Suspicion Of Acute Coronary Syndrome Research Articles

Broken Heart! Surprised to Know Why!

A 70-year-old female attended the emergency department with cardiac sounding chest pain, cough, new concerning ECG changes and recent history of long flight. Her cardiac enzymes were elevated raising the suspicion of Acute Coronary syndrome. She was taken for urgent percutaneous coronary intervention which did not reveal any significant obstructive coronary artery disease however, ventriculogram revealed severe left ventricular systolic dysfunction (LVSD) with typical apical akinesis resembling takatsubo. A transthoracic echocardiogram confirmed severely reduced left ventricular ejection fraction. In addition, she was also treated for pneumonia which was the possible trigger of the event.

Troponin efficacy in the diagnosis of acute coronary syndrome in patients with chronic renal failure.

There is no consensus on whether cardiac troponins with high reliability values should be different diagnostic criteria for acute myocardial infarction in patients with and without renal dysfunction. Although it is often emphasized that the etiology of elevated troponin levels in chronic kidney disease (CKD) remains unclear, elevated cardiac troponin (cTnT) levels have been associated with increased subclinical cardiac damage in these patient groups. In this study, we investigated the value of cTnT value in diagnosing acute coronary syndrome in CKD patients with high clinical suspicion of acute coronary syndrome and without acute ST segment elevation on electrocardiogram. The aim was to prevent cardiac ischemia from being overlooked in CKD patients. Coronary angiography revealed vessel occlusion in 192 patients, and the mortality rate after treatment decisions was 6.7%. The first measured troponin results showed a significant difference in patients who did not survive, indicating the prognostic value of troponin levels. Troponin values were compared with cardiovascular pathologies obtained by angiography, and elevated troponin levels strongly correlated with pathologic angiography results. The conclusion highlighted that despite prognostic uncertainties, biomarkers used for acute myocardial infarction diagnosis in patients with renal insufficiency are reliable in those with renal dysfunction. Elevated cTnT levels in CKD patients are considered a clear marker of cardiac ischemia, emphasizing the need for careful consideration of troponin values in this population.

AORTIC DISSECTION MISDIAGNOSED AS A HYPERTENSIVE CRISIS: A CASE REPORT

Acute aortic dissection is an uncommon disorder which can have fatal results in the event of treatment delay or misdiagnosis. This case examines a 61-year-old woman presenting with hypertension initially diagnosed as hypertensive crises relieved by antihypertensive medication. She was referred to the cardiology with clinical suspicion of acute coronary syndrome (ACS). However, she was later diagnosed with acute aortic dissection by CT-angiography and sent to surgical unit. Aortic dissection patient presents with many non-specific complaints so mostly misdiagnosed. This case report of a 61-years-old female with diagnosis of Stanford Type A acute aortic dissection misdiagnosed as a hypertensive crisis aiming towards highlighting this potentially fatal condition and importance of early diagnosis The early assessment and early CT-angiography can help in reaching the diagnosis so that early and accurate intervention can be done to save the life of patient from this fatal disease.

Predictors of major adverse cardiac events among patients with chest pain and low HEART score in the emergency department

AimFor patients who present to the emergency departments (ED) with undifferentiated chest pain, the risk of major adverse cardiac events (MACE) may be underestimated in low-HEART score patients. We aimed to identify characteristics of patients who were classified as low risk by HEART score but subsequently developed MACE at 6 weeks. MethodsWe studied a multiethnic cohort of patients who presented with chest pain arousing suspicion of acute coronary syndrome to EDs in the Netherlands and Singapore. Patients were risk-stratified using HEART score and followed up for MACE at 6 weeks. Risk factors of developing MACE despite low HEART scores (scores 0–3) were identified using logistic and Cox regression models. ResultsAmong 1376 (39.8%) patients with low HEART scores, 63 (4.6%) developed MACE at 6 weeks. More males (53/806, 6.6%) than females (10/570, 2.8%) with low HEART score developed MACE. There was no difference in outcomes between ethnic groups. Among low-HEART score patients with 2 points for history, 21% developed MACE. Among low-HEART score patients with 1 point for troponin, 50% developed MACE, while 100% of those with 2 points for troponin developed MACE. After adjusting for HEART score and potential confounders, male sex was independently associated with increased odds (OR 4.12, 95%CI 2.14–8.78) and hazards (HR 3.93, 95%CI 1.98–7.79) of developing MACE despite low HEART score. ConclusionMale sex, highly suspicious history and elevated troponin were disproportionately associated with MACE. These characteristics should prompt clinicians to consider further investigation before discharge.

Fibrinogen to albumin and C-reactive protein to albumin ratio can play an important role in catheterization decisions in COVID-19 pneumonia patients: A retrospective cohort study

Background/Aim: Elevated troponin T (Tp) is an important indicator in the decision to catheterize. However, since COVID-19 infection may cause elevated Tp, different biomarkers are needed to make the decision for catheterization. We aimed to investigate the importance of fibrinogen-to-albumin ratio (FAR) and CRP-to-albumin ratio (CAR) values in predicting obstructive coronary artery disease (CAD) in patients hospitalized with COVID-19 pneumonia and catheterized with the suspicion of acute coronary syndrome (ACS). Methods: In this retrospective cohort study, clinical, laboratory, catheterization, and electrocardiography data of all patients were analyzed. Patients with obstructive CAD were defined as the MI group, and patients with normal coronary arteries were defined as the normal group. Results: The MI group consisted of 49 patients (66.2%), and the normal group consisted of 25 patients (33.8%). Both FAR and CAR were significantly higher in the MI group (P=0.007; P=0.009, respectively). FAR and CAR were found to be independent predictors of obstructive CAD (95% CI 0.06 [0.000-34.052], P=0.024; 95% CI 1.35 [0.803-2.255], P=0.025, retrospectively). A cut-off value of 0.64 for FAR has an 80% sensitivity and a 40% specificity, and a cut-off value of 0.65 for CAR has an 83% sensitivity and a 41% specificity in predicting obstructive CAD. Conclusion: A decision for ACS and catheterization in patients hospitalized with COVID-19 pneumonia in the ICU should not be based only on elevated Tp, as it is useful to evaluate FAR and CAR values in addition to Tp.

Features of Diagnostics and Course of Hypertrophic Cardiomyopathy in Real Clinical Practice

Introduction and purpose. Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular (LV) wall thickening not associated with increased afterload (hypertension and aortic stenosis), is usually caused by mutations in sarcomeric protein genes, and is inherited in an autosomal dominant manner. Unlike HCM, myocardial hypertrophy in its phenocopies is associated with the accumulation of substances such as amyloid, glycogen, etc. in the myocardium. The aim of our work was to analyze the features of the diagnosis and course of HCM in real clinical practice. Material and methods. A retrospective analysis of medical records of 80 patients (56.3 % of men) discharged with a diagnosis of HCM from a multidisciplinary hospital in Moscow in the period from 2007 to 2021 was carried out. The diagnosis of HCM in all patients was established on the basis of echocardiography data. The median age (25th and 75th percentiles are indicated in brackets) was 57 (48.5; 63) years. The duration of hospitalization was 8 (6; 12.5) days. Results. The reason for hospitalization was angina syndrome in 35 %, suspicion of acute coronary syndrome in 16.3 %, paroxysmal atrial fibrillation (AF) in 11.3 %, decompensation of chronic heart failure in 11.3 %, syncope in 7.5 % %, hypertensive crisis in 3.8 %, coronary angiography in 3.8 %, pacemaker implantation in 2.5 %, consultation with an arrhythmologist in 2.5 %, implantation of a cardioverter-defibrillator in 1.2 %, medical examination to resolve the issue of fitness for military service in 1.2 %, acute cerebrovascular accident in 1.2 %, hypotension in 1.2 %, drug bradycardia in 1.2 % of patients. Before hospitalization, a history of myocardial infarction was diagnosed in 15 %, arterial hypertension — in 53.8 %, chronic heart failure — in 77.6 %, chronic kidney disease — in 21.3 % of patients. Prior to the analyzed hospitalization, a history of myocardial infarction was diagnosed in 15 %, arterial hypertension in 53.8 %, chronic heart failure in 77.6 %, chronic kidney disease in 21.3 % of patients. LV wall thickness ≥1.5 cm was detected in 91.2 %, symmetrical form of hypertrophy — 22.1 %, apical — 5.2 %, papillary muscle hypertrophy — 1.3 %, interventricular septum — 71.4 % of patients. Permanent obstruction of the LV outflow tract (LVOTO) was detected in 62.8 % (9.0 % of patients had a history of septal reduction), transient LVOTO — in 1.3 %, non-obstructive HCM — in 35.9 %. The ejection fraction (EF) of the LV (according to Simpson) was 63 (55-70) %, CHF with reduced LV EF <40 % was detected in 3.8 %, with a moderately reduced LV EF (40-49 %) — in 5 %, with preserved LV EF — in 68.8 % of patients. Anterior systolic movement of the anterior leaflet of the mitral valve occurred in 47.5 %, prolapse of the anterior leaflet of the mitral valve was described in 7.14 %. Mitral regurgitation was registered in 75 % of patients. 45 % of patients with HCM suffered from AF: permanent 15 %, paroxysmal 23.8 %, persistent 6.2 % of patients. During hospitalization, ventricular tachycardia was registered in 7.5 %, supraventricular tachycardia — 3.8 %, conduction disturbances were noted in 36.3 % of patients, of which atrioventricular block in 6.3 %, blockade of the right bundle branch block in 21.3 %, left bundle branch block in 15 %, and Wolff-Parkinson-White syndrome in 1.3 % . Implantation of a pacemaker in history was in 5 %, including in connection with MorgagniAdams-Stokes attacks — in 3.8 % of patients. During a median follow-up of 87 (interquartile range 45–131.5) months, 13.8 % of patients with HCM died. In deceased patients, LVOTO was significantly more common (in the dead 100 %, in the living 58.2 %, p = 0.006) and AF (in the dead 72.7 %, in the living 40.6 %, p = 0.047). Genetic testing and exclusion of HCM phenocopies was not performed during hospitalization and was not recommended for any patient. Conclusion. In real clinical practice, in most cases, only phenotypic diagnosis of HCM is carried out according to echocardiography, and screening for genetic mutations and HCM phenocopies is not performed. It is necessary to widely introduce genetic testing and screening for HCM phenocopies for the timely diagnosis of pathology that requires the appointment of specific pathogenetic therapy to improve the prognosis of patients

P333 A RARE CAUSE OF SHOCK: AORTO–PULMONARY FISTULA AS AORTIC ANEURYSM COMPLICATION

Abstract Clinical case A 69–year–old man with right shoulder discomfort, malaise for one hour and hemodynamic instability was admitted to our Emergency Department (ED). The patient had a history of arterial hypertension, diabetes, renal failure on peritoneal dialysis and ischemic cardiomyopathy with preserved ejection fraction treated by angioplasty and stent implantation on right coronary. At first medical contact out of hospital the patient appeared confused with severe hypotension (BP 70/40 mmHg). ECG transmitted to our Cardiology Unit showed sinus tachycardia with repolarization abnormalities consistent with diffuse ischemia. The patient was centralized with clinical suspicion of acute coronary syndrome complicated by cardiogenic shock. In ED, BP was 65/35 mmHg. On physical examination extremities were cold and mottled, crackles in the lower lung zones and turgid jugulars were present. Pulses were weak but present. ECG was repeated and no evolutive signs were detected. Echocardiography finding were: not dilated left ventricle with global systolic function at the lower limits, moderate aortic insufficiency, right ventricle with dimensions at the upper limits and hypocontractile, moderate tricuspid regurgitation, inferior vena cava dilated with preserved inspiratory collapse. Aortic root was non dilatated but aortic arch was 55 mm with no images of dissection flap. At blood test lactates were 4,2 with metabolic acidosis, troponin was just above the upper limit, inflammation indices were negative and electrolytes were in range. Vasopressor support with norepinephrine was started. With the high suspicion of acute aortic disease, CT angiography was performed showing a voluminous aneurysm of the aortic arch of 70x56 mm rupturing into the left pulmonary artery (Figure 1,2). Concomitant bilateral iliac artery dissection was detected. Cardiac and Vascular Surgeons were promptly alerted to plan tan emergent surgical intervention whose complexity was increased by the difficult vascular cannulation for iliac dissection. However, the patient‘s hemodynamic rapidly deteriorated requiring intubation and, after subsequent episodes of cardiac arrest in pulseless electrical activity (PEA), his death was assessed.

Correlation Between Coronary Artery Calcium Score and Triglyceride-Glucose Index in Post-menopausal Women.

To clarify the correlation between coronary artery calcium score (CACS) and triglyceride-glucose (TyG) index in post-menopausal women. Post-menopausal women who underwent computed tomography angiographywith the suspicion of acute coronary syndrome were included in the study. Patients were categorized into three groups (CACS < 100 as group 1, CACS = 100-300 as group 2, and CACS > 300 as group 3). Groups were compared with regardto demographic characteristics, laboratory test outcomes, electrocardiogram findings, and the TyG index. The study was conducted by examining the data of 228 patients. Median TyG index was 9.0 and median CACS was 79.5. The median age was significantly lower in group 1 (p = 0.001). Diabetes mellitus rate and smoking rate were higher in group 3 compared to the other groups (p = 0.037 and p = 0.032). The glucose level was significantly higher for group 3 (p = 0.001). Additionally, the TyG index was 9.3 in group 3 and was statistically significantly higher than the values in group 1 and group 2 (8.9 and 9.1, respectively) (p = 0.005). There was a moderate correlation between CACS and age (correlation coefficient (CC): 0.241, p = 0.001). Also, there was a significant correlation between glucose level and CACS (CC: 0.307, p = 0.001). A high correlation was found between the TyG index and CACS (CC: 0.424, p = 0.001). Our study demonstrated for the first time that there was a strong correlation between the TyG index and CACS in post-menopausal patients. In addition, patients with increased age, patients with higher glucose levels, and diabetic patients had significantly higher CACS.

Diagnoses and Outcomes of Patients with Suspicion of Acute Coronary Syndrome and Raised High Sensitive Troponin I: A Single Center Study from Pakistan.

Objectives Troponins are classically raised in acute coronary syndrome (ACS) although other cardiovascular and non-cardiovascular causes are recognized. We aimed to see the association of high sensitivity (Hs) Troponin I values exceeding the sex-specific 99th percentile upper reference limit (URL) with diagnoses, emergency department (ED) outcomes, 30-day outcomes of admitted patients and predictors of ACS in both genders. Materials and Methods A retrospective study of all patients presenting to the emergency department from January 2019 to April 2021 with suspicion of ACS and Hs-Troponin I values greater than the sex-specific 99th percentile URL. Statistical Analysis SPSS version 24 was used, Pearson's chi-square tests, Fisher's exact test, Kruskal-Wallis test, Mann-Whitney U test, and odds ratios, including the 95% confidence intervals, for each characteristic were used for analysis. A p -value of < 0.05 was considered significant. Results There were a total of 5,982 patients (3,031 males, 2,951 females), out of which 878 patients were admitted under the cardiology specialty. In patients who were admitted to the ward, mortality was higher in females (8.2%) with less than a 10-fold rise in Hs-Troponin I while similar in both genders (7.6%) in patients with Hs-troponin I greater than 10-fold of sex-specific 99th percentile URL. Raised low-density lipoprotein-cholesterol was a significant factor associated with 2.4 times higher odds of ACS. Conclusion Women with Hs-Troponin values up to 10 times the URL, i.e., 15.6-160 ng/L have higher mortality than their male counterparts. LDL-cholesterol is a significant risk factor for ACS which should be controlled for its prevention.

Renal angina index as a predictor of acute kidney injury in patients admitted to the emergency department

Acute renal failure (ARF) is a syndrome that occurs due to multiple causes of injury and is characterized by an abrupt decrease in glomerular filtration rate. The concept of renal angina is made to highlight the characteristics of renal injury, as an analogy to the concept of angina pectoris, which is used to increase the suspicion of acute coronary syndrome in cardiology. Material and methods: Prospective, observational and descriptive study. The present study will be carried out on patients admitted and attended in the Emergency Department of the Hospital de Alta Especialidad (UMAE) No. 14. Adolfo Ruiz Cortínez from September 1 to November 30, 2022. The data described in the data collection instrument will be collected in order to later concentrate them in a database for analysis. Results: Of the 73 patients who entered the study, 42 patients were male, the mean age was 55 years, the minimum 18 and the maximum 75, the mode was 70 years. Of the patients included 49 were diabetic and of these 38.36% were male, only 11 had sepsis without much difference between the two sexes, representing 15.07% of the total number of patients. Of the total number of patients only 12 were admitted to the intensive care unit, 16.44%; the male sex was the most prevalent group, only 23.9% of the total number of patients required mechanical ventilation and 10.96% required vasopressor (Of the total number of patients only 15 (20.5%) had acute renal injury and of these the most affected age group was 61 to 80 years old). Conclusion: The percentage of patients with a positive renal angina index (&gt;8) who had AKI was 100% of the 73 patients only 15 developed AKI. Sepsis, vasopressor use and mechanical ventilation did not have a significant value for the development of AKI within this study in comparison to the study "Renal angina: "The beginning of the end" where out of 95 patients included in their study, sepsis, vasopressor use and mechanical ventilation did have a significant value for the development of AKI.

The impact of prehospital blood sampling on the emergency department process of patients with chest pain: a pragmatic non-randomized controlled trial.

In patients with chest pain who arrive at the emergency department (ED) by ambulance, venous access is frequently established prehospital, and could be utilized to sample blood. Prehospital blood sampling may save time in the diagnostic process. In this study, the association of prehospital blood draw with blood sample arrival times, troponin turnaround times, and ED length of stay (LOS), number of blood sample mix-ups and blood sample quality were assessed. The study was conducted from October 1, 2019 to February 29, 2020. In patients who were transported to the ED with acute chest pain with low suspicion for acute coronary syndrome (ACS), outcomes were compared between cases, in whom prehospital blood draw was performed, and controls, in whom blood was drawn at the ED. Regression analyses were used to assess the association of prehospital blood draw with the time intervals. Prehospital blood draw was performed in 100 patients. In 406 patients, blood draw was performed at the ED. Prehospital blood draw was independently associated with shorter blood sample arrival times, shorter troponin turnaround times and decreased LOS (P<0.001). No differences in the number of blood sample mix-ups and quality were observed (P>0.05). For patients with acute chest pain with low suspicion for ACS, prehospital blood sampling is associated with shorter time intervals, while there were no significant differences between the two groups in the validity of the blood samples.

Electrocardiographic Analysis of Patients with Suspicion of Acute Coronary Syndrome in Yaounde, Cameroon

Electrocardiographic Analysis of Patients with Suspicion of Acute Coronary Syndrome in Yaounde, Cameroon

Acute Myocardial Infarction Following the Consumption of Energy Drink in a 28-Year-Old Male: A Case Report.

Excessive intake of energy drinks is increasingly realized to have a detrimental effect on platelet and endothelial functions with resultant hypercoagulable state and consequently increased risk of thrombosis. A 28-year-old man of African origin presented to the emergency department with an 8-hour history of retrosternal chest pain. His symptoms started 4 hours after consuming 5 cans (1250 cc) of an energy drink whose principal ingredients are caffeine, taurine, sugar, and glucuronolactone. His past medical and surgical history was unremarkable, and he had no apparent cardiovascular risk factor. Physical examination was unremarkable; however, electrocardiogram and echocardiogram showed features of anterolateral myocardial infarction (STEMI). Catheterization confirmed a 100% thrombotic occlusion of the proximal left anterior descending (LAD) artery and revascularization with a drug-eluting stent was successful. In conclusion, sudden onset of chest pain following energy drink consumption should raise an index of suspicion for acute coronary syndrome. With the preponderance of data suggesting increased incidence of energy drink-associated coronary events, it is prudent to advocate a limited consumption of such beverages.

1155 CORONARY ARTERY DISEASE AND SEVERE AORTIC STENOSIS IN THE COVID-19 ERA: A CASE REPORT

Abstract An 81-years-old with a history of hypertension, dyslipidemia, and chronic ischemic heart disease with prior stent implantation of right coronary artery in 2011. Due to its poor compliance, no recurrent symptoms, and, finally, the COVID-19 pandemic, the patient did not perform any cardiological follow-up during these years. Unfortunately, the last six months he has reported the onset of dyspnea and typical angina due to moderate efforts, undervalued by the patient. Because of the rapid worsening of dyspnea and typical angina in the last 5 days, he went to the local emergency department (ED). The role in/role out routine exams performed in the ED documented a COVID-19 infection. At the ED, his vital signs were normal, with a blood pressure of 135/75 mm Hg, heart rate of 74 regular beats/min, body temperature of 36.5 °C, oxygen saturation of 97% in ambient air, and respiratory rate of 16/min. Of note, the chest x-ray was normal, as well as no alterations were documented at the CT scan performed a few hours later. First-line blood sample tests were within range except for Hb 10 mg/dl. Therefore, a cardiological evaluation was requested. Electrocardiogram (ECG) showed inverted T-waves in V1-4 leads, and echocardiography showed normal left ventricular ejection fraction (FE 55% Simpson), left ventricular anterolateral wall hypokinesia, and severe aortic stenosis (V max 4.78 m/s, Gr max 4.78 m/s, Gr medium 59 mmHg). Since myocardial necrosis enzymes were increased (T-hs 118.7 ng/dl; CK-MB 6.3 ng/L; NT-ProBNP 761 ng/dl), leading to the suspicion of acute coronary syndrome the patient underwent coronary angiography, showing critical stenoses of the left descending artery (LAD), circumflex (LCX), I obtuse marginal (IOM), and patent stent of the right coronary artery. Therefore, the Heart team deemed the patient at high operatory risk choosing, in agreement with the patient, for a percutaneous coronary intervention (PCI) followed by TAVR. Accordingly, the patients underwent PCI of LAD with the implantation of a Xience-Serra 3.0×15 mm and PCI of LCX with the implantation of an Onyx 2.75×18 mm stent. After COVID -19 resolution, which happen 7 days later, the patient was moved to our cardiology department. Two days later in the same procedure, we performed the first PCI of I-OM with the implantation of a Xience Sierra 3.0×18 mm stent following a TAVI with the implantation of Evolute Pro valve 29 mm. The post-procedure echocardiogram showed an optimal valve position with a transvalvular mean pressure gradient of 4 mm Hg. After six days post-TAVI, for a complete atrioventricular block, the patient also underwent a pacemaker implantation. The patient was finally discharged after 10 from TAVI. Discussion This case report offers several foods for thought. First, the COVID-19 pandemic has negatively affected primary and secondary prevention, even for patients affected by cardiovascular disease. Our patient has postponed clinical checks even when the symptoms reappeared, also because of the concerns lead by the COVID-19 pandemic. Second, completeness and timing of coronary disease revascularization, which in this case was staged and performed before TAVI. Finally, the late occurrence of advanced heart block requiring PM implantation. For instance, in an era of fast-track TAVI, more studies are warranted to identify patients who are at higher risk of late PM implantation.

Long Term Follow up of CT Angiography in Low to Intermediate Risk Patients of Suspected Acute Coronary Syndrome (ACS)

Objective: To assess long term outcomes of CT Angiography in low to intermediate risk patients of suspected ACS and to assess if CT-angiography is a safe modality to discharge patients with clinically non-significant coronary artery disease.&#x0D; Study Design: Descriptive cross-sectional study Place and Duration of Study: Tertiary Cardiac Center in Rawalpindi, from Dec 2021 to Apr, 2022.&#x0D; Methodology: A total of (n=600) patients who presented with ischemic sounding chest pain and suspicion of acute coronary syndrome (ACS) were selected via consecutive sampling technique and were followed up to 5-months. Patients' demographics, CT-Angiography findings and their outcomes were noted on data collection sheet. Data was analyzed by SPSS version-23. Descriptive statistics were run to present categorical data in frequencies and percentages. Chi-square and Fisher Exact Test was applied to find the association between study variables at 95% CI and 5% margin of error (α=5%).&#x0D; Results: Out of (n=600) suspected cases of acute coronary syndrome (ACS), n=352 (58.7%) were males and n=248 (42.3%) were females. As a result of follow-up of the ptaients, cases that represented in emergency department, readmission cases and revascularized cases were (n=10,4, 1;1.7%, 0.7%, &amp; 0.2%) respectively. Frequency of ACS and STEMI patient was 0.0%. Mortality rate was 0.0%. There was significant association of comorbids with CT-angiography findings and the findings with outcome variables (p&lt;0.05) except revascularization (p&gt;0.05).&#x0D; Conclusion: In low to intermediate risk patients of suspected ACS, discharge decision from emergency department based on CT-angiography findings is safe and shows excellent long-term outcomes with no major adverse cardiac event (MACE) on long-term follow-up.

Exploring adherence to an early rule-out pathway for myocardial infarction in the emergency department using mixed-methods

Abstract Background Incorporating a high-sensitivity cardiac troponin assay into a care pathway for the assessment of suspected acute coronary syndrome has enabled myocardial infarction to be ruled out earlier. Purpose Using mixed methods, we explored adherence to an early rule-out pathway in the HiSTORIC (High-Sensitivity Cardiac Troponin on Presentation to Rule Out Myocardial Infarction) randomised controlled trial. Methods In 16,972 consecutive patients we evaluated clinician adherence to an early rule-out pathway for the assessment of suspected acute coronary syndrome. Adherence was defined in patients with presentation cardiac troponin I concentrations &amp;lt;5ng/L and symptom onset &amp;gt;2 hours from presentation without serial troponin testing (type 1 adherence); presentation troponin &amp;lt;5ng/L and symptom onset ≤2 hours from presentation with serial testing (type 2 adherence); or presentation troponin between 5ng/L and sex-specific 99th centile with serial testing (type 3 adherence). Semi-structured interviews were conducted with 23 clinicians to aid interpretation of the quantitative analysis. Qualitative data were coded and organized into themes. Results In patients with troponin &amp;lt;5ng/L presenting &amp;gt;2hr from symptom onset, adherence was achieved in 81% of patients. In patients presenting ≤2hr from symptom onset, 35% of patients had a second troponin test. In patients with an initial troponin concentration between 5ng/L and the 99th centile, 65% of patients had a second troponin test. Compared to patients managed by clinicians who were adherent to the pathway, patients with troponin over-testing (type 1 non-adherence) were more likely to be older (mean age 52±16 years versus 58±14, P&amp;lt;0.001) and have a history of coronary disease (11% versus 27%, P&amp;lt;0.001). In contrast, patients with under testing (type 2 non-adherence) tended to be younger (mean age 49±16 versus 63±15, P&amp;lt;0.001), female (50% versus 37%, P&amp;lt;0.001) and have lower presentation troponin levels (median concentration 1.0ng/L IQR 1.0 to 2.0, versus 5.0ng/L IQR 2.0–10.0) compared to those in whom testing was performed according to pathway recommendations. Semi-structured interview data revealed how pathway adherence was influenced by five main themes: guideline characteristics, patient characteristics, the healthcare practitioner, the healthcare system and scientific evidence. Clear visual pathway layout was fundamental in achieving optimal adherence. Strong clinical suspicion of acute coronary syndrome promoted repeat troponin testing and deviation from the pathway was felt to be justifiable by more senior clinicians. Conclusion This analysis revealed successful implementation of the early rule-out pathway with interview data aiding interpretation of trial data. Younger patients with lower troponin concentrations were less likely to receive pathway recommended serial troponin testing. Clinical judgement is one of the main reasons for discontinuation of pathway recommendations. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Concomitant Pulmonary Embolism and Anterior Myocardial Infarction as the Initial Presentation of Antiphospholipid Syndrome

Antiphospholipid antibody syndrome (APLS) is a systematic autoimmune disease characterized by thrombotic events, including arterial, venous, and microvascular complications. Often, patients initially present with either arterial or venous thromboembolism but rarely present simultaneously with arterial and venous thromboembolic events.1Garcia D. Erkan D. Diagnosis and management of the antiphospholipid syndrome.N Engl J Med. 2018; 378: 2010-2021https://doi.org/10.1056/NEJMra1705454Crossref PubMed Scopus (321) Google Scholar We report an unusual case of a 21-year-old woman who presented to our hospital with chest pressure secondary to a concomitant pulmonary embolism (PE) and anterior myocardial infarction. A 21-year-old woman with no significant past medical history, only on oral contraceptive pills, presented to the hospital with complaints of 4 days of progressively worsening substernal chest pressure associated with dizziness and lightheadedness. In the emergency department, she was mildly tachycardic but otherwise hemodynamically stable. An electrocardiogram revealed sinus rhythm with anterior T-wave abnormality (Figure 1A). Initial laboratory testing revealed mild thrombocytopenia and elevated troponin I levels of 9.63 ng/mL. A computed tomography angiography of the chest revealed small nonocclusive emboli in the right lower lobe pulmonary artery (Figure 1B); therefore, venous duplex ultrasound of the lower extremities was performed, which showed no evidence of deep vein thrombosis. Anticoagulation with intravenous heparin was started, and the patient was admitted to the floor with telemetry monitoring. Early morning on day 2 of hospitalization, the patient reported worsening chest pain, and the troponin I levels subsequently trended up to 20.08 ng/mL. A repeat electrocardiogram showed subtle ST-segment elevations, with QS complexes in the anterior leads. A bedside transthoracic echocardiogram revealed hypokinesis of the anterior wall and a severely reduced left ventricular ejection fraction. The patient was transferred to the cardiac catheterization laboratory for emergency coronary angiography. Coronary angiography showed 100% occlusion of the left anterior descending artery (LAD) at the ostium. The right coronary artery was patent with extensive right to left collaterals supplying the LAD. A filling defect was noted in the proximal LAD, consistent with a thrombus. Thrombus aspiration was performed using the Indigo System CAT RX (Penumbra, Inc), followed by the placement of a single 3.0 × 18 mm XIENCE Skypoint (Abbott) drug-eluting stent in the proximal LAD, with resultant TIMI-3 flow. A formal transthoracic echocardiogram demonstrated a left ventricular ejection fraction of 35%-40%, with a large left ventricular thrombus. Subsequent testing revealed antibody positivity for APLS, with elevated titers of anticardiolipin, lupus anticoagulant, and beta-2-glycoprotein antibodies. The patient was discharged on aspirin, ticagrelor, and warfarin along with high-intensity statin therapy, a low-dose angiotensin-converting enzyme inhibitor, and β-blocker therapy. The patient’s oral contraceptive pills were discontinued, and the patient was counseled about the use of an alternative nonhormonal mode of contraception. Approximately 12 weeks after discharge, the patient’s outpatient laboratory reports showed persistent elevation of all 3 antibodies, thus establishing the diagnosis of triple-positive APLS. Massive or submassive PEs can cause acute right heart strain and result in a small elevation of troponin levels. However, a high initial troponin level in patients with a nonmassive PE should raise suspicion of acute coronary syndrome, even with a low pretest probability of acute coronary syndrome.2Meyer T. Binder L. Hruska N. Luthe H. Buchwald A.B. Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction.J Am Coll Cardiol. 2000; 36: 1632-1636https://doi.org/10.1016/S0735-1097(00)00905-0Crossref PubMed Scopus (277) Google Scholar,3Kilinc G. Dogan O.T. Berk S. Epozturk K. Ozsahin S.L. Akkurt I. Significance of serum cardiac troponin I levels in pulmonary embolism.J Thorac Dis. 2012; 4: 588-593https://doi.org/10.3978/j.issn.2072-1439.2012.10.13Crossref PubMed Scopus (15) Google Scholar Therefore, the detection of a high initial troponin level should be followed by serial troponin level testing and electrocardiograms, an echocardiogram, and an ischemic evaluation. Patients with APLS may present with complications of arterial or venous thromboembolism; however, they rarely present with both simultaneously. Myocardial infarction and PE associated with APLS have been extensively reported in the literature; however, there are limited reports regarding the incidence of simultaneous events as the initial presentation of APLS.4Nazir S. Tachamo N. Lohani S. Hingorani R. Poudel D.R. Donato A. Acute myocardial infarction and antiphospholipid antibody syndrome: a systematic review.Coron Artery Dis. 2017; 28: 332-335https://doi.org/10.1097/MCA.0000000000000476Crossref PubMed Scopus (32) Google Scholar A high index of suspicion should be maintained for APLS in young patients presenting with concomitant arterial and venous thromboembolic events because the timely diagnosis and initiation of anticoagulation can prevent further thromboembolic complications. Further research is required regarding optimal anticoagulation strategies after percutaneous coronary interventions in patients with hypercoagulation disorders. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

SVEAT score outperforms HEART score in patients admitted to a chest pain observation unit.

BACKGROUNDTimely and accurate identification of subgroup at risk for major adverse cardiovascular events among patients presenting with acute chest pain remains a challenge. Currently available risk stratification scores are suboptimal. Recently, a new scoring system called the Symptoms, history of Vascular disease, Electrocardiography, Age, and Troponin (SVEAT) score has been shown to outperform the History, Electrocardiography, Age, Risk factors and Troponin (HEART) score, one of the most used risk scores in the United States. AIMTo assess the potential usefulness of the SVEAT score as a risk stratification tool by comparing its performance to HEART score in chest pain patients with low suspicion for acute coronary syndrome and admitted for overnight observation.METHODSWe retrospectively reviewed medical records of 330 consecutive patients admitted to our clinical decision unit for acute chest pain between January 1st to April 17th, 2019. To avoid potential biases, investigators assigned to calculate the SVEAT, and HEART scores were blinded to the results of 30-d combined endpoint of death, acute myocardial infarction or confirmed coronary artery disease requiring revascularization or medical therapy [30-d major adverse cardiovascular event (MACE)]. An area under receiving-operator characteristic curve (AUC) for each score was then calculated. C-statistic and logistic model were used to compare predictive performance of the two scores.RESULTSA 30-d MACE was observed in 11 patients (3.33% of the subjects). The AUC of SVEAT score (0.8876, 95%CI: 0.82-0.96) was significantly higher than the AUC of HEART score (0.7962, 95%CI: 0.71-0.88), P = 0.03. Using logistic model, SVEAT score with cut-off of 4 or less significantly predicts 30-d MACE (odd ratio 1.52, 95%CI: 1.19-1.95, P = 0.001) but not the HEART score (odd ratio 1.29, 95%CI: 0.78-2.14, P = 0.32). CONCLUSIONThe SVEAT score is superior to the HEART score as a risk stratification tool for acute chest pain in low to intermediate risk patients.

ESSENTIAL THROMBOCYTHEMIA AS A CAUSE OF SEVERE CHEST PAIN: CASE REPORT

Essential thrombocythemia is a myeloproliferative dise­ase that is characterized by elevated platelet count, speci­fic changes of megakaryocyte lineage in bone marrow as well as non-specific clinical symptoms. This case report presents a 40-year-old female complaining of episodic chest pain and shortness of breath. Cardiologists ruled out cardiovascular pathologies after performing electrocar­diography (ECG), echocardiography, a complete blood count, and a treadmill test. After a recurring episode of chest pain, the patient was sent to the emergency depar­tment on suspicion of acute coronary syndrome or pul­monary embolism but routine tests (ECG, troponin I, D-dimers, computed tomography pulmonary angiography) excluded these diagnoses. Essential thrombocythemia was diagnosed based on bone marrow trephine biopsy results and positive genetic testing for JAK2 mutation. The patient was assigned to the low-risk group, there­fore, she received aspirin therapy as well as correction of cardiovascular risk factors.

High-Sensitivity Cardiac Troponin I Levels Below 99th Percentile Upper Reference Limit in Patients Presenting with Suspicion of Acute Coronary Syndrome (ACS) in Emergency Department at a Tertiary Care Hospital in Karachi, Pakistan.

Troponin I levels are biomarkers of choice for diagnosis of acute myocardial infarction (AMI). However, prognostic significance of values below the 99th percentile upper reference limit (URL) in patients presenting with symptoms suggestive of Acute coronary syndrome (ACS) need further evaluation. The objectives of the study were to find the association of High sensitivity (hs)-Troponin I values below 99th percentile URL with age and the Emergency Department (ED) outcome, to determine single cut-off for safe discharge of these patients from the ED and to determine the 30-day outcome of the patients admitted under cardiac speciality. This is a retrospective study of patients presenting with suspicion of ACS in the ED between January 2019 till April 2021 and hs-Troponin I values below 99th percentile URL. Among 15,441 patients, 8034 (52%) were males and 7407 (48%) were females. 9677 (63%) of the patients had hs-Troponin I values < 5 ng/L while 5764 (37%) had values between 5 ng/L and 99th percentile URL. Higher hs-Troponin I values were associated with a worse ED outcome. Serial troponin I levels were performed in only 2.4% of the cohort. Receiver operating characteristics for ACS demonstrated an AUC of 0.84 at a cut off value of 12.75 ng/L, with sensitivity (76.9%) and specificity was 75.1%. The 30-day outcome of the patients admitted under cardiac speciality revealed no mortality in either group. An overall single cut-off value of 12.75 ng/L can be used in our population for ruling our ACS provided it is unaccompanied by other supportive clinical and ECG findings.