Thrombolysis In Myocardial Infarction Score Research Articles

Performance of the TIMI risk score in predicting mortality after primary percutaneous coronary intervention in elderly women: Results from a developing country.

BackgroundDespite women undergoing primary percutaneous coronary intervention (PPCI) having a higher rate of adverse outcomes than men, data evaluating prognostic risk scores, especially in elderly women, remains scarce. This study was conducted to validate the predictive value of Thrombolysis in Myocardial Infarction (TIMI) risk score in elderly female patients.Materials and methodsThis was a retrospective analysis of elderly (>65 years) female patients who underwent PPCI for ST-elevated myocardial infarction (STEMI) from October 2016 to September 2018. Patients’ demographic details and elements of TIMI risk score including age, co-morbidities, Killip classification; weight, anterior MI and total ischemic time were extracted from hospital records. The primary outcome was in-hospital mortality and post-discharge mortality reported on telephonic follow-up.ResultsA total of 404 elderly women with a median age of 70 years were included. The mean TIMI score was 5.25±1.45 with 40.3% (163) patients of TIMI score > 5. In-hospital mortality rate was 6.4% (26) and was found to be associated with TIMI score (p<0.001). The in-hospital mortality rate increased from 3.1% at TIMI score of 0–4 to 34.6% at the score of 8. On follow-up (16.43±7.40 months) of 211 (55.8%) patients, the overall mortality rate was 20.3%, and this was also associated with TIMI score (p<0.001). The mortality rate increased from 5.6% at the score of 0–4 to 54.5% at the score of 8. The predictive values (area under the curve) of TIMI risk score for in-hospital and post-discharge mortality were 0.709 (95% CI 0.591–0.827; p <0.001) and 0.689 (95% CI 0.608–0.770; p <0.001), respectively.ConclusionIncreased adverse outcomes were observed with higher TIMI risk score for in hospital and post-discharge follow-up. Therefore, the prognostic TIMI risk score is a robust tool in predicting both in-hospital as well as post-discharge mortality in elderly females.

Time-Dependent Myocardial Necrosis in Patients With ST-Segment-Elevation Myocardial Infarction Without Angiographic Collateral Flow Visualized by Cardiac Magnetic Resonance Imaging: Results From the Multicenter STEMI-SCAR Project.

BackgroundAcute complete occlusion of a coronary artery results in progressive ischemia, moving from the endocardium to the epicardium (ie, wavefront). Dependent on time to reperfusion and collateral flow, myocardial infarction (MI) will manifest, with transmural MI portending poor prognosis. Late gadolinium enhancement cardiac magnetic resonance imaging can detect MI with high diagnostic accuracy. Primary percutaneous coronary intervention is the preferred reperfusion strategy in patients with ST‐segment–elevation MI with <12 hours of symptom onset. We sought to visualize time‐dependent necrosis in a population with ST‐segment–elevation MI by using late gadolinium enhancement cardiac magnetic resonance imaging (STEMI‐SCAR project).Methods and Results ST‐segment–elevation MI patients with single‐vessel disease, complete occlusion with TIMI (Thrombolysis in Myocardial Infarction) score 0, absence of collateral flow (Rentrop score 0), and symptom onset <12 hours were consecutively enrolled. Using late gadolinium enhancement cardiac magnetic resonance imaging, the area at risk and infarct size, myocardial salvage index, transmurality index, and transmurality grade (0–50%, 51–75%, 76–100%) were determined. In total, 164 patients (aged 54±11 years, 80% male) were included. A receiver operating characteristic curve (area under the curve: 0.81) indicating transmural necrosis revealed the best diagnostic cutoff for a symptom‐to‐balloon time of 121 minutes: patients with >121 minutes demonstrated increased infarct size, transmurality index, and transmurality grade (all P<0.01) and decreased myocardial salvage index (P<0.001) versus patients with symptom‐to‐balloon times ≤121 minutes.ConclusionsIn MI with no residual antegrade and no collateral flow, immediate reperfusion is vital. A symptom‐to‐balloon time of >121 minutes causes a high grade of transmural necrosis. In this pure ST‐segment–elevation MI population, time to reperfusion to salvage myocardium was less than suggested by current guidelines.

Incidence and Predictors of Obstructive Coronary Artery Disease and the Role of Cardiac Troponin Assays in Patients with Unstable Angina.

In a time when cardiac troponin assays are widely used to detect myocardial injury, data remain scarce concerning the incidence and predictors of substantial obstructive coronary artery disease that causes unstable angina. This retrospective single-center study included consecutive patients hospitalized for unstable angina from January 2015 through January 2016. Patients with troponin I levels above the upper reference limit and those who did not undergo angiography were excluded. Multivariate logistic regression analysis was used to identify predictors of obstructive coronary artery disease that warranted revascularization and of major adverse cardiac events up to 6 months after discharge from the hospital. Of the 114 patients who met the inclusion criteria, 46 (40%) had obstructive coronary artery disease. In the univariate analysis, male sex, white race, history of coronary artery disease, prior revascularization, hyperlipidemia, chronic kidney disease, aspirin use, long-acting nitrate use, and Thrombolysis in Myocardial Infarction score ≥3 were associated with obstructive coronary artery disease. History of coronary artery disease, prior revascularization, hyperlipidemia, and long-acting nitrate use were associated with major adverse cardiac events. Male sex was an independent predictor of obstructive coronary artery disease (adjusted odds ratio=4.82; 95% CI, 1.79-13; P=0.002) in the multivariate analysis. Our results showed that coronary artery disease warranting revascularization is present in a considerable proportion of patients who have unstable angina. The association that we found between male sex and obstructive coronary artery disease suggests that the risk stratification of patients presenting with unstable angina may need to be refined to improve outcomes.

Evaluating Serum Levels of Pentraxin-3, von Willebrand Factor and C-X-C Motif Chemokine Ligand 13 as Inflammatory Markers of Unstable Angina Pectoris

Unstable angina pectoris (USAP) is a complex condition in which widespread coronary inflammatory processes have important implications for clearer understanding of its pathogenesis and also its treatment. This study aimed at evaluating the diagnostic as well as prognostic value of serum inflammatory markers of pentraxin-3 (PTX-3), Von Willebrand Factor (vWf) and C-X-C Motif Chemokine Ligand 13 (CXCL13) in such patients. Out of sixty-nine patients, thirty-nine had USAP, thirty had stable angina pectoris (SAP), and thirty-nine were healthy controls. For all participants, serum PTX-3, vWf and CXCL13 levels were measured using ELISA. For each patient with USAP, the Thrombolysis in Myocardial Infarction (TIMI) and the scores of Global Registry of Acute Coronary Events (GRACE) were calculated to determine the severity of the disease. We, then, analyzed the relation of PTX-3, vWf and CXCL13 levels with TIMI and GRACE scores in patients with USAP. Serum PTX-3, vWf and CXCL13 levels were significantly higher in USAP group than those in either SAP or control groups (p˂0.001). Strong correlation was observed between CXCL13 level and TIMI risk score (p=0.019). In receiver operating characteristic (ROC) curves, area under the curve (AUC) values of PTX3, vWf and CXCL13 for detection of USAP were 0.755, 0.751, and 0.906, respectively. The levels of serum PTX3, vWf and CXCL13 increased in patients with USAP. The notable correlation implied that CXCL13 might be a sensitive and specific biomarker for the diagnosis of USAP as well as its severity. It might also show additional diagnostic values when measured in combination with vWf.

The safety and efficacy of dexmedetomidine versus propofol for patients undergoing endovascular therapy for acute stroke: A prospective randomized control trial.

Background:It is uncertain if dexmedetomidine has more favorable pharmacokinetic profile than the traditional sedative drug propofol in patients who undergo endovascular therapy for acute stroke. We conducted a prospective randomized control trial to compare the safety and efficacy of dexmedetomidine with propofol for patients undergoing endovascular therapy for acute stroke.Methods:A total of 80 patients who met study inclusion criteria were received either propofol (n = 45) or dexmedetomidine (n = 35) between January 2016 and August 2018. We recorded the favorable neurologic outcome (modified Rankin score <3) both at discharge and 3 months after stroke, National Institute of Health Stroke scale (NIHSS) at 48 hours post intervention, modified thrombolysis in myocardial infarction score on digital subtraction angiography, intraprocedural hemodynamics, recovery time, relevant time intervals, satisfaction score of the surgeon, mortality, and complications.Results:There were no significant differences between the 2 groups (P > .05) with respect to heart rate, respiratory rate, and SPO2 during the procedure. The mean arterial pressure (MAP) was significantly low in the propofol group until 15 minutes after anesthesia was induced. No difference was recorded between the groups at the incidence of fall in MAP >20%, MAP >40% and time spent with MAP fall >20% from baseline MAP. In the propofol group, the time spent with MAP fall >40% from baseline MAP was significantly long (P < .05). Midazolam and fentanyl were similar between the 2 groups (P > .05) that used vasoactive drugs. The time interval from stroke onset to CT room, from stroke onset to groin puncture, and from stroke onset to recanalization/end of the procedure, was not significantly different between the 2 groups (P > .05). The recovery time was longer in the dexmedetomidine group (P < .05). There was no difference between the groups with respect to complications, favorable neurological outcome, and mortality both at hospital discharge and 3 months later, successful recanalization and NIHSS score after 48 hours (P > .05). However, the satisfaction score of the surgeon was higher in the dexmedetomidine group (P < .05).Conclusions:Dexmedetomidine was undesirable than propofol as a sedative agent during endovascular therapy in patients with acute stroke for a long-term functional outcome, though the satisfaction score of the surgeon was higher in the dexmedetomidine group.

Correlation between Thrombolysis in Myocardial Infarction and The Global Registry of Acute Coronary Syndromes Risk Scores and Severity of Coronary Artery Disease in Patients with Non-ST Elevation Acute Coronary Syndrome

Background: the prognosis of non-ST elevation acute coronary syndrome (NSTEACS) patients is frequently done by using thrombolysis in myocardial infarction (TIMI) and global registry of acute coronary events (GRACE) risk scores. Only few studies were done for prediction ability of the scores with coronary artery disease. Methods: this prospective cross-sectional study included 100 patients was conducted at Mabaret Misr Alqadema and Al-Azhar University Hospitals from May 2017 till September 2018. We calculated the TIMI and the GRACE risk scores for all patients on admission then patients had coronary angiography to detect the extent of the coronary artery disease (CAD). We assessed the severity of CAD by using Gensini score and vessel score. Results: the TIMI and GRACE scores have an acceptable predictive value in identifying the extent of the CAD. A TIMI score ≥3 and GRACE score ≥102 was significantly associated with 3 vessel disease and left main disease (p <0.014 for TIMI and p <0.007 for GRACE). On comparison of the two risk scores, the discriminatory accuracy of the GRACE score was nonsignificantly superior to the TIMI score in predicting 3 vessel and left main (LM) diseases but the combination of both scores has a higher accuracy (p <0.006). Conclusions: the CAD is more extensive by coronary angiography in patients with NSTEACS who had higher TIMI or GRACE risk scores, as they have a good predictive value. However, when both compared, the GRACE score has a non-statistically significant superiority with multivessel and LM disease, and combination of both scores has a higher accuracy.

Correlation between Thrombolysis in Myocardial Infarction and The Global Registry of Acute Coronary Syndromes Risk Scores and Severity of Coronary Artery Disease in Patients with Non-ST Elevation Acute Coronary Syndrome

Background: the prognosis of non-ST elevation acute coronary syndrome (NSTEACS) patients is frequently done by using thrombolysis in myocardial infarction (TIMI) and global registry of acute coronary events (GRACE) risk scores. Only few studies were done for prediction ability of the scores with coronary artery disease. Methods: this prospective cross-sectional study included 100 patients was conducted at Mabaret Misr Alqadema and Al-Azhar University Hospitals from May 2017 till September 2018. We calculated the TIMI and the GRACE risk scores for all patients on admission then patients had coronary angiography to detect the extent of the coronary artery disease (CAD). We assessed the severity of CAD by using Gensini score and vessel score. Results: the TIMI and GRACE scores have an acceptable predictive value in identifying the extent of the CAD. A TIMI score ≥3 and GRACE score ≥102 was significantly associated with 3 vessel disease and left main disease (p <0.014 for TIMI and p <0.007 for GRACE). On comparison of the two risk scores, the discriminatory accuracy of the GRACE score was nonsignificantly superior to the TIMI score in predicting 3 vessel and left main (LM) diseases but the combination of both scores has a higher accuracy (p <0.006). Conclusions: the CAD is more extensive by coronary angiography in patients with NSTEACS who had higher TIMI or GRACE risk scores, as they have a good predictive value. However, when both compared, the GRACE score has a non-statistically significant superiority with multivessel and LM disease, and combination of both scores has a higher accuracy.

Gender Variation of In-Hospital Outcome In Patients With Unstable Angina by Timi Risk Score

Background: The TIMI (Thrombolysis in Myocardial Infarction) risk score is a seven item risk stratification tool derived from trials of patients with Unstable Angina (UA) that has been validated in Emergency Department (ED) patients with potential Acute Coronary Syndromes (ACS). To evaluate frequency, outcome and correlation of the gender variation of in-hospital outcome in patients of unstable angina by TIMI risk score. Materials and methods: This was an observational study of Cardiac Care Unit (CCU) patients with unstable angina. Data included demographics, medical and cardiac history, and components of the TIMI risk score. Investigators followed the hospital course daily. The outcomes were death, Acute Myocardial Infarction (AMI) heart failure and arrhythmia during hospital stay as stratified by TIMI risk score and compared between genders using 2 tests. Data were analyzed by SPSS version-19. Results: In this study 62% patients were male and 38% patients were female. 55.20% female had low TIMI score whereas 16.10% male and 18.40% female had very high TIMI scores. The mortality rate was 0% in low TIMI score but the rate was increased in high TIMI score e.g. 3.30% in male patients and 2.60% in female patients with unstable angina. The rate of occuring MI, Cardiogenic shock, Heart failure is increased respectively from low to high TIMI score. In case of Arrhythmia, 17.70% male and 15.70% female had low TIMI score whereas 25.80% male and 26.30% female had high TIMI score. Conclusion: The TIMI risk score successfully stratifies risk in both males and females with UA at the time of CCU presentation; however, males have worse outcome at low TIMI scores than female.&#x0D; JCMCTA 2018 ; 29 (2) : 35-40

A Pathognomonic Electrocardiogram That Requires Urgent Percutaneous Intervention: A Case of Wellens Syndrome in a Previously Healthy 55-Year-Old Male

Patient: Male, 55Final Diagnosis: Wellens’ syndromeSymptoms: Chest painMedication: —Clinical Procedure: —Specialty: CardiologyObjective:Rare diseaseBackground:Acute chest pain is a common presentation in emergency departments worldwide. Ruling out acute coronary syndrome is essential in ensuring patient safety. Workup includes electrocardiogram (ECG) and cardiac biomarkers. Wellens syndrome is characterized by a history of chest pain, normal or minimally elevated biomarkers, no STEMI/Q-waves, and specific ECG changes. These changes consist of biphasic T waves in lead V2 and V3 or deep symmetrically inverted T waves in leads V1–V4.Case Report:A 55-year-old male presented to the emergency department with acute chest pain in a background of active smoking, hypertension, and hyperlipidemia. His ECG was characteristic of Wellens syndrome type 1 and negative cardiac biomarkers. His TIMI (thrombolysis in myocardial infarction) score was 2, however, he failed conservative management necessitating urgent coronary angiogram. Critical stenosis of the proximal left anterior descending (LAD) coronary artery was found which required 2 drug eluting stents. He was discharged home asymptomatic on optimal medical therapy.Conclusions:Conventional management of patients with NSTEMI (non-ST-elevation myocardial infarction) and unstable angina with risk stratification utilizing TIMI score may not be appropriate in patient with Wellens syndrome. This highlights the importance of ECG recognition and urgent percutaneous intervention in patients with Wellens syndrome. Failure to identify this clinical syndrome could result in significant morbidity and mortality because it relates to critical stenosis and imminent large myocardial infarction.

ED Chest Pain Rules: Follow Your HEART?

ED Chest Pain Rules: Follow Your HEART?

Coronary Artery Aneurysm after Second-Generation Drug-Eluting Stent Implantation.

PurposeWe evaluated the incidence, predictors, and prognosis of coronary artery aneurysm (CAA) after second-generation drug-eluting stent (DES) implantation.Materials and MethodsA total of 976 consecutive patients (1245 lesions) who underwent follow-up angiography after second-generation DES implantation were analyzed. Incidence and predictors of CAA were assessed, and clinical prognosis was compared with 34 cases of CAA after first-generation DES implantation using previous CAA registry data.ResultsAll 10 cases of CAA (0.80% per lesion) in 10 patients (1.02% per patient) were detected at follow up. Compared to lesions without CAA, those with CAA had greater involvement of the proximal segment (90% vs. 51%, p=0.014), a higher proportion of pre-intervention, a Thrombolysis in Myocardial Infarction score of 0 or 1 flow (80% vs. 16%, p<0.001), more chronic total occlusions (40% vs. 10%, p<0.001), and longer implanted stents (41.9±23.2 mm vs. 28.8±14.8 mm, p=0.006). As for CAA morphology, instances of CAA after second-generation DES were predominantly the single fusiform type (90%), whereas instances of CAA after first-generation DES were multiple saccular (47%) and single saccular (35%) types (p<0.001). Myocardial infarction with stent thrombosis occurred in 5 patients with CAA after first-generation DES (15%), and no adverse events were observed in patients with CAA after second-generation DES over a median follow-up duration of 4.3 years (p=0.047, log-rank).ConclusionAlthough CAAs after second-generation DES implantation were detected at a similar incidence to that for CAAs after first-generation DES implantation, second-generation DES-related CAAs had different morphologies and more benign clinical outcomes versus first-generation DES-related CAAs.

Deep learning for predicting in-hospital mortality among heart disease patients based on echocardiography.

Heart disease (HD) is the leading cause of global death; there are several mortality prediction models of HD for identifying critically-ill patients and for guiding decision making. The existing models, however, cannot be used during initial treatment or screening. This study aimed to derive and validate an echocardiography-based mortality prediction model for HD using deep learning (DL). In this multicenter retrospective cohort study, the subjects were admitted adult (age≥18years) HD patients who underwent echocardiography. The outcome was in-hospital mortality. We extracted predictor variables from echocardiography reports using text mining. We developed deep learning-based prediction model using derivation data of a hospital A. And we conducted external validation using echocardiography report of hospital B. We conducted subgroup analysis of coronary heart disease (CHD) and heart failure (HF) patients of hospital B and compared DL with the currently used predictive models (eg, Global Registry of Acute Coronary Events (GRACE) score, Thrombolysis in Myocardial Infarction score (TIMI), Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score, and Get With The Guidelines-Heart Failure (GWTG-HF) score). The study subjects comprised 25776 patients with 1026 mortalities. The areas under the receiver operating characteristic curve (AUROC) of the DL model were 0.912, 0.898, 0.958, and 0.913 for internal validation, external validation, CHD, and HF, respectively, and these results significantly outperformed other comparison models. This echocardiography-based deep learning model predicted in-hospital mortality among HD patients more accurately than existing prediction models and other machine learning models.

A Novel Marker of Inflammation: Azurocidin in Patients with ST Segment Elevation Myocardial Infarction.

(1) To investigate the role of azurocidin, an antimicrobial protein, in patients with ST segment elevation myocardial infarction (STEMI). (2) This single-center prospective observational study included patients with STEMI and healthy age- and sex-matched control subjects. Baseline demographic, clinical and biochemical data were compared between the two groups. Azurocidin levels at baseline were determined using an enzyme-linked immunosorbent assay. Multivariate linear regression analysis with enter method was used to test the association between azurocidin and independent variables, such as the thrombolysis in myocardial infarction (TIMI) score, synergy between percutaneous coronary intervention with TAXUS and cardiac surgery score, global registry of acute coronary events score, Killip class, C-reactive protein (CRP), and creatinine kinase-myocardial band (CK-MB). (3) A total of 76 patients with STEMI and 30 healthy control subjects were enrolled in the study. Mean ± SD azurocidin levels were significantly higher in patients compared with healthy controls (18.07 ± 13.99 versus 10.09 ± 5.29 ng/mL, respectively). In a receiver-operating characteristic curve analysis, an azurocidin cut-off level of >11.46 ng/mL had 74% sensitivity and 58% specificity in predicting myocardial infarction. Azurocidin levels had a positive correlation with TIMI score (r = 0.651). In multivariate linear regression analysis, the TIMI score was an independent predictor of the azurocidin level. (4) Azurocidin is an infection marker that may be important in patients with STEMI.

Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac Events in Patients Presenting With Chest Pain: A Systematic Review and Meta-analysis.

The HEART score has been proposed for emergency department (ED) prediction of major adverse cardiac events (MACE). We sought to summarize all studies assessing the prognostic accuracy of the HEART score for prediction of MACE in adult ED patients presenting with chest pain. We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception through May 2018 and included studies using the HEART score for the prediction of short-term MACE in adult patients presenting to the ED with chest pain. The main outcome was short-term (i.e., 30-day or 6-week) incidence of MACE. We secondarily evaluated the prognostic accuracy of the HEART score for prediction of mortality and myocardial infarction (MI). Where available, accuracy of the Thrombolysis in Myocardial Infarction (TIMI) score was determined. We included 30 studies (n = 44,202) in analysis. A HEART score above the low-risk threshold (≥4) had a sensitivity of 95.9% (95% confidence interval [CI]= 93.3%-97.5%) and specificity of 44.6% (95% CI= 38.8%-50.5%) for MACE. A high-risk HEART score (≥7) had a sensitivity of 39.5% (95% CI= 31.6%-48.1%) and specificity of 95.0% (95% CI= 92.6%-96.6%) for MACE, whereas a TIMI score above the low-risk threshold (≥2) had a sensitivity of 87.8% (95% CI= 80.2%-92.8%) and specificity of 48.1% (95% CI= 38.9%-57.5%) for MACE. A high-risk TIMI score (≥6) was 2.8% sensitive (95% CI= 0.8%-9.6%), but 99.6% (95% CI= 98.5%-99.9%) specific for MACE. A HEART score ≥ 4 had a sensitivity of 95.0% (95% CI= 87.2%-98.2%) for prediction of mortality and 97.5% (95% CI= 93.7%-99.0%) for prediction of MI. The HEART score has excellent performance for prediction of MACE (particularly mortality and MI) in chest pain patients and should be the primary clinical decision instrument used for the risk stratification of this patient population.

HEART pathway and Emergency Department Assessment of Chest Pain Score–Accelerated Diagnostic Protocol application in a local emergency department of Hong Kong: An external prospective validation study

Background: The conventional chest pain protocol using thrombolysis in myocardial infarction score as the risk stratifying tool may not perform well in the emergency department in which a mix of low- and high-risk patients are encountered. Newer chest pain scores such as HEART pathway and Emergency Department Assessment of Chest Pain Score–Accelerated Diagnostic Protocol (EDACS-ADP) are found to have high sensitivity with good specificity. Objectives: This study aims to validate and compare two chest pain scores: HEART pathway and EDACS-ADP in the Accident and Emergency Department of a local hospital in Hong Kong. Methods: A prospective cohort study was carried out at the Accident and Emergency Department of Kwong Wah Hospital in Hong Kong from 1 June 2016 to 31 May 2017. Patients ⩾18 years old with chest pain lasting 5 min or more who were observed with chest pain protocol on observation ward were recruited. Results: A total of 238 patients were recruited; 231 eligible patients completed follow-up. There were five patients with major adverse cardiac events in 30 days of follow-up. The sensitivity, specificity, and negative predictive values of HEART pathway and EDACS-ADP were 100%, 74.3%, 100% and 100%, 73.5.0% and 100%, respectively. Both scores had almost the same performance in terms of major adverse cardiac events at 30 days (area under the curve = 0.87). Conclusion: Our study showed both EDACS-ADP (modified) and HEART pathway achieved high sensitivity (~100%) for detecting major adverse cardiac events in 30 days while being able to discharge more than 70% of patients as low risk for early discharge.

299 Retrospective Study of a Low-Risk Chest Pain Protocol in a Socioeconomically Disadvantaged Population

Standardized chest pain (CP) protocols are implemented in emergency departments (EDs) to safely and efficiently assess CP visits and provide the most appropriate disposition without excess resource utilization. However, whether the success of such an approach may be affected by the socioeconomic status of the target population is not known. We sought to determine the effectiveness of a standardized CP protocol in a primarily socioeconomically disadvantaged population. On November 1, 2012, a new CP protocol that utilizes the thrombolysis in myocardial infarction (TIMI) risk score, electrocardiography, and contemporary sensitivity troponin I to triage patients into low, intermediate and high-risk categories was implemented in our Detroit-based ED. Discharged low-risk patients were provided an outpatient cardiology follow-up appointment within 48 hours. We performed a retrospective analysis of patients greater than 18 years of age who presented with a chief complaint of low risk CP (TIMI score 0-1) during a 1-year period (6 months pre- and 6 months post-protocol implementation), comparing the proportion deemed low risk, ED disposition and 30-day ED recidivism rates over time using chi-square. A total of 3613 patients were included (n=1837 pre-protocol versus n=1776 post-protocol). The pre- and post-protocol populations were demographically similar with mean ages of 47.0 and 47.4, respectively. There was no statistical difference in the proportion deemed at low-risk in the pre- versus post-protocol periods (67% pre- versus 68% post-protocol; p=0.167). However, significantly more low-risk patients were discharged post-protocol implementation (55% versus 44%; p<0.001). Of the patients who were discharged, 41.9% kept their appointment with the cardiologist. ED recidivism was also significantly greater in the post-protocol versus pre-protocol (2.98% versus 1.63%; p=0.0035). Post-implementation of a CP protocol, a greater proportion of ED patients with low-risk CP were discharged, yet a higher rate of ED recidivism was seen. Such recidivism may reflect difficulty accessing outpatient follow-up in our socioeconomically disadvantaged population (Detroit has an 82.7% African-American population, and 35.7% of people live below the poverty line), but the precise cause of this important finding is unclear.Tabled 1Comparison Pre- and Post-ProtocolOutcomePre (N=1837)Post (N=1776)Low Risk1227 (67%)1213 (68%)Discharged808 (44%)970 (55%)ED Recidivism30 (1.63%)53 (2.98%) Open table in a new tab

Received care compared to ADP-guided care of patients admitted to hospital with chest pain of possible cardiac origin.

PurposeTo assess the extent to which accelerated diagnostic protocols (ADPs), compared to traditional care, identify patients presenting to emergency departments (EDs) with chest pain who are at low cardiac risk and eligible for early ED discharge.Patients and methodsRetrospective study of 290 patients admitted to hospital for further evaluation of chest pain following negative ED workup (no acute ischemic electrocardiogram [ECG] changes or elevation of initial serum troponin assay). Demographic data, serial ECG and troponin results, Thrombolysis in Myocardial Infarction (TIMI) score, cardiac investigations, and outcomes (confirmed acute coronary syndrome [ACS] at discharge and major adverse cardiac events [MACEs]) over 6 months of follow-up were analyzed. A validated ADP (ADAPT-ADP) was retrospectively applied to the cohort, and processes and outcomes of ADP-guided care were compared with those of care actually received.ResultsPatients had mean (±SD) TIMI score of 1.8 (±1.7); six (2.0%) patients were diagnosed with ACS at discharge. At 6 months, one patient (0.3%) re-presented with ACS and two (0.6%) died of non-coronary causes. The ADAPT-ADP defined 97 (33.4%) patients as being at low risk and eligible for early ED discharge, but who instead incurred mean hospital stay of 1.5 days, with 40.2% in telemetry beds, and 21.6% subject to non-invasive testing with only one positive result for coronary artery disease. None had a discharge diagnosis of ACS or developed MACE at 6 months.ConclusionCompared to traditional care, application of the ADAPT-ADP would have allowed one-third of chest pain patients with initially negative investigations in ED to have been safely discharged from ED.

Evaluación de la indicación de cateterismo cardíaco diagnóstico a pacientes con enfermedad arterial coronaria.

Objetivo. Identificar si el procedimiento de cateterismo cardíaco es indicado adecuadamente a los pacientes con sospecha de enfermedad arterial coronaria, en el Hospital Médico Quirúrgico del Instituto Salvadoreño del Seguro Social, de enero a diciembre 2016. Metodología. Estudio descriptivo retrospectivo. Se realizó una revisión de 290 expedientes clínicos, se calculó la muestra a través del net quest, resultando 209 expedientes de pacientes sometidos a cateterismo cardíaco. Se cataloga la indicación del cateterismo como apropiada, incierta o inadecuada. El riesgo pre test de coronariopatía se calculó con los Global Registry of Acute Coronary Events and Thrombolysis in Myocardial Infarction Scores. Utilizando Chi-cuadrado se compararon las variables categóricas. Resultados. La mayor parte de pacientes sometidos a cateterismo cardíaco fueron hombres mayores de 50 años, con alto riesgo pretest para coronariopatía, tanto por el Global Registry of Acute Coronary Events Score como por el Thrombolysis in Myocardial Infarction Score. Se observó una relación entre el grado del riesgo pre test para coronariopatía y la identificación de lesión angiográfica. Respecto a la categoría asignada con base en los “Criterios de uso apropiado del cateterismo cardiaco diagnóstico”, el 68% de los cateterismos se catalogaron como indicación apropiada y de estos, en el 99% se pudo detectar enfermedad arterial coronaria. Conclusiones. Los cateterismos cardíacos están siendo indicados de manera adecuada en el Hospital Médico Quirúrgico. Existe relación entre el riesgo pretest para coronariopatía y la categoría asignada a la indicación del cateterismo, de acuerdo con el Appropriate Use Criteria for Diagnostic Catheterization en la identificación de enfermedad arterial coronaria.Alerta Año 2018, Vol. 1 No. 1: 18-25

P103: Performance characteristics of the modified Sgarbossa criteria for diagnosis of acute coronary occlusion in emergency department patients with ventricular paced rhythm and symptoms of acute coronary syndrome

Introduction: The ECG diagnosis of acute coronary occlusion (ACO) in the setting of ventricular paced rhythm (VPR) is purported to be impossible. However, VPR has a similar ECG morphology to LBBB. The validated Smith-modified Sgarbossa criteria (MSC) have high sensitivity (Sens) and specificity (Spec) for ACO in LBBB. MSC consist of 1 of the following in 1 lead: concordant ST Elevation (STE) 1 mm, concordant ST depression 1 mm in V1-V3, or ST/S ratio &lt;−0.25 (in leads with 1 mm STE). We hypothesized that the MSC will have higher Sens for diagnosis of ACO in VPR when compared to the original Sgarbossa criteria. We report preliminary findings of the Paced Electrocardiogram Requiring Fast Emergency Coronary Therapy (PERFECT) study Methods: The PERFECT study is a retrospective, multicenter, international investigation of ED patients from 1/2008 - 12/2016 with VPR on the ECG and symptoms suggestive of acute coronary syndrome (e.g. chest pain or shortness of breath). Data from four sites are presented. Acute myocardial infarction (AMI) was defined by the Third Universal Definition of AMI. A blinded cardiologist adjudicated ACO, defined as thrombolysis in myocardial infarction score 0 or 1 on coronary angiography; a pre-defined subgroup of ACO patients with peak cardiac troponin (cTn) &gt;100 times the 99% upper reference limit (URL) of the cTn assay was also analyzed. Another blinded physician measured all ECGs. Statistics were by Mann Whitney U, Chi-square, and McNemars test. Results: The ACO and No-AMI groups consisted of 15 and 79 encounters, respectively. For the ACO and No-AMI groups, median age was 78 [IQR 72-82] vs. 70 [61-75] and 13 (86%) vs. 48 (61%) patients were male. The median peak cTn ratio (cTn/URL) was 260 [33-663] and 0.5 [0-1.3] for ACO vs. no-AMI. The Sens and Spec for the MSC and the original Sgarbossa criteria were 67% (95%CI 39-87) vs. 46% (22-72; p=0.25) and 99% (92-100) vs. 99% (92-100; p=0.5). In pre-defined subgroup analysis of ACO patients with peak cTn &gt;100 times the URL (n=10), the Sens was 90% (54-100) for the MSC vs. 60% (27- 86) for original Sgarbossa criteria (p=0.25). Conclusion: ACO in VPR is an uncommon condition. The MSC showed good Sens for diagnosis of ACO in the presence of VPR, especially among patients with high peak cTn, and Spec was excellent. These methods and results are consistent with studies that have used the MSC to diagnose ACO in LBBB.

Combining fragmented QRS and TIMI score for predicting in-hospital short-term prognosis after acute myocardial infarction.

Acute myocardial infarction (AMI) has a high mortality rate and poor prognosis for patients. The primary causes of death are arrhythmia and heart failure. For patients admitted because of myocardial infarction, various risk evaluations are initiated to foresee possible complications. The thrombolysis in myocardial infarction (TIMI) risk score, which can be used to predict the prognosis and the need for revascularisation, is the most convenient and commonly used system, but is inadequate for AMI patients on admittance. Fragmented QRS (fQRS) has been shown to be a valuable electrocardiographic (ECG) index for predicting the prognosis of patients with coronary heart disease. Also, fQRS is considered to predict an increased likelihood of a poor outcome and mortality in patients with coronary artery disease (CAD), even for some successfully revascularized AMI patients. So what would happen if fQRS and the TIMI risk score were combined? This study focused on the investigation of the short-term prognostic value of fQRS combined with the TIMI risk score for patients with AMI.