Signs Of Acute Coronary Syndrome Research Articles

Diagnostic utility of high-sensitive troponin T in patients with acute coronary syndrome

Cardiovascular diseases are the first cause of death in the world. Early detection of coronary pathologies contributes to the prevention of acute coronary events. High-sensitive troponin T is a valuable biomarker for diagnosing and assessing these patients. A retrospective cross-sectional study was performed from January 2018 to December 2020 at Hospicor-Manta. We included 571 patients who attended the Intensive Care Unit and had at least one high-sensitive troponin T determination with symptoms in the first 6 hours. Analyzing from the upper reference limit (99th percentile, allows understanding and interpreting data from the values below which a certain percentage is found for cardiac troponins. Elderly male patients tended to suffer acute coronary syndrome (p<0.05). The most frequent comorbidities were: arterial hypertension, dyslipidemia and diabetes (p< 0.05). There was evidence of the correlation between high-sensitive troponin T values and electrocardiographic signs of acute coronary syndrome (p<0.05). There was a moderate correlation between high-sensitive troponin T analysis and acute coronary syndrome (p< 0.05). Keywords: Cardiovascular diseases, acute coronary syndrome, high-sensitive troponin T.

Takotsubo cardiomyopathy following blunt trauma: Early recognition and diagnosis

Takotsubo Cardiomyopathy (TTC) is characterized by reversible left ventricular apical ballooning in the absence of angiographically significant coronary artery disease. While TTC is usually preceded by an emotionally stressful event, physical trauma has been documented as a precipitating incident as well.An 82-year-old female with no past medical history, presented to the emergency department following a motor vehicle collision. Trauma workup was significant for an ulnar fracture, elevated cardiac enzymes, and ST-segment changes. Bedside echocardiogram revealed apical ballooning. She underwent cardiac catheterization, which failed to demonstrate significant coronary artery disease. The patient developed cardiogenic shock and required temporary vasopressor support after failing a trial of intra-aortic balloon pump.Takotsubo Cardiomyopathy is a rare complication of trauma, which presents with signs and symptoms similar to acute coronary syndrome (ACS) but without evidence of obstructive coronary artery disease. Following trauma, signs of ACS in elderly women should raise provider's suspicion for TTC and prompting bedside echocardiography, which can assist with early diagnosis.

Сердечные тропонины: современное представление о клиническом и прогностическом значении в многопрофильном стационаре

The increase of patients with elevated cardiac troponins in blood without signs of acute coronary syndrome in recent years, associated, among other reasons with the pandemic of coronavirus infection, has made differential diagnosis difficult for physicians of multidisciplinary hospitals. Aim of the study: to investigate the clinical and prognostic significance of elevated cardiac troponins associated with non-coronarogenic causes, including in the COVID-19 pandemic conditions. Materials and methods: a search of 57 literature sources from eLIBRARY, PubMed, Web of Science, Scopus, Google Scholar, and freely available Yandex and Google databases was performed. The results of the literature review showed that the use of highly sensitive cardiac troponins is relevant for clinical evaluation of the course and differential diagnosis of heart diseases (coronary and non-coronary) and other internal organs pathology, but the accuracy of the troponin test, combined with its nonspecificity, requires a cautious approach to the interpretation of the results. Also isolated elevation of cardiac troponins does not indicate the mechanism of myocardial damage and is not an indication for patients transfer to intensive care units or vascular centers. Routine use of troponin tests makes it difficult to make true diagnosis for patients in a multidisciplinary hospital. Many studies have shown that elevated troponin levels not associated with acute coronary syndrome have a negative prognostic value, but when the coronary event is excluded, elevated troponin levels should not be ignored; it is necessary to look for the cause of such changes. The integration of cardiac troponins in predicting the risk of occurrence, progression, and complications of various diseases is a promising area for further research.

Apical Ballooning Syndrome: A Cardiac Syndrome Mimicking Acute Myocardial Infarction

Introduction: Apical ballooning syndrome, Takotsubo cardiomyopathy, or broken heart syndrome, is a rare but currently well recognized clinical entity. It occurs after severe emotional or physical stress, most often in postmenopausal women, and mimics the symptoms and signs of acute coronary syndrome, in the absence of significant coronary injury. This cardiomyopathy is rapidly and completely reversible. The exact pathophysiological mechanism of the condition remains debated; several hypotheses have been put forward, the most credible of which seems to be a sudden hyperadrenergic reaction related to stress. Objective: To report the case of a patient with clinical features of possible myocardial infarction but diagnosed as Takotsubo cardiomyopathy. Case Report: The patient was a 64-year-old woman with no cardiovascular risk factors other than age and menopause, and no particular pathological history. She was admitted on Day 3 with infarct-like chest pain, which appeared following an episode of emotional stress, associated with NYHA stage III dyspnea. On admission, the patient was pain free. The clinical examination found a conscious patient, hemodynamically and respiratory stable, apyretic. The cardiovascular examination was unremarkable. The ECG was in sinus rhythm, showing a QS aspect in the anterosepto-apical area associated with negative T waves in the inferolateral area. The biological workup showed an inflammatory syndrome, with positive troponin at 650ng/l. The thoracic echocardiography showed an aspect of hypokinetic cardiopathy at the dilated stage with severe LV dysfunction (LVEF at 38%), a thin and flexible mitral valve with restriction of the small mitral valve with moderate mitral insufficiency (SOR at 20 cm2 and RV at 19 ml), a dilated left atrium. Coronary angiography showed angiographically healthy coronary arteries, and an MRI was performed, confirming the diagnosis of Takutsbo cardiomyopathy. Discussion and Conclusion: Takotsubo cardiomyopathy is an increasingly recognized clinical entity, characterized by apical left ventricular dysfunction with chest pain, electrocardiographic changes, minimal biomarker changes, and no coronary lesions. In most cases, an episode of emotional or physical stress precedes the event. Its pathophysiological mechanism remains unknown, but high circulating catecholamines seem to be the triggering factor and the most plausible explanation for this primary acquired cardiomyopathy. It is important to be aware of this diagnosis in patients presenting with ACS because its evolution is most often spontaneously favorable.

PO-651-05 ISCHEMIC EVALUATIONS IN PATIENTS PRESENTING WITH MONOMORPHIC VENTRICULAR TACHYCARDIA ELECTRICAL STORM

Monomorphic ventricular tachycardia (VT) related electrical storm (ES) in patients with structural heart disease is dependent on a scarred myocardial substrate. The role of routine ischemic evaluation in those patients with monomorphic ES without signs of acute coronary syndrome (ACS) is unknown.

Anaesthetic management for an emergency obstructive femoral hernia repair with dynamic ischemic ECG changes: A case report

Obstruction in femoral hernias occurs more frequently than expected. Preoperative coronary syndromes present additional challenges in their anaesthetic management. Here is an example of such a case A 60-year-old female with a BMI of 23.3 presented to us with an obstructed femoral hernia that had developed over the course of one day. There were no comorbidities in her case. Her heart rate was 110 beats per minute, and her blood pressure was 120/70 millimetres of mercury. The ECG showed signs of acute coronary syndrome. The cardiologists advised coronary intervention but postponed it in favour of urgency of the surgical procedure. We used a combined spinal epidural with intrathecal narcotics since this patient was completely asymptomatic with stable hemodynamics. The gangrene gut was resected, and the mesh repair was done. The procedure went smoothly. The repeat ECG was comparable to the preoperative one with normal quantitative troponin tests in the post-operative period. The potassium level was 2.7 meq which was corrected. The ECG became normal after 5 days. We hypothesise that the ECG changes were caused by inexplicit hypokalaemia. We report this case due to the extreme rarity of a strangulated femoral hernia with ACS-like ECG changes that later resolved.

MARKEDLY ELEVATED TROPONIN WITH COVID-19 PNEUMONIA WITHOUT ACUTE CORONARY SYNDROME

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: COVID infection can present with diverse manifestations. We present an interesting case of very high troponin elevation in patient with COVID infection without obvious reason for troponin elevation. CASE PRESENTATION: A 66-year-old man with history of HTN, DM2, CAD (CABG in 2009, percutaneous vascularization of RCA with multiple DES in 2018), NSTEMI- 1 year ago, PVD, status post left BKA, ESRD on HD presented with 1 week of watery diarrhea after being tested positive for COVID. He denied chest pain, had minimal SOB. He received first dose of COVID vaccine 2 weeks prior. Vital signs: afebrile, BP 145/68 mmhg, HR 75 beats/min, RR 20/min, oxygen saturation 90% on RA and 96% on 3L of O2 via NC. PE: R- IJ permanent catheter, L- BKA, lungs clear. Labs: COVID PCR assay (+), D dimer 359 D-DU ng/ml, LDH 330 U/l, ferritin 3207 ng/ml, CRP quant 87 ml/l, SARS-CoV-2 Ig G (RBD) 1.14 S/CO, SARS-COV-2 IgM (Beckman) 2.56. troponin (AccuTnI) 13.46 ng/ml, CPK normal, Cr 7.5 (at the baseline), EKG - sinus rhythm, left axis deviation, negative T waves in lateral leads and ST depression up to 1 m in anterior leads, no changes from old EKG, CXR - Increased b/l pulmonary opacities compatible with atypical/viral pneumonia. The most recent ECHO 1 year ago – mild LV dysfunction with thin and akinetic inferior and basal posterior walls, LVEF 50%. Patient was already on aspirin, plavix, statin and that treatment was continued during hospital course. COVID pneumonia was treated with dexamethasone and convalescent plasma versus placebo (VA Cures- 1 Trial). His hospital stay was uneventful, he remained hemodynamically stable and asymptomatic and was discharged home DISCUSSION: Our patient has known history of CAD and ESRD which are well known cause for elevated troponin. However his Cr level was at his baseline and his previous troponin levels were never this high even when he had NSTEMI, it was only 1.44 ng/ml. During this admission with Covid infection his troponin level was as high as 13.46 ng/ml and trended down to 4.15 ng/ml on discharge, his baseline level of troponin is 0.03-0.88 ng/ml. Reasons for such a high level of troponin can be due to Type II MI or myocarditis. In the settings of COVID infection it has been suggested that troponemia can be due to microvascular damage occurring in the heart with perfusion defects, vessel hyperpermeability, vasospasm and high cytokine levels may represent the key player of myocardial injury (1). Our patient did not have a very severe form of COVID pneumonia that required intubation in fact, he was saturating well on minimal oxygen requirements. He remained asymptomatic with no new interval EKG changes or any other signs of acute coronary syndrome (ACS). CONCLUSIONS: Serum Troponin can be significantly elevated in the setting of COVID infection and in the absence of ACS. REFERENCE #1: Reference #1: Tersalvi G, Vicenzi M, Calabretta D, Biasco L, Pedrazzini G, Winterton D. Elevated Troponin in Patients With Coronavirus Disease 2019: Possible Mechanisms. J Card Fail. 2020;26(6):470-475. doi:10.1016/j.cardfail.2020.04.009 DISCLOSURES: no disclosure on file for Moses Bachan;no disclosure on file for Zinobia Khan;No relevant relationships by Dileep Kumar, source=Web Response No relevant relationships by Mirjana Petrovic Elbaz, source=Web Response

Diagnostic pitfalls: intramyocardial lymphoma metastasis mimics acute coronary syndrome in a diffuse large B cell lymphoma patient\u2014case report

BackgroundCardiac tumors are very uncommon compared to other cardiac diseases. Their clinical symptoms can vary from absent to non-specific. The most common symptoms are arrhythmias, blood flow obstruction due to valvular dysfunction, shortness of breath, systemic embolization, and accumulation of pericardial fluid. Hereby, we describe a very rare case of a diffuse large B cell lymphoma patient who presented with the symptoms and signs of acute coronary syndrome (ACS) but the patient’s complaints were caused by his intramyocardial lymphoma metastasis.Case presentationForty-eight-year-old diffuse large B cell lymphoma patient was admitted to our emergency department with chest pain, effort dyspnea, and fever. The patient had normal blood pressure, blood oxygen saturation, sinus tachycardia, fever, crackles over the left lower lobe, novum incomplete right bundle branch block with Q waves and minor ST alterations, elevated C-reactive protein, high-sensitivity troponin-T, and d-dimer levels. Chest X-ray revealed consolidation on the left side and enlarged heart. Bed side transthoracic echocardiography showed inferior akinesis with pericardial fluid. Coronary angiography showed no occlusion or significant stenosis. Chest computed tomography demonstrated the progression of his lymphoma in the myocardium. He was admitted to the Department of Hematology for immediate chemotherapy and he reached complete metabolic remission, followed by allogeneic hematopoietic stem cell transplantation. Unfortunately, about 9 months later, he developed bone marrow deficiency consequently severe sepsis, septic shock, and multiple organ failure what he did not survive.ConclusionsOur case demonstrates a very rare manifestation of a heart metastasis. ACS is an unusual symptom of cardiac tumors. But our patient’s intramyocardial lymphoma in the right atrium and ventricle externally compressed the right coronary artery and damaged the heart tissue, causing the patient’s symptoms which imitated ACS. Fortunately, the quick diagnostics and immediate aggressive chemotherapy provided the patient’s remission and suitability to further treatment.

Problemy s traheostomičeskimi kanûlâmi u pacientov s COVID-19 - pričiny i sposoby rešeniâ

Patients with severe lung injury due to COVID-19 are often in need of mechanical ventilation. Due to the predicted length of invasive respiratory support, tracheostomy is commonly indicated to improve patient comfort, to reduce the need for sedation and to allow safer airway care [7] [8] [15]. In this article we report two clinical cases of patients with COVID-19, who suffered cardiac arrest due to problems with tracheostomy canula placement. The first case report is regarding a 74-year-old patient, who was transported to CT from the ICU. Problems first occurred in the elevator, where specialist were forced to switch to bag ventilation, when the oxygen supply ran out. As a result, an episode of desaturation to 80% was registered. Upon arriving in the ICU, the patient was connected to a mechanical ventilator, however ventilation was ineffective: peak pressure was more than 40 cmH2O and the tidal volume was less than 100 ml. Debridement of the trachea was performed, the position of the cannula was secured with no effect. While preparing for oropharyngeal intubation, the patient's saturation dropped to 70%, haemodynamics were unstable (BP 76/40), ECG showed bradycardia of 30 bpm, which quickly turned to asystole. Cardiopulmonary resuscitation was performed and the patient was intubated, mechanical ventilation was effective. The total time of cardiac arrest was around 2 minutes, when ROSC was achieved and sinus rhythm was registered on the ECG. In 6 hours after ROSC signs of acute coronary syndrome were registered, the patient received treatment accordingly. Despite the complications, the patient's condition improved and he was transferred to the therapeutics ward and later discharged home with no signs of neurological impairment. The second case presents a similar clinical situation with an alternate outcome. A 32-year-old patient with COVID-19 was transferred to ICU due to signs of respiratory distress. His condition worsened and the patient was intubated, and soon percutaneous dilatational tracheostomy was performed. On day 9 of treatment in ICU an episode of desaturation to 75% was registered. Debridement of the trachea was not possible due to a block in the cannula. Due to rapid demise in the patient's condition, the cannula was removed and the patient was intubated. After bronchoscopy, re-tracheostomy was performed. During the procedure, it was noted that the standard cannula was displaced at an angle to the posterior wall of the trachea. The cannula was replaced by an armored cannula. In the following hours, hypoxemia was observed, as well as subcutaneous emphysema of the patient's face and upper body. Applying a thoracic X-ray, a left-side pneumothorax was diagnosed, which was urgently drained. In the following days of intensive care the patient's condition gradually improved, mechanical ventilation was effective and signs of respiratory distress were fading. Neurologically the patient was responsive, able to perform simple tasks. Unfortunately, on the 15th day of ICU care the patient's condition worsened: his fever spiked to 39-40,2C, CRP was 149, and CT showed signs of ARDS progression and vasopressors were administered due to hemodynamic instability. An episode of desaturation to 88% was noted. It was assumed that the tracheostomy cannula had been displaced, which was not proven by bronchoscopy. Later that day, while turning the patient to the side, bradycardia was noted on the monitor with progression to asystole. Cardiopulmonary resuscitation was performed for 5 minutes until ROSC. The tracheostomy cannula was then removed, due to inadequate ventilation and the patient was intubated and ventilated through an IT tube. After ROSC the patient's neurological status was closely monitored. Without sedation the patient was unconscious (coma), non-responsive, hyporeflexive with little response to pain stimuli. In two weeks his neurological condition was regarded as a vegetative state (GCS -6).

Syncope: Chief complaint for spontaneous coronary artery dissection without other signs of acute coronary syndrome

Introduction: Spontaneous coronary artery dissection is an exceptionally rare cause of acute coronary syndrome (ACS) with a reported incidence of 1–4% of all ACS cases. It is most prevalent in young women with the left anterior descending artery and left main are the most common arteries involved. Case Report: The patient is a 75-year-old man with a prior medical history of hypertension, gastroesophageal reflux disease (GERD), and pulmonary fibrosis presented to the emergency department (ED) with syncope. The patient reported a burning sensation over the central chest different from his GERD. On physical exam, the patient had a 3/6 holosystolic murmur throughout the left pericardium. His laboratory workup was benign with negative troponins and normal electrocardiogram (EKG). Chest X-ray during this time revealed no acute processes and computed tomography angiography (CTA) of the chest was positive for a 4.1 mm fusiform ascending aortic aneurysm. 2D Echo revealed new cardiomyopathy with ejection fraction (EF) of 35–40% with trivial mitral regurgitation (MR) and mild aortic regurgitation. Left heart catheterization revealed left main stenosis of 75%, left anterior descending (LAD) with ostial stenosis of 80% and 30% stenosis of the left circumflex and right coronary artery (RCA). The LAD had a proximal eccentric plaque which under intravascular ultrasound (IVUS) revealed a dissection. The patient underwent a coronary artery bypass grafting (CABG) and did well until discharge home. His postoperative course was complicated by new onset of atrial fibrillation/flutter. The patient was discharged to rehab with Eliquis, baby aspirin, Coreg, and Digoxin. Conclusion: Our case is unique in view of the unconventional age group, gender, and odd symptomatology. We hope to increase the awareness among medical practitioners for this high morbidity diagnosis if not identified correctly.

Cardiac magnetic resonance features of acute myocarditis presenting as acute coronary syndrome

Abstract Background Clinical presentation of myocarditis varies, one specific form of myocarditis appears with the clinical signs of acute coronary syndrome (ACS). Cardiac magnetic resonance (CMR) is an important method for assessing ventricular function and morphology, additionally provides accurate tissue specific and functional information of the heart. Aims Our aim was to investigate the characteristics, and prognosis of myocarditis presenting with ACS symptoms. Methods 113 patients with the clinical signs of ACS but nonobstructed coronary arteries in whom the CMR revealed acute myocarditis were included in our study. CMR was performed in acute phase and at 3–6-month follow-up. Left ventricular (LV) volumes, mass and strain parameters expressing myocardial deformity were determined. Additional images were taken to represent tissue specific information. Relationships between laboratory and CMR parameters were investigated. Parameters predicting changes in LV ejection fraction (LVEF) were analyzed by logistic regression. Results A total of 113 patients with myocarditis (98 males, 31±11 years) underwent acute and follow-up CMR. Sixty two patients reported fever or infection before the beginning of their complaints, most commonly gastroenteritis (33%) and pharyngitis (32%). The creatinine kinase MB value measured in the acute phase showed positive correlation with the extent of necrosis, and the global longitudinal- and circumferential strain. The extent of the LV necrosis showed negative correlation with LVEF and positive correlation with global circumferential strain (GCS) (p<0.05). On the control CMR examination LVEF and all global strain values improved, fibrosis persisted in 82% of cases but shrank (15±11 vs 5±4 g) and LV mass decreased (p<0.01) compared to the acute phase. Compared to the acute phase, 21% of the patients had lower LVEF on the follow-up CMR. Lower initial LVEF, worse acute GCS, and greater LV necrosis were independent predictors of LVEF reduction in the logistic regression model. During a median follow-up of 6-years of patients treated at our clinic (n=39) no patient suffered cardiac death, heart failure, or documented ventricular arrhythmia but 21% of them had recurrent myocarditis. Conclusion Myocarditis mimicking ACS affects predominantly young men and shows functional improvement and good prognosis on follow-up, but it may reoccur in some cases. The reduction of LV function on control CMR may be predicted by worse initial LVEF, GCS, and a larger LV scar. Strain, LGE in acute phase and follow-up Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277).

The Impact of Routine Cardiology Consultation on Critically Ill Patients with Elevated Troponin Levels

Cardiac troponin (cTn) is used to diagnose acute coronary syndrome (ACS). However, cTn can also be elevated in critically ill patients secondary to demand ischaemia or myocardial injury. In a meta-analysis of 20 different studies involving critically ill patients, cTn was found to be elevated in 43% of patients.1 Prior studies have evaluated the significance of cTn as a prognostic factor and mortality predictor in different clinical entities in intensive care units (ICU).2,3 However, the data on the impact of cardiology consultation on the outcomes in this specific context of critical care patients are limited. While prior studies have addressed such an impact on the outcomes among different groups of surgical patients,4,5 to the authors’ knowledge, no prior studies have examined that impact on critically ill patients with elevated cTn. This study aimed to investigate the impact of cardiology consultation on critically ill patients in the medical ICU with elevated cTn and no signs of ACS.

Advanced cardiac magnetic resonance imaging in takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC) is a reversible condition in which there is transient left ventricular (LV) dysfunction characterised most commonly by basal hyperkinesis and mid-apical LV ballooning and hypokinesia. It is said to be triggered by stress and mimics, such as acute coronary syndrome (ACS) clinically. Diagnosis is usually suspected on echocardiography due to the characteristic contraction pattern in a patient with symptoms and signs of ACS but normal coronary arteries on catheter angiography. Cardiac magnetic resonance (CMR), with its latest advancements, is the diagnostic modality of choice for diagnosis, prognosis and follow-up of patients. The advances in CMR (including T1, T2, ECV mapping and threshold-based late gadolinium enhancement (LGE) measurements have revolutionised the role of CMR in tissue characterisation and prognostication in patients with TC. In this review, we highlight the current role of CMR in management of TC and enumerate the CMR findings in TC as well the current advances in the field of CMR, which could help in prognosticating these patients.

Young male with chest pain and abnormal T-waves

Early recognition of ECG signs of acute coronary syndrome is essential for prompt treatment. But presentation with atypical ECG changes constitute a diagnostic challenge. We here report a case of 23-year-old male who presented with chest pain having atypical ECG changes with hyper-acute T waves called de Winters T wave. This is a rare presentation of patient with acute Left Anterior Descending artery occlusion. Some authors propose that de Winters pattern should be considered as “STEMI Equivalent”.

Endothelial Cells Strengthening: Improving Functions in Management of Acute Coronary Syndrome (A Double Blind Randomized Interventional Control Trial)

Objective: Endothelial dysfunction/injury is the main reason for Acute Coronary Syndrome (ACS). Current therapy includes antiplatelet, lipid lowering and thrombus removal by drugs/ intervention. Endothelial strengthening in management of ACS is less narrated in literature. This study describes endothelial strengthening and clinical outcome in ACS with Triphala powder, a mixture of Amla (Phyllanthus emblica), Harad (Terminalia chebula), and Behda (Terminalia bellirica). Methods: This is a double blind randomized interventional control trial. 80 cases coming to the emergency department were selected for study, divided into two groups. Group 1 (n=40, control), group 2 (n=40, study). Further subdivided into subgroup 1A and 2A ST-Elevation Myocardial Infarction (STEMI) and subgroup 1B and 2B Unstable Angina (UA). All subgroups were given clopidogrel, aspirin and atorvastatin and subjected to thrombolysis or Coronary Angiography (CAG) according to requirement. In addition study group was given Triphala powder 10 grams in a cup of water. Outcome was observed for relief in chest pain, ECG, Echocardiography changes at 50 minutes; (SSR) Sympathetic Skin Response was done initially. Statistical analysis was done by SPSS 20 software. Results: In intervention subgroups 2A and 2B there was significant relief in chest pain, settling down of ECG changes, and improvement in regional wall motion in echocardiography (p<0.001). There was increased sympathetic activity in all subgroups (spike response in SSR). Conclusion: Sudden mismatch in ATP (Adenosine Triphosphate) supply results in endothelial dysfunction. It occurs primarily due to increase in sympathetic discharge. Endothelial dysfunction results in UA/STEMI. Triphala increases ATP synthesis by increasing mitochondrial capacity to maximum; strengthens endothelium which behaves like normal endothelium and resolves symptoms and signs of ACS.

Knowledge and Socioeconomic Status as The Factors of Pre-hospital Delay in Patients with Acute Coronary Syndrome

Acute Coronary Syndrome (ACS) is a cardiac emergency condition that requires fast and precise action while a pre-hospital delay in a patient to come to the ED is still common. This pre-hospital delay is related to the socioeconomic and knowledge factor. The purpose of this study is to determine the relationship of socioeconomic and knowledge with the pre-hospital delay of ACS patients to come to Integrated Heart Service in Emergency Department of Sanglah General Hospital, Denpasar. This research is a quantitative research with cross-sectional design and purposive sampling as data collection technique with 292 patients. The results showed that 55.8% of patients have low socioeconomic status and there are 71.6% of patients who do not know ACS. The pre-hospital delay, in this case, is associated with low socioeconomic status and knowledge of ACS so that health workers need to provide counseling to patients and families about ACS signs and symptoms, healthy lifestyles, and the importance of coming to theemergency department when signs of ACS are felt.

Cardiac computed tomography in patients with symptomatic new-onset atrial fibrillation, rule-out acute coronary syndrome, but with intermediate pretest probability for coronary artery disease admitted to a chest pain unit

BackgroundAtrial fibrillation (AF) and coronary artery disease (CAD) may be encountered coincidently in a large portion of patients. However, data on coronary artery calcium burden in such patients are lacking. Thus, we sought to determine the value of cardiac computed tomography (CCT) in patients presenting with new-onset AF associated with an intermediate pretest probability for CAD admitted to a chest pain unit (CPU).MethodsCalcium scores (CS) of 73 new-onset, symptomatic AF subjects without typical clinical, electrocardiographic, or laboratory signs of acute coronary syndrome (ACS) admitted to our CPU were analyzed. In addition, results from computed tomography angiography (CTA) were related to coronary angiography findings whenever available.ResultsCalcium scores of zero were found in 25%. Median Agatston score was 77 (interquartile range: 1–270) with gender- and territory-specific dispersal. CS scores above average were present in about 50%, high (> 400)-to-very high (> 1000) CS scores were found in 22%. Overall percentile ranking showed a relative accordance to the reference percentile distribution. Additional CTA was performed in 47%, revealing stenoses in 12%. Coronary angiography was performed in 22% and resulted in coronary intervention or surgical revascularization in 7%. On univariate analysis, CS > 50th percentile failed to serve as an independent determinant of significant stenosis during catheterization.ConclusionsWithin a CPU setting, relevant CAD was excluded or confirmed in almost 50%, the latter with a high proportion of coronary angiographies and subsequent coronary interventions, underlining the diagnostic value of CCT in symptomatic, non-ACS, new-onset AF patients when admitted to a CPU.

Cardiac Biomarkers and Left Ventricular Hypertrophy in Asymptomatic Hemodialysis Patients.

BACKGROUND:Cardiac biomarkers are often elevated in dialysis patients showing the presence of left ventricular dysfunction. The aim of the study is to establish the plasma levels of high-sensitivity cardiac troponin T (hs TnT), precursor of B-natriuretic peptide (NT-proBNP) and high sensitivity C-reactive protein (hs CRP) and their relation to the presence of left ventricular hypertrophy (LVH) in patients undergoing hemodialysis without signs of acute coronary syndrome or heart failure.MATERIAL AND METHODS:We studied 48 patients - 26 men and 22 women. Pre and postdialysis levels of hs cTnT, NT-proBNP and hs CRP were measured at week interim procedure. Patients were divided in two groups according to the presence of echocardiographic evidence of LVH - gr A - 40 patients (with LVH), and gr B - 8 patients (without LVH).RESULTS:In the whole group of patients was found elevated predialysis levels of all three biomarkers with significant increase (p < 0.05) after dialysis with low-flux dialyzers. Predialysis values of NT-proBNP show moderate positive correlation with hs cTnT (r = 0.47) and weaker with hs CRP (r = 0.163). Such dependence is observed in postdialysis values of these biomarkers. There is a strong positive correlation between the pre and postdialysis levels: for hs cTnT (r = 0.966), for NT-proBNP (r = 0.918) and for hs CRP (r = 0.859). It was found a significant difference in the mean values of hs cTnT in gr. A and gr. B (0.07 ± 0.01 versus 0.03 ± 0.01 ng/mL, p < 0.05) and NT-proBNP (15,605.8 ± 2,072.5 versus 2,745.5 ± 533.55 pg/mL, p < 0.05). Not find a significant difference in hs CRP in both groups.CONCLUSIONS:The results indicate the relationship of the studied cardiac biomarkers with LVH in asymptomatic patients undergoing hemodialysis treatment.

It is high time we changed our habits. Chest pain: when ECG is not enough and echo makes the difference

Patients and methods Case History. A 31 years old man was in his office when he felt a sudden chest pain, localized in the left hemi-thorax and radiated to the back. In a few minutes an ambulance reached the place. The vital signs were good. A 12 lead ECG was registered and sent to the hub hospital. The answer was: “ECG normal. No signs of acute coronary syndrome. Transport the patient to the nearest local hospital”. Meanwhile the patient started feeling better. At the arrival to the emergency department the triagist assigned to the patient a green code (“will eventually need help but can wait for others”) and wrote: “ Non specific chest pain. Anxiety.” After two and half hours the poor guy called the doctor and told him that the pain was going much better and he wanted go home. The doctor took the patient in a room, switched on the echo machine and spent 2 minutes to make the right diagnosis. The heart was normal but was visualized only from the subcostal window. Para-sternal and apical windows were impossible to find. The reason was quite simple. A left pneumothorax was present, as documented by the absence of normal lung sliding and lung point sign. (see video clips 1-5) . A chest tube was then inserted and the problem solved. Results The clinical strategy was wrong. It is not enough to perform a 12 lead ECG and send it to a remote cardiologist to be sure that everything is right On the other side a point of care echography examination proved to be so powerful that in a very short time the right diagnosis was made [1,2]. It is not enough to exclude a STEMI by a 12 lead ECG.

The predictive potential of asymptomatic mild elevation of cardiac troponin I on mortality risk of stable patients with vascular disease

ObjectivesDue to improved analytical performance of the newest generation of troponin assays, several patients have mild elevations of this parameter. Nevertheless, they do not show any signs of acute coronary syndrome. We speculated whether non-acute cardiac troponin I (cTnI) concentrations may improve prediction of residual mortality risk in clinically stable outpatients with chronic vascular disease. Design and methodsWe followed 830 patients (mean age 65.2years) after myocardial infarction, coronary revascularization or first ischemic stroke (pooled Czech samples of EUROASPIRE III and EUROASPIRE-stroke surveys, interviewed in 2006/2007) in a prospective cohort study. In addition to standard protocol, troponin I and brain natriuretic peptide (BNP) was estimated from frozen samples. Vital status and declared cause of death from death certificates was registered to ascertain a 5-year all-cause and cardiovascular mortality. ResultsDuring a median follow up of 2050days (5.6years) 168 patients died. In the multivariate Cox proportional hazard model, cTnI≥0.03ng/mL independently predicted an all-cause 5-year mortality with HRR 1.76 (95% CI: 1.09–2.83). In the Cox model, the better predictor of mortality was BNP >150ng/L [HRR 3.47 (95% CI: 2.23–5.41)]. However, the combination of BNP with cTnI did not substantially improve its sensitivity or predictive power. ConclusionWe cannot confirm the utility of asymptomatic mild cTnI elevation as a tool to detect residual risk of stable patients with vascular disease. On the other hand, BNP seems to be more appropriate for this purpose.