Self-report of chest pain symptoms and coronary artery disease in patients undergoing angiography.

The relation of self-reported chest discomfort to the presence of atherosclerosis was examined, taking age and gender differences into account. Sixteen practicing cardiologists independently rated the items of a self-report questionnaire of angina pectoris (AP) symptoms according to their adjudged likelihood of being associated with coronary artery disease (CAD). Inpatients' (130 male and 82 female) responses to this questionnaire were obtained on the day prior to coronary angiography and scored according to their reporting of 12 symptoms endorsed by all 16 cardiologists, 25 symptoms endorsed by at least 90% of the cardiologists, and responses to items used in the Rose questionnaire, a brief survey tool for diagnosis of chest pain. Finally, patients' angiographic results were rated for presence of 75% or more CAD of one or more coronary arteries. Surprisingly, more symptoms were reported by patients without significant CAD, regardless of age or gender.     

An alternative tool for triaging patients with possible acute coronary symptoms before admission to a chest pain unit

Objective

This study aimed to develop a triage tool to more effectively triage possible ACS patients presenting to the emergency department (ED) before admission to a protocol-driven chest pain unit (CPU).

急诊室胸痛患者发生急性冠状动脉综合征的风险与心房纤颤的相关性分析

目的 探讨在急诊室就诊的胸痛患者存在心房纤颤(AF)是否会增加发生急性冠状动脉综合征(ACS)的风险.方法 收集我院2001-07～2006-08急诊室胸痛患者的资料,分为AF组和对照组.观察是否发生ACS[急性心肌梗死(AMI)和不稳定型心绞痛(UA)].评估发生ACS的相对危险与AF的相关性.结果 共有140例AF患者和683例符合标准的对照患者入选.AMI的发生率在AF组和对照组分别为11.4%和10.8%,UA分别为16.4%和15.8%,ACS分别为27.9%和26.7%.AF患者发生ACS的相对危险没有增加:AMI 1.05[95%置信区间(CI)=0.63～1.75],UA 1.05(95%CI=0.6～1.7),ACS 1.05(95%CI=0.78～1.04).结论 在急诊室就诊的胸痛患者中,AF与发生ACS的风险增加没有相关性.     

Improved outcome in acute coronary syndrome by establishing a chest pain unit

Aims  

Chest pain units (CPUs) have been established to optimize treatment of patients with acute coronary syndrome (ACS) and to early and accurately discharge patients with non-coronary chest pain. The aim of this analysis was to elucidate whether treatment of ACS patients in the CPU versus emergency department (ED) has prognostic implications.     

Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain

BACKGROUND: Patients with acute, undifferentiated chest pain present a frequent diagnostic challenge to clinicians. Clinical features are often used to determine which patients may have acute coronary syndrome (ACS). AIM: To identify clinical features that independently predict ACS in patients with acute, undifferentiated chest pain. DESIGN: Prospective study of patients enrolled in a randomized controlled trial. METHODS: The presenting characteristics of participants in the ESCAPE randomized trial of chest pain unit vs. routine care were recorded in a standardized manner. Follow-up consisted of troponin T measurement at 2 days, postal questionnaire at 1 month, and telephone contact at 6 months. ACS was defined as elevated troponin T at 2 days or major adverse cardiac event within 30 days of presentation. Multivariate analysis identified independent clinical predictors of ACS. RESULTS: ACS was diagnosed in 77 (7.9%) of the 972 patients recruited. The following characteristics were independent predictors of ACS (odds ratio, p): age (1.09, p < 0.001), male gender (8.6, p < 0.001), indigestion or burning-type pain (3.0, p = 0.034), pain radiating to the left (2.4, p = 0.013) or right (5.7, p < 0.001) arm, vomiting (3.5, p = 0.007), and previous (5.1, p < 0.001) or current (3.7, p < 0.001) smoking. DISCUSSION: In addition to previously recognized predictors of ACS, it appears that indigestion or burning type pain predicts ACS in patients attending the emergency department with acute, undifferentiated chest pain. Diagnosis of acute 'gastro-oesophageal' chest pain should be avoided in this setting.     

A new simple risk score in patients with acute chest pain without existing known coronary disease

Objective

To derive and validate a prediction rule in patients with acute chest pain (CP) without existing known coronary disease.

Methods

Cohort study including 2233 patients with CP. Based on clinical judgment, 1435 were discharged as very low risk and the remaining 798 underwent exercise tolerance test (ETT). End point: 6-month composite of cardiovascular death, nonfatal myocardial infarction, and revascularization. The prediction rule was derived from a randomly selected test cohort (n = 1106) summing factors of variables selected by multivariate regression analysis: CP score higher than 6 (factor of 3), male gender, age older than 50 years, metabolic syndrome, and diabetes mellitus (factor of 1, for each). The prediction rule was validated in the remaining cohort (n = 1127). All patients with CP were categorized into 3 groups: group A (prediction rule 0-1), B (2-4), or C (5-6). Outcomes and prognostic yield of ETT were compared among each group.

Results

In the test cohort, 55 patients (5%) reached the composite end point. Event rate increased as the prediction rule increased: 1% for group A, 6% for B, and 25% for C (P < .001). This pattern was confirmed in the validation cohort (P < .001). A normal ETT did not significantly improve the high (99%) negative predictive value in group A and did not succeed in excluding the composite end point (17%) in group C.

Conclusions

In patients with acute CP without existing coronary disease, a prediction rule based on clinical characteristics provided a useful method for prognostication with possible implication in decision making.     

Diagnostic efficacy of myeloperoxidase to identify acute coronary syndrome in subjects with chest pain

Abstract

Background. Early diagnosis of acute coronary syndrome (ACS) is frequently a challenging task.

Aims. To assess the role of novel biomarkers to identify ACS.

Methods. Concentrations of lipids, lipoproteins, oxidized LDL (oxLDL), high-sensitivity C-reactive protein (hsCRP), paraoxonase-1 (PON1), secretory phospholipase A2 (sPLA2), and myeloperoxidase (MPO) were measured in 703 patients (mean age 65.5 ± 11.2 years; 422 men, 281 women) without diabetes mellitus assigned to coronary angiogram. The subjects were divided into three groups: ACS (n = 242), stable angina pectoris (SAP) (n = 242), and normal coronary artery (NCA) (n = 219).

Results. HDL-cholesterol (HDL-C) (P < 0.001) and apolipoproteinA-I concentrations (P < 0.0001) were lowest in subjects with ACS. LDL-C (P = 0.008) and non-HDL (P < 0.0001) were higher in the ACS group than in the SAP group. Leukocyte count (P < 0.0001), oxLDL (P < 0.05), hsCRP (P < 0.001), sPLA2 (P < 0.05), and MPO (P < 0.0001) were highest in the ACS group. In multivariate models, comprising all biomarkers, elevated level of MPO had the best discriminatory power to identify patients with ACS. Receiver-operating characteristic curve with and without MPO comparison differed significantly (P = 0.03 for both ACS versus NCA and ACS versus SAP).

Conclusion. Our study shows that ACS associates with low HDL-C and biomarkers of oxidative stress and inflammation. The addition of MPO in biomarker panels might improve diagnostic accuracy for ACS.     

Frequency of acute coronary syndrome in patients presenting to the emergency department with chest pain after methamphetamine use

We reviewed the frequency of acute coronary syndrome (ACS) in patients presenting to our Emergency Department (ED) with chest pain after methamphetamine (MAP) use during a 2-year interval. Thirty-three patients (25 males, 8 females; average age 40.4 ± 8.0 years) with a total of 36 visits met study inclusion criteria: 1) non-traumatic chest pain, 2) positive MAP urine toxicology screen, 3) admission to “rule-out” myocardial infarction, 4) chest radiograph demonstrating no infiltrates. An ACS was diagnosed in 9 patients (25%). Three patients (8%) (2 ACS and 1 non-ACS) suffered cardiac complications (ventricular fibrillation, ventricular tachycardia, supraventricular tachycardia, respectively). Age, gender, cardiac risk factors, prior coronary artery disease, initial systolic blood pressure and heart rate did not differ significantly in the ACS and non-ACS groups. The initial and subsequent electrocardiograms (EKG) were normal in 1/9 (11%) patients with ACS and 16/27 (59%) without ACS (p < 0.05). Our findings suggest that: 1) ACS is common in patients hospitalized for chest pain after MAP use, and 2) the frequency of other potentially life-threatening cardiac complications is not negligible. A normal EKG lowers the likelihood of ACS, but an abnormal EKG is not helpful in distinguishing patients with or without ACS.     

Short- and long-term cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram

Aim

The aim of this study is to evaluate incidence of adverse cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram (ECG) and initial troponin.

Methods

Prospective, nonrandomized study enrolled low-risk patients with normal ECG and troponin on admission who underwent observation and/or stress testing by unstandardized clinical judgment. Patients who experienced recurrent angina or positive ECGs or positive troponins during observation or patients with positive stress testing were admitted; otherwise, they were discharged.

End Point

The end points are cardiac events at short- and long-term follow-up including cardiovascular death, myocardial infarction, unstable angina, and revascularization.

Results

Of 5656 patients considered, 1732 with ischemic ECG were initially admitted and, therefore, excluded from the analysis; 2860 with pleuritic chest pain and normal ECG were discharged; 1064 with visceral chest pain and normal ECG were enrolled. Patients with known coronary disease (45%) were older and likely presented known vascular disease. Patients with known vascular disease, older age, female sex, diabetes mellitus, and lower chest pain score were likely managed with observation. In patients with known coronary disease as compared with patients without, overall cardiac events account for 35% vs 14%, respectively (P < .001), as follows: in-hospital, 23% vs 10%, (P < .001); 1 month, 4% vs 2% (P = .133); and 9.9 ± 4.9 months, 8% vs 2%, respectively (P < .001).

Conclusions

One-third of patients with chest pain with known coronary disease, negative ECG, and biomarkers were subsequently found to have adverse cardiac events. The value of this research for an emergency medicine audience could be extended to all clinicians and general practitioners beyond cardiologists.     

A simple score for predicting coronary artery disease in patients with chest pain

BACKGROUND: We have previously derived a chest pain score by comparing those with and without coronary artery disease on angiography, which was subsequently validated in patients attending coronary angiography. AIM: To test the predictive validity of the score prospectively in a more varied out-patient population, and to determine whether it had predictive validity in addition to exercise testing. DESIGN: Prospective clinical study. METHODS: The score was applied to 405 out-patients with chest pain who subsequently underwent coronary angiography. Framingham risk analysis and exercise testing were performed in 155. RESULTS: The score had a sensitivity of 91.4% and specificity of 28% for coronary artery disease, which was found in 31.8%, 51%, 63%, and 82% of those with scores of 0, 1, 2, and 3, respectively. Gender (p < 0.001), age (p < 0.001), and chest pain score (p = 0.009) independently predicted coronary artery disease on multivariate Poisson regression analysis. The chest pain score had additive predictive value with Framingham risk analysis and Duke's score. DISCUSSION: This simple chest pain score can predict coronary anatomy with similar sensitivity to exercise testing, and can be used in conjunction with exercise testing and other measures. Further validation of the chest pain score in the primary care setting will be useful.     

Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain

A retrospective cohort study and chart review were performed to estimate the absolute and relative prevalence of the serious diagnoses that might cause a patient to present to the Emergency Department (ED) with a chief complaint of chest pain. In this study, we queried a database of 347,229 complete visits to the San Francisco General Hospital Emergency Department between July 1, 1993 and June 30, 1998 for visits by patients > 35 years old with a chief complaint of chest pain and no history of trauma. Visits for chest pain that resulted in hospitalization were assigned to one of nine diagnostic groups according to final diagnoses as coded in the database. Manual chart review by trained abstractors using explicit criteria was done when group assignment based on coded diagnoses was unclear and in all diagnoses of pulmonary embolism and aortic dissection. Of 8711 visits (2.5% of all visits) with a chief complaint of non-traumatic chest pain, 3271 (37.6%) resulted in hospitalization. Of the 3078 (94.1% of those hospitalized) assigned a final diagnosis, 329 (10.7% of hospitalizations, 3.8% of all visits) had acute myocardial infarction, 693 (22.5%) had either unstable angina or stable coronary artery disease, and 345 (11.2%) had pulmonary causes (mainly bacterial pneumonia) deemed serious enough to require hospitalization. Pulmonary embolism and aortic dissection were diagnosed in only 12 (0.4%) and 8 (0.3%) patients, respectively. In 905 (29.4%) hospitalizations for chest pain, myocardial infarction was “ruled out” and no cardiac ischemia or other serious etiology for the chest pain was diagnosed. Among patients presenting with chest pain, those in older age groups had dramatically increased risk of acute myocardial infarction. Women presenting with chest pain had a lower risk of acute myocardial infarction than men. In conclusion, the prevalence of acute myocardial infarction in the undifferentiated ED patient with a chief complaint of chest pain is only about 4%. An equal number of patients will have a serious pulmonary cause as the etiology of their pain. Pulmonary embolism and aortic dissection are important but extremely rare causes of a chest pain presentation to the ED.     

肾功能不全的急性冠状动脉综合征患者应用替罗非班的安全性观察

目的评价伴有肾功能不全的急性冠状动脉综合征(ACS)患者应用血小板糖蛋白Ⅱb/Ⅲa受体拮抗剂盐酸替罗非班(欣维宁)的安全性。方法经皮冠状动脉介入治疗(PCI)的ACS患者567例,根据患者肾小球滤过率(GFR)分为肾功能正常组、肾功能轻度受损组和肾功能中度受损组,分别比较各组服用替罗非班后的出血并发症,并通过logistic多因素回归和叉生分析综合分析伴有肾功能不全的患者应用替罗非班的安全性,评价两因素间有无交互效应。结果患者PCI术后出血并发症的发生率肾功能轻度受损组和中度受损组较肾功能正常组出血并发症升高(12.8%和31.0%vs 4.1%,均P<0.01),肾功能中度受损组又较肾功能轻度受损组出血并发症升高(12.8%vs31.0%,P<0.05)。伴有轻中度肾功能不全患者应用替罗非班的联合治疗出血风险并没有如预期的增加,两因素间无交互效应(交互作用指数S=1.057,P>0.05)。结论肾功能不全及应用盐酸替罗非班可以增加接受PCI的ACS患者出血并发症的发生风险,但肾功能轻中度受损组的ACS患者对替罗非班有很好的耐受性,肾功能轻中度受损患者应用替罗非班是安全的,二者之间没有交互作用。     

Culturally competent care of patients with acute chest pain

PURPOSE: To inform nurse practitioners (NPs) about the influence of culture on patients' responses to pain using the example of acute chest pain. DATA SOURCES: Selected clinical and research articles on pain and culture and the authors' clinical experiences providing care across a variety of cultures. CONCLUSIONS: There is very little written and even fewer studies on the connection of culture and the response to acute chest pain. This topic needs more attention by nurse researchers. Implications for practice If NPs are not aware that some patients may not demonstrate behavior typically expected in acute myocardial infarction, they may miss the diagnosis and fail to treat or refer these patients for immediate treatment.     

Laboratory diagnosis of patients with acute chest pain.

The enzyme activities of creatine kinase (CK), its isoenzyme MB (CK-MB) and of lactate dehydrogenase isoenzyme 1 (LD-1) have been used for years in diagnosing patients with chest pain in order to differentiate patients with acute myocardial infarction (AMI) from non-AMI patients. These methods are easy to perform as automated analyses, but they are not specific for cardiac muscle damage. During the early 90's the situation changed. First creatine kinase MB mass (CK-MB mass) replaced the measurement of CK-MB activity. Subsequently cardiac-specific proteins troponin T (cTnT) and troponin I (cTnI) appeared on the scene, displacing LD-1 analysis. However, troponin concentrations in blood increase only from four to six hours after onset of chest pain. Therefore a rapid marker such as myoglobin, fatty acid binding protein or glycogen phosphorylase BB could be used in early diagnosis of AMI. On the other hand, CK-MB isoforms alone may also be useful in rapid diagnosis of cardiac muscle damage. Myoglobin, CK-MB mass, cTnT and cTnI are nowadays widely used in diagnosing patients with acute chest pain. Myoglobin is not cardiac-specific and therefore requires supplementation with some other analyses such as troponins to support the myoglobin value. Troponins are very highly cardiac-specific. Only the sera of some patients with severe renal failure, which requires hemodialysis, have elevated cTnT and/or cTnI without there being any evidence of cardiac damage. On the other hand, the latest studies have shown that elevated troponin levels in sera of hemodialysis patients point to an increased risk of future cardiac events in a similar manner to the elevated troponin values in sera of patients with unstable angina pectoris. In addition, the bedside tests for cTnT and cTnI alone or together with myoglobin and CK-MB mass can be used instead of quantitative analyses in the diagnosis of patients with chest pain. These rapid tests are easy to perform and they do not require expensive instrumentation. For routine clinical laboratory practice we suggest that in diagnosis of patients with chest pain, myoglobin and CK-MB mass measurements should be performed whenever they are requested (24 h/day) and cTnT or cTnI on admission to the hospital and then 4-6 and 12 hours later.