Suspicion Of Acute Coronary Syndrome Research Articles

Prevalence of acute coronary syndrome among patients presenting with chest pain in a tertiary care cardiac centre

Background and aims: Chest pain is one of the common reason for hospital visit. Acute coronary syndrome is an important cause of chest pain. We aimed to study the prevalence of acute coronary syndrome among patients presenting with the chest pain and its association with common cardiovascular risk factors.
 Methods: Observational study conducted at Shahid Gangalal National Heart Centre from 20th January 2022 to 25th March 2022 enrolling 112 participants consecutively. Participants were interviewed focusing history of hypertension, diabetes, smoking and nature of chest pain. The diagnosis of participants whether it was acute coronary syndrome or not were recorded. Prevalence of acute coronary syndrome was calculated. Linear regression analysis was done to see the correlation with tested variables. 
 Results: Mean age was 53.83±15.23 years. Seventy-five (66.96%) were male. Forty-two (37.5%) were hypertensive, 30 (26.78%) were diabetes and 26 (23.21%) were smoker. Fifty-six (50%) had nonspecific chest pain, 35 (31.25%) had atypical chest pain and 21 (18.75%) had typical chest pain. Among the participants 38 (33.93%) had acute coronary syndrome. Acute coronary syndrome showed positive correlation with age, gender, nature of chest pain, hypertension and smoking.
 Conclusion: Acute coronary syndrome was one of the common cause of chest pain among participants. Age, gender, nature of chest pain, hypertension and smoking showed positive correlation with it. Patients with these risk factor needs strong suspicion of acute coronary syndrome and further workup for prompt diagnosis and management.

Acute coronary syndrome in the prehospital phase and in the emergency department

Acute coronary syndrome is the most common reason for the deployment of emergency medical services in Germany. Approximately 20-25% of all medical emergencies result from the indications for the suspicion of acute coronary syndrome. Asubstantial proportion of the total mortality rate is observed in the preclinical phase. Consequently, targeted diagnostics and treatment are of particular importance in this early phase. This article provides recommendations for the approach to patients with acute coronary syndrome in the prehospital phase and in the emergency department.

P411 MINOCA OR NOT MINOCA? THE DECISIVE ROLE OF CARDIAC MAGNETIC RESONANCE IN THE DIFFERENTIAL DIAGNOSIS OF MYOCARDIAL DAMAGE

Abstract Cardiac MRI can facilitate the differential diagnosis of myocardial damage in patients without coronary artery disease. Our case report is about a 50–year–old man who was admitted to the Emergency Department of the Maggiore Hospital in Bologna in October 2021 for oppressive chest pain at rest; previously he had experienced a similar episode but of minor intensity. He had not previous medical records. When the patient arrived at the emergency department chest pain had regressed, blood pressure was elevated (170/110 mmHg). The ECG showed sinus tachycardia at 100 bpm without electrocardiographic abnormalities suggestive of acute ischemia. Cardiac biomarkers were elevated (hsTnI 312 ng / L –> 975 ng / L – n.v. <19.8 ng / L); blood gas analysis showed pH 7.42, pO2 47 mmHg and pCO2 33 mmHg. Chest CT scan excluded pulmonary embolism and acute aortic syndrome. The patient was transferred to Cardiology Ward in the suspicion of acute coronary syndrome, where echocardiogram showed normal biventricular volumes, mild wall hypertrophy and hypokinesia of the lower middle wall (EF 52%). Coronary angiography didn’t showed any obstructive stenosis in any epicardial vessels. In consideration of the clinical presentation and instrumental evidences, the patient was discharged with a diagnosis of myocardial infarction with non–obstructive coronary arteries (MINOCA), but a cardiac MRI was scheduled in the post–discharge to clarify its genesis. MRI didn’t showed any areas of signal hyperintensity, any perfusion deficits in the first pass study and any areas of late gadolinium enhancement (LGE). Those images permitted to exclude areas of necrosis or inflammation, orienting the diagnosis to myocardial damage during hypertensive crisis. Therefore, the antiplatelet therapy recommended at discharge was suspended. In this case report, cardiac magnetic resonance showed that it can improve the etiological diagnosis of MINOCA, allowing for better clinical and therapeutic management.

Diagnostic Efficacy of Perfusion Index and Pleth Variability Index in Patients Admitted to the Emergency Department with Chest Pain

Objective: Acute coronary syndrome (ACS) is the leading cause of death worldwide. Therefore, rapid differential diagnosis and treatment is required in patients who present to the emergency department (ED) with chest pain. In this disorder, in which rapid diagnosis and treatment are life-saving, novel diagnostic methods are being proposed every day. This study aimed to reveal the contributions of the Perfusion Index (PI) and the Pleth Variability Index (PVI) measurements to management of patients with chest pain.
 Materials and Methods: PI and PVI measurements were carried out during routine clinical procedure by a trained 
 triage nurse who was blinded to the study using the Masimo Radical 7 Pulse Oximetry Device in all adult patients who were admitted to the ED with the complaint of chest pain between April 1st, 2019 and October 1st, 2019. The demographic characteristics, PI, PVI, HEART score, ECG findings, and troponin levels were recorded.
 
 Results: A total of 154 patients, 96 (62.3%) of whom were males, were included in our study. The mean age was calculated as 55.1 ±18.2 years in men, 56.8 ±20.2 years in women, and 56.3±18.9 years in total. Of all patients, 66 (42.8%) were hospitalized with ACS diagnosis, and 88 (57.2%) were discharged from ED. The hospitalized patients had statistically higher values for Troponin, HEART score, and mean age. There was no difference between the two groups regarding PI and PVI.
 Conclusion: We think that the contributions of PI and PVI to emergency physicians in the management of patients who are evaluated with suspicion of ACS in the ED will be limited.

Impact of rubidium imaging availability on management of patients with acute chest pain

ObjectiveEvaluate the impact of 82-Rubidium positron emission tomography (PET) myocardial perfusion imaging (MPI) availability on patient management presenting at the emergency department (ED) with chest pain (CP). MethodsThis is a single-center retrospective study of clinical databases. Patients presenting with CP with a non-definitive suspicion of acute coronary syndrome (ACS) at the ED between April 2016 and February 2020 were divided into 2 groups based on PET availability. The proportion of invasive coronary angiography (ICA) without significant coronary artery disease (CAD), length of stay (LoS), and additional downstream testing were evaluated. ResultsThere were 21,242 ED visits for CP without definitive ACS: 5,492 when PET is not available and 15,750 when PET is available. When PET is available, proportion of patients undergoing a MPI study was greater (20.7% vs 17.6%, P<0.0001), proportion of ICA without significant CAD was similar (18.5% vs 21.4%, P=0.24), and median ED LoS was shorter (16.6 vs 18.1 hours, P=0.03). Patients undergoing SPECT MPI had significantly more downstream testing (8.9% vs 6.4%, P=0.003) and a higher rate of coronary angiogram without significant CAD (21.2% vs 14.2%, P=0.09) compared to those who underwent PET MPI. ConclusionAvailability of PET MPI was associated with an increased number of MPI referral from the ED, similar rates of ICA without significant CAD, decreased LoS, and fewer downstream testing.

Abstract 14253: Combining History Of Present Illness With Risk Stratification Scores To Predict Intensive Care Admission For Suspicious Acute Coronary Syndrome Patients In The Emergency Department

Introduction: Patient symptom data are recorded in free text notes in the electronic health records and are difficult to extract. Natural language processing (NLP) is a technique that can be used to mine key patient symptoms that can be combined with risk stratification tools to improve patient outcomes. Hypothesis: Adding symptom data to the National Early Warning Score (NEWS) and quick sequential organ failure assessment score (qSOFA) will improve the area under the receiver operating curve (AUC) performance. Methods: NEWS scores and qSOFA scores were calculated with assistance from an emergency medicine physician for each patient with suspicion of acute coronary syndrome at initial emergency department (ED) assessment. Independent reviewers annotated the outcome of admission to the intensive care unit as a binary outcome (yes/no). The Apache clinical Text Analysis Knowledge Extraction System (cTAKES), an open access NLP platform, was used to preprocess and run analysis on patient free text ED history of present illness notes. Patient symptom data were extracted and used as patient features/input variables and combined with variables from the NEWS and qSOFA scores. Logistic regression model was used to do prediction. We used DeLong’s test to determine the statistical difference between each scores’ AUC. Results: 70 patients out of 1195 had an intensive care admission. The AUC for the NEWS and qSOFA scores were 0.75 and 0.67, respectively. After adding symptoms features, the AUCs improved to 0.81 and 0.79, respectively. There were statistical differences between the AUCs between each score. Conclusion: Adding patient symptom data improves performance of both the NEWS and qSOFA risk stratification scores. Enhanced risk stratification scores with symptom data could identify those at high risk for clinical deterioration and could help augment accurate decision making at ED disposition.

Abstract 13156: Acute Myocardial Infarction With Biventricular Thrombi Due to Blunt Thoracic Trauma

To our knowledge, this is the first ever reported case of biventricular thrombi with acutemyocardial infarction following blunt thoracic wall trauma. We present a case of a man who presented with non-ST segment elevation myocardial infarction with left anterior descending artery (LAD) occlusion and biventricular thrombi after a blunt thoracic wall trauma. Clinical Vignette: A 56-year-old man with past medical history of diabetes mellitus and hypothyroidism presented to our ED with dizziness after motor vehicle collision. Initial workup revealed biventricular thrombi, pulmonary embolus, and dural sinus thrombosis. 2D echocardiogram showed decreased systolic function with ejection fraction of 15% and enlargement of both ventricles with biventricular thrombi. Serial troponin I levels consistently elevated from 0.3 to 0.6. After initiating cangrelor and heparin infusion, patient underwent coronary angiography which revealed LAD occlusion with a thrombus. Patient then successfully underwent mechanical thrombectomy with restoration of TIMI grade III blood flow. Discussion: Hence, we presented the first ever reported case of biventricular thrombi with LAD occlusion resulting from blunt thoracic wall trauma. While trauma induced musculoskeletal pain may mask symptoms of myocardial infarction, a high index of suspicion for acute coronary syndrome can lead to desirable outcomes in such patients.

Abstract 11526: Nardilysin is a Potential Biomarker for the Early Diagnosis of Non-St-Segment Elevation Acute Coronary Syndrome, A Multicenter Prospective Cohort Study, Nardi-ACS Study

Background: Rapid and accurate diagnosis of acute coronary syndrome (ACS) is critical to prevent the fatal complication accompanied with the delay of the treatment. However, the diagnosis of non-ST-segment elevation ACS (NSTE-ACS), especially shortly after the onset, is not straightforward because even high-sensitivity cardiac troponin (hs-cTn) is sometimes not elevated at that phase. We previously reported in a retrospective study that serum nardilysin is a potential biomarker for the early detection of NSTE-ACS. Here, we present the results of the Nardi-ACS study, a multicenter prospective study conducted at six centers in Japan to clarify the significance of nardilysin for the early detection of ACS. Methods and Results: We analyzed serum nardilysin and hs-cTnI (Architect; Abbott) in the sequential 2 independent cohorts; phase I primary cohort (435 patients with chest pain who consecutively visited to the emergency room (ER)) and phase II validation cohort (486 patients with a strong suspicion of ACS who underwent coronary angiography). The frequency of non-ACS, STEMI and NSTE-ACS was 64.4, 22.5, and 13.1 (%) in the phase I, and 14.0, 60.0, and 25.9 (%) in the phase II cohort, respectively. The cutoff value of serum nardilysin was set at 1350.9 pg/ml (mean +2SD) obtained in 246 healthy volunteers, while the cutoff of hs-cTnI was set at 52 pg/ml. The initial blood test in the phase I cohort revealed that nardilysin was significantly elevated in ACS patients, compared to non-ACS patients (p&lt;0.05). The sensitivity of hsTnI, nardilysin, and nardilysin combined with hsTnI for the diagnosis of NSTE-ACS was 52.6, 57.9, and 78.9 (%), and the negative predictive value (NPV) was 90.7, 88.7, and 92.4 (%), respectively. When focused on hsTnI-negative patients, the sensitivity and NPV of nardilysin in STEMI and NSTE-ACS were 64.7/91.4 and 55.6/91.4 (%), respectively. Furthermore, the sensitivity of nardilysin for the early detection of STEMI and NSTE-ACS patients, whose blood was examined within 3 hours after the onset was 77.6 and 60.4 (%), respectively, both of which were higher than that of hsTnI (51.2 and 56.3%). Conclusion: Nardilysin could be a potential biomarker for the early diagnosis of troponin-negative NSTE-ACS.

Clinical profile and in hospital mortality of invasively managed patients with suspicion of acute coronary syndrome during the COVID-19 pandemic

Abstract Background The pandemic of COVID-19 significantly changed the treatment of patients with suspicion of ACS and COVID-19 infection. Access to cardiology department and possibility of invasive diagnosis and treatment of ACS are still significantly impaired. Aim Our aim was to evaluate the characteristic and prognosis of patients with suspicion of ACS and COVID-19 infection. Materials and methods Our department of cardiology was transformed for Covid unit and was dedicated for diagnosis and treatment of patients with suspicion of ACS. COVID-19 confirmed cases were defined by a positive SARS-CoV-2 polymerase chain reaction (PCR) test. From 14th of October 2020 to 14th of March we performed 39 coronary angiographies. We included 39 patients (27 men) with mean age 69±8.5. In that group 11 patients had NSTEMI, 10 patients had STEMI, 2 patients Tako-Tsubo and 16 unstable angina. All patients underwent coronary angiography, and in 27 patients we performed PCI. Results In hospital mortality rate was 35% (14 patients). Cardiac arrest was present in 3 (8%) patients and cardiogenic shock in 4 (10%) patients. The rate of NSTEMI was higher in patients who died 7 vs 4 (p=NS) and STEMI were comparable in both groups 4 vs 6, (p=ns). The IL 6 levels in patients who died were 389±278pg/mL, in compare to 101±93pg/mL (p=0.3) who survived. Independent predictors of death were: sex with the OR=1,1 (95% CI: 0.6–2.4), p=0,03 and IL-6 level on admission OR=1,4 (95% CI: 0.6–2.4), p=0,04. There were no statistically significant differences regarding age, left ventricle ejection fraction, CRP levels and oxygen saturation od admission. Conclusion This study confirms the higher risk of death in patients with ACS and SARS-CoV-2. In the multivariable analysis only sex and Il-6 level on admission were the independent risk factors of the in hospital death. Further investigations of the underlying physiopathological relations between COVID-19 and ACS are needed. Funding Acknowledgement Type of funding sources: None.

Online educational module for paramedics on prehospital 15-lead ECG recording – results of the educational part of the “Finding LCX AMI With posterior ECG leads” (FLAWLESS) trial

Abstract Background The diagnosis of ST elevation myocardial infarction (STEMI) is challenging when the culprit is in the left circumflex coronary artery (CX) territory because ST elevations are often not captured by the standard 12-lead electrocardiogram (ECG). Although, guidelines recommend the acquisition of the additional posterior leads V7-V9 (pECG) when the suspicion of acute coronary syndrome (ACS) is high and the ECG non-diagnostic, this is not routinely done. Purpose The purpose of the FLAWLESS trial, was to improve the prehospital CX STEMI diagnostic. The study consisted of 2 parts: a) a training and implementation study, and b) an outcomes study after implementation. In the implementation study we evaluated the FLAWLESS process from the paramedic's point of view on experiences, implementation of pECG lead recordings and its barriers. Methods Before initiating the trial, all active paramedics in 2 health care regions were educated via a specifically designed and mandatory online 30 min course and all 250 ambulances equipped with a SMART-CARD (instructing how to record pECG leads) and FAQ-sheet. All paramedics were invited by email to anonymously answer an online questionnaire (OQ) designed in REDCap® and interviewed. Utility-score and difficulty-score, ranging from 0 (not useful at all/very easy) to 100 (very useful/very difficult), were introduced for quantitative assessments. Results A total of 1268 paramedics were invited to answer the OQ. The response rate was intermediate at 35%. Among responders, 89% had completed the OEP. On duty 80% had used FAQ-sheet and 74% SMART-CARD in the field. The median utility scores were 80 (25th and 75th quartiles 67–90) for OEP, 79 (61–90) for FAQ-sheet and 85 (75–97) for SMART-CARD, respectively. The implementation of pECG leads recordings was fairly high – 54% reported always recording V7-V9 in ACS patients and 36% reported doing it frequently. Difficulty-score for recording V7-V9 leads in the prehospital setting was 50 (19–70). Finally, 43% reported difficulties that were related to technicalities i.e. defibrillators not having dedicated V7, V8 and V9 cables, hence ambulance staff is forced to record and transmit a second ECG after moving the V4, V5 and V6 cables to the V7-V9 positioned electrodes. Conclusion We demonstrated that large-scale online training of paramedics in the recording of prehospital 15-lead ECG is feasible. The evaluation was positive regarding training and support tools in the ambulances but almost 50% of paramedics found the recording very difficult in the field. Future ECG machines used in emergency settings should be constructed with 13 instead of 10 cables to allow simultaneously recording of 15 leads (standard, precordial and the V7-V9 posterior). This would ease acquisition, facilitate implementation of guideline recommendation. Funding Acknowledgement Type of funding sources: None.

Demystifying Renal Angina

Clinically, the concept of Renal Angina (RA) was put forth to highlight the characteristics of renal injury and to assist in the determination of which patients are at highest risk for Acute Kidney Injury (AKI). It has been used as an analogy, with reference to the concept of angina pectoris, which is used to increase the suspicion of acute coronary syndrome

Thrombolytic Therapy in Treatment in Patients with Pulmonary Embolism not High-risk: SIRENA Registry Data

Aim. To study the features of the use of thrombolytic therapy (TLT) in normotensive patients with pulmonary embolism (PE) in real clinical practice in Russian hospitals.Material and Methods. From 04/1 5/2018 to 04/15/2019 patients hospitalized with a diagnosis of PE consistently were included in the Russian multicenter observational prospective register "SIRENA” (RusSIan REgistry of pulmoNAry embolism).Results. For 12 months in the registry was included 609 patients with a lifetime confirmed diagnosis of PE. TLT was performed in 152 patients with PE (25.0%), of which only 51 (33.8%) were indicated as "high risk" (shock or hypotension). In 101 not high risk patients, the indications for TLT were: severe shortness of breath/respiratory failure - 19 (18.8%), massive venous thrombosis - 7 (6.9%), signs of massive/submassive PE - 10 (9.9%), intermediate-high risk - 14 (13.9%), suspicion of acute coronary syndrome with ST segment elevation - 3 (2.9%), high pulmonary hypertension -2 (2.0%). The other 46 (45.5%) non-high-risk patients had no clear indication of the reasons for TLT in their medical history. To study the features of management of patients with not high-risk PE who received TLT (group 1), a selection of pairs of patients from the "SIRENA” registry, comparable in gender and age, in a ratio of 1:1 of patients with not high-risk PE who did not perform TLT (group 2). Hospital mortality was 4 (4%) patients in the TLT group and 6 (5.9%) patients in group 2 (р=0,748). Logistic regression analysis showed that floating blood clot in the veins of the lower extremities, syncopes in the debut of PE, respiratory rate over 22 per minute were independent clinical factors that significantly influence the doctor's decision to perform thrombolysis, and probability of completion TLT decreased in the presence of a history of bleeding, chronic kidney disease, surgery in the previous 12 months, increase in the size of the right atrium on EchoCG (statistical significance of the model x2=51.574; p&lt;0.001). The development of bleeding during hospitalization was recorded only in 10 (9.9%) patients of group 1, including severe (3 stage on the BARC scale) in 2 patients. Patients without TLT more often developed an acute heart failure (25.9% vs. 8.5%, p=0.043).Conclusion. In real clinical practice, there is a high frequency of TLT in patients with not high-risk PE. Floating blood clot in the veins of the lower extremities, syncope in the debut of PE, respiratory rate over 22 per minute were independent clinical factors that significantly influence the doctor's decision to perform thrombolysis.

Characteristics and 1-year prognosis of non-obstructive acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Among patients admitted at catheterization laboratory with suspicion of acute coronary syndrome (ACS) a minority have no obstructive epicardial coronary disease (MINOCA). The characteristics and outcomes of this subgroup remains unclear. Purpose The aim of the present study is to characterize MINOCA patients and assess the 1-year prognosis regarding total mortality. Methods A standardized registry was prospectively performed for all ACS patients admitted in a single tertiary care centre during a ten-year period. Patients were divided according to have at least one obstructive coronary artery (G1), defined by a stenosis above 50%, or not (G2) and baseline characteristics were compared between the two groups. All-cause mortality at 30 days and at 1 year were also compared using univariate Cox analysis. Results From 3765 ACS patients admitted during the study period, 461 (12.2%) were included in G2. G2 patients were older (62.6 ± 13.1 vs 66.2 ± 13.7; p &amp;lt; 0.001) and more frequently women (26.3% vs 44.2%; p &amp;lt; 0.001). Smoking was more frequent in G1 (40.0% vs 21.9%; p &amp;lt; 0.001) but the prevalence of hypertension was higher in G2 (55.2% vs 64.2%; p &amp;lt; 0.001). There were no differences regarding dyslipidaemia and diabetes. End-stage chronic kidney disease was higher in G2 (2.4% vs 4.1%; p = 0.025). Regarding the clinical evolution during hospitalization, G2 presented more frequently with Killip-Kimball class ≥II (13.9% vs 19.3%; p = 0.001), but at release there was no difference in the proportion of patients with left ventricular ejection fraction ≤50% (34.8% vs 32.1%; p = 0.286). ACS with ST-segment elevation was more common in G1 (58.8% vs 52.1%; p = 0.006), but no differences were found regarding left and right bundle branch block patterns at presentation. In-hospital and 30-day mortality was not significantly different between groups (5.9% vs 7.4%; p = 0.205). However, at 1-year follow-up, G2 had a worse outcome regarding total mortality (HR (95%CI); 1.473 (1.103-1.969); p = 0.008, figure 1). Conclusion MINOCA patients seem not to be a low-risk group of ACS patients, since in this study they had a higher 1-year mortality than ACS patients with obstructive coronary disease. This higher mortality only became apparent after 30 days from the ACS. A systematic diagnostic work-up for further implementation of the most appropriate treatment should be crucial for getting better outcomes with this group of patients. Abstract Figure.

Inter-Rater Reliability of ST-Segment Measurement at a University Hospital in Argentina

The accurate determination of the electrocardiographic ST-segment elevation in a patient with clinical suspicion of acute coronary syndrome is essential for treatment with urgent myocardial reperfusion. The aim of this study was to determine the inter-rater reliability of ischemic and non-ischemic ST-segment elevation measurement among physicians with different specialties and experience. We performed an observational, cross-sectional study, with a comparative correlation and paired sampling. 56 physicians from a university hospital in Buenos Aires city were included: Cardiologists from the Coronary Care Unit (CCU) and Cardiology Division, Internal Medicine physicians from the hospitalization, ambulatory care and Emergency divisions, and third- and fourth-year Internal Medicine residents. Each participant analyzed 6 electrocardiograms and was asked to determine the magnitude of the ST-segment elevation at the J-point, and the corresponding diagnosis. The inter-rater coefficient was lower than 0.2, and the global kappa coefficient was 0.06 (p &lt; 0.001). The global correct interpretations were: inferior wall myocardial infarction (MI): 89.3%; anterior wall MI: 51.8%; lateral wall MI: 75%; left bundle branch block: 91.1%; left ventricle hypertrophy: 44.6%; acute pericarditis: 25%. We believe that the low correlation was probably due to the difficulty in determining the J-point. These findings could suggest the need to strengthen the electrocardiographic concepts of ischemia, and the differentiation between ischemic and non-ischemic ST-segment elevations.

Stanford Type a Aortic Dissection Presenting with Dyspnea: A Case Report.

Acute Aortic dissection is relatively uncommon but can lead to fatal outcome due to misdiagnosis and/or delay treatment [1]. In this report we present a case of a 45-year-old man presenting with chief complaint of substernal chest pain with no remarkable laboratory and echocardiography finding. He was admitted to the cardiology service with clinical suspicion of acute coronary syndrome (ACS). However, further evaluation led to the diagnosed of acute aortic dissection and referral for urgent repair. Aortic dissection could mimic other disorders such as ACS and pulmonary embolism due to variation in the presenting symptoms [1]. Therefore, high clinical suspicious could lead to timely diagnosis and initiation of life-saving therapeutic interventions.

Abstract 12667: Racial Disparities in Emergency Care of Patients With Suspected ACS Undergoing Cardiac CT Angiography: Insights From Romicat II and ACRIN-PA

Introduction: A disparity in health outcomes between black and white patients with coronary artery disease (CAD) has also been reported with pathophysiological differences in CAD and racial disparities in providing health care as potential explanations. Hypothesis: To determine racial disparity in emergency care of patients with suspected acute coronary syndrome (ACS) undergoing cardiac CT angiography (cCTA), which provides knowledge of underlying CAD status. Methods: We combined patient level data of the ACRIN-PA 4005 (American College of Radiology Imaging Network, Pennsylvania) and ROMICAT II (Rule Out Myocardial Infarction using Computer Assisted Tomography) trials, which enrolled patients presenting with suspicion of ACS who were randomized to cCTA as a first diagnostic test at 14 US sites. Sample was restricted to subjects with known CAD status based on cCTA. Self-reported race while the race ‘Black’ were defined as “a person having origins in any of the black racial groups of Africa” and the race ‘white’ as “a person having origins in any of the original peoples of Europe, the Middle East, or North Africa”. Results: We included 1,191 patients (53% white, 47% black). Pretest probability for ACS was similar (TIMI score, p=0.77) between black and white patients, while black patients had lower presence and extent of CAD (calcium score: 39.3±189.3 vs. 88.2±292.1, p&lt;0.001; obstructive CAD 8.3% vs. 17.5%, p&lt;0.001) and ACS (4.0% vs 6.9%, p=0.03). After accounting for the underlying CAD, black patients were more likely admitted to the hospital (β: 0.29 [95%CI: 0.05-0.54-]) and were more likely to undergo additional testing (β: 0.47 [95%CI: 0.09-0.85]) while remaining management showed no significant differences. Conclusions: After adjustment for underlying CAD, among patients in the ED with suspicion of ACS, those who are black received more downstream testing and were more frequently admitted to hospital than white patients.

Epicardial fat tissue: a new tool for identification of coronary artery disease patients?

Abstract Introduction Epicardial fat (EF), the true visceral fat depot of the heart, has been strongly correlated with both coronary artery disease (CAD) incidence and severity. However, the methods for its measurement were not always affordable. Its measurement by echocardiography is fast, accessible and easily reproducible, turning it into a promising clinical tool for assessing cardiovascular risk to predict the incidence of CAD. Purpose To determine the correlation between EF tissue dimensions measured by transthoracic echocardiography and the presence of CAD. Methods We prospectively analysed data from 196 consecutive patients admitted for acute coronary syndrome in our coronary care unit. All patients underwent diagnostic coronary angiography and echocardiogram during stay. EF dimensions were obtained with transthoracic echocardiography by measuring maximum EF diameter (mm) at the basal right ventricular free wall (PLAXB) level and mid-right ventricular free wall (PLAXM) level [in paraesternal long-axis view (PLAX)] and maximum right-ventricle free wall EF diameter at basal (PSAXB) level and papillary-muscle (PSAXM) level [in paraesternal short-axis view (PSAX)]. All measures were taken at end-systole. Patients were divided in 2 groups according to the presence of significant CAD (sCAD) or not (nCAD), defined as having at least 1 diseased epicardial vessel with a stenosis &amp;gt;50%. Results One-hundred and sixty-three (83.2%) had significant CAD. 22 patients (11.2%) were admitted for unstable angina, 60 patients (30.6%) for non-ST elevation myocardial infarction and 93 patients (47,4%) for ST-elevation myocardial infarction. Mean EF diameters were as follows: PLAXB (19,3±5.1 mm), PLAXM (11.3±2.6), PSAXB (10,6±2.8), PSAXM (10.5±2.8). We found a direct correlation between number of diseased epicardial coronary vessels and epicardial fat thickness in PLAXB (r=0.506, p&amp;lt;0.001), PLAXM (r=0.372, p&amp;lt;0.001), PSAXB (r=0.445, p&amp;lt;0.001) and PSAXM (r=0.372, p&amp;lt;0.001). EF was significantly different between groups: PLAXB (20,6±4.4 vs. 13.8±3,8, p&amp;lt;0.001), PLAXM (11.8±2.5 vs. 9.0±1.9, p&amp;lt;0.001), PSAXB (11.1±2.7 vs. 8.3±2.3, p&amp;lt;0.001) and PSAXM (11.0±2.6 vs. 8.2±4, p&amp;lt;0.001). Receiver operating characteristic curve analysis showed that the predictive value of mean right ventricular EF [(PLAXB+PSAXB)/2] for significant CAD was 0.895 (AUC=0.895, CI 95% 0.818–0,972, p&amp;lt;0.001). For a [(PLAXB+PLAXM)/2] value of 12.57 mm, sensitivity was 86.3% and specificity was 79.3%. Conclusions In a population of high suspicion of acute coronary syndromes, echocardiographic EF is a sensitive and specific marker of the presence of significant coronary disease and could become an important tool for coronary risk prediction. Figure 1 Funding Acknowledgement Type of funding source: None

Acute coronary syndrome in Dextrocardia

Situs inversus with dextrocardia is both a clinical and diagnostic challenge for emergency physicians to properly identify acute coronary syndrome. While dextrocardia itself does not independently increase the risk of coronary artery disease, mirrored symptoms, including right-sided and rightward radiating chest pain in any patient with cardiac risk factors should raise suspicion for acute coronary syndrome. In patients with a reversed cardiac silhouette on a chest radiograph, a reversed electrocardiogram, to include both the precordial and limb leads, is necessary to evaluate for cardiac ischemia in presumed dextrocardia. The authors present a case of a 66-year-old man with dextrocardia who presented with shortness of breath and hypotension. Rapid application of a reversed electrocardiogram resulted in the timely diagnosis of ST-segment elevation myocardial infarction and activation of the cardiac catheterization laboratory resulting in the preservation of this patient's life.

Unsupervised learning of early post-arrest brain injury phenotypes

IntroductionTrials may be neutral when they do not appropriately target the experimental intervention. We speculated multimodality assessment of early hypoxic-ischemic brain injury would identify phenotypes likely to benefit from therapeutic interventions. MethodsWe performed a retrospective study including comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA) by one of 126 emergency medical services or in-hospital arrest at one of 26 hospitals from 2011 to 2019. All patients were ultimately transported to a single tertiary center for care including standardized initial neurological examination, brain imaging and electroencephalography; targeted temperature management (TTM); hemodynamic optimization targeting mean arterial pressure (MAP) >80 mmHg; and, coronary angiography for clinical suspicion for acute coronary syndrome. We used unsupervised learning to identify brain injury phenotypes defined by admission neurodiagnostics. We tested for interactions between phenotype and TTM, hemodynamic management and cardiac catheterization in models predicting recovery. ResultsWe included 1086 patients with mean (SD) age 58 (17) years of whom 955 (88%) were resuscitated from OHCA. Survival to hospital discharge was 27%, and 248 (23%) were discharged with Cerebral Performance Category (CPC) 1–3. We identified 5 clusters defining distinct brain injury phenotypes, each comprising 14% to 30% of the cohort with discharge CPC 1–3 in 59% to <1%. We found significant interactions between cluster and TTM strategy (P = 0.01), MAP (P < 0.001) and coronary angiography (P = 0.04) in models predicting outcomes. ConclusionsWe identified patterns of early hypoxic-ischemic injury based on multiple diagnostic modalities that predict responsiveness to several therapeutic interventions recently tested in neutral clinical trials.

Causes of Elevated Troponin in Patients with Normal Coronary Angiography

Troponin rise indicates myocardial cell injury. However, elevated values of troponin are not always consequence of infarction or ischemia. In this paper, aim was to elucidate diverse etiologies of elevated troponin in patients with normal coronary angiography. At KBC Zagreb in 2014 there was 976 patients identified from catheterization database who underwent coronary angiography due to suspicion of acute coronary syndrome (ACS). We identified 30 (3.1%) patients who had alternative cause for myocyte injury other than coronary artery disease (CAD), meaning that there was less than 30 % coronary arterial luminal stenosis. The elevation of cardiac troponin T (cTnT) in patients with normal coronary angiography was attributed to diverse etiologies, including hypertensive crisis, Takotsubo syndrome, severe aortic stenosis, atrial fibrillation (AF), chronic obstructive pulmonary disease (COPD) exacerbation, advanced heart failure, hypertensive cardiomyopathy, acute pulmonary embolism, malignant disease progression, and cardiogenic shock. Apart from ACS, cTnT could be elevated in a number of different conditions, which should be considered according to clinical presentation, different diagnostic procedure, and still could reflect myonecrosis, even in the absence of significant angiographic CAD.