decreased by 11% and UA by 18% (p < 0.001 for both conditions). In seven patients with ACEs, the post-scan probabilities of AMI and UA increased, but neither was statistically significant. Scan results led to hypothetical disposition changes in 29 patients (42%), of which 27 (93%) were optimal (nine patients were reassigned to a lower level of care, two to a higher level, and 16 additional patients to "discharge-home" status). The strategy of scanning all patients who were low to moderate risk for acute cardiac ischemia would result in an increase of direct costs of care of $222 per patient evaluated, due to added cost of sestamibi scanning. Sestamibi scanning results appropriately affected the EPs' estimates of the probability of AMI and UA and improved disposition decisions. Scanning all low-risk patients would likely be associated with increased costs at this medical center.

Acute toxicities of betel nut: rare but probably overlooked events.

Betel nut chewing has long been a social habit in Taiwan and other Asian and tropical countries. It produces various autonomic and psychoneurologic effects including tachycardia, flushing, warmth, cholinergic activation, alertness, and euphoria. Although the oral carcinogenic effects are well known, data concerning its acute toxicity are few. To better understand the toxicity of betel nut, cases reported to the Taiwan Poison Control Center as probable or possible betel nut-related toxicity (January 1988-June 1998) were reviewed. In the 17 cases suitable for review (14 males, 3 females, age 21 to 60 years), the most common manifestations were tachycardia/palpitations (7); tachypnea/dyspnea (6); hypotension and sweating (5); vomiting, dizziness, and chest discomfort (4); abdominal colic, nausea, numbness, and coma (3); and acute myocardial infarction and related manifestations (2). The reported quantity of betel nut used was low (1 to 6 nuts), except an extract of 100 betel nuts was used in 1 case and 66 chewed in another. Most cases recovered within 24 hours after the exposure. One patient developed probable acute myocardial infarction and ventricular fibrillation and died despite repeated cardiac defibrillation. Although betel nut chewing is widespread, significant toxicity as reported to a poison center is rare. Because most betel nut-related effects are transient and mild in nature, the incidence of such events is likely to be underreported. Nevertheless, betel nut chewing can produce significant cholinergic, neurological, cardiovascular, and gastrointestinal manifestations. It is possible that it may aggravate cardiac diseases in susceptible patients but this hypothesis must be further investigated. Treatment is symptomatic. With timely support, rapid and complete recovery is anticipated but a small risk of major complications cannot yet be discounted.

Management and outcome of acute myocardial infarction in older patients in the thrombolytic era.

Acute myocardial infarction (AMI) is an important cause of mortality and morbidity in older patients. The aim of this study was to determine the proportion of unselected admissions with AMI that is older than 75 years and to examine management and outcomes in this group. An historical cohort study of consecutive unselected admissions with AMI identified using the Hospital In Patient Enquiry (HIPE) database and validated according to MONICA criteria for definite or probable AMI. An acute cardiac unit in a university teaching hospital/cardiac tertiary referral center. Of 1059 patients, 606 (57%) were older than 65 years and 309 (29.2%) were older than 75 years. Mean age in this group was 80.5 years. Hospital mortality was almost twice as high as in patients younger than 75 years (28% vs 15%, P < .001), and age was an independent predictor of short- and long-term mortality following AMI. Women constituted a significantly higher proportion of older patients. Family history of AMI and cigarette smoking were less prevalent in older patients. Mean cholesterol was lower and comorbidities were higher. Other baseline characteristics, including previous AMI, did not differ. However older patients were less likely to receive thrombolysis (13% vs 36%, P < .001), aspirin (76% vs 86%, P < .01), or beta-blockers (25% vs 51%, P < .001) and were less likely to undergo cardiac catheterization or revascularization. Only 53% were admitted to coronary care. Patients more than age 75 comprise almost one-third of patients with AMI and have a poor prognosis. Although age is an independent predictor of mortality following AMI, suboptimal management may contribute to the high mortality in these patients.