Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain

Background

Chest pain is a frequent chief complaint among the pediatric population. To date, limited data exist on the full spectrum of emergent cardiac disease among such patients; and existing data have been limited to relatively small cohorts.

Objectives

The aims of the study were to investigate the emergent cardiac etiologies of chest pain in a large cohort of patients presenting to a tertiary care pediatric emergency department (PED) and to examine the use of resources (electrocardiogram, chest radiograph, echocardiogram, and laboratories) in those with and without cardiac-related chest pain.

Methods

Patient visits to 2 tertiary care PEDs were evaluated over a 3 and half-year period. Records of patients less than 19 years of age with a chief complaint of chest pain and no history of cardiovascular disease were reviewed. Patients were categorized as having cardiac or noncardiac etiologies or history of cardiovascular disease at the time of discharge, based on PED attending's final diagnoses. Final diagnoses classified as emergent cardiac etiologies were determined a priori.

Results

Four thousand four hundred thirty-six patients reported a chief complaint of chest pain during the study period. Three percent were excluded secondary to a history of heart disease. Only 24 (0.6%) of the remaining 4288 were determined to have chest pain of cardiac origin. Those with cardiac-related chest pain had a rate of admission of 50% compared to those without cardiac disease at 4% (P < .001). Nine patients had an arrhythmia, 6 had pericarditis, 4 had myocarditis, 3 had acute myocardial infarction, and 1 had pulmonary embolism and pneumopericardium. Ninety-two percent of the cardiac-related chest pain cohort received electrocardiograms compared to those without cardiac-related chest pain at 27% (P < .01). Only 1 (4%) of 24 subjects with cardiac-related chest pain had a prior emergency department visit within 72 hours suggesting a high detection rate upon initial presentation. The most common noncardiac etiologies for the chest pain were 56% musculoskeletal disorders; 12% related to wheezing, asthma, and cough; 8% infectious causes; 6% gastrointestinal; and 4% related to sickle cell anemia.

Conclusion

Cardiac-related chest pain in pediatric patients is rare but potentially serious. Arrhythmia was the most common cardiac-related etiology among this cohort. Those with myocarditis and myocardial infarction were the most acutely ill. An electrocardiogram in addition to history and physical examination was most useful in detecting relatively uncommon but significant cardiac-related chest pain. Using a thorough physical examination and potentially an electrocardiogram evaluation by a pediatric emergency care physician has an excellent rate of detection of cardiac-related causes.     

The diagnosis of acute myocardial infarction in the emergency department; Part 1.

Despite major advances in treatment, the accurate diagnosis of acute myocardial infarction (AMI) in the emergency department (ED) remains a difficult clinical problem and is still mainly based on the history and interpretation of the electrocardiogram. Although the physician's clinical impression is a highly sensitive indicator for AMI, at least 4% of patients presenting to the ED with AMI may be mistakenly sent home. Although chest pain is the most common chief complaint, the clinical presentation can be extremely variable, particularly in the elderly. Complaints of sharp chest pain or chest wall tenderness should not be relied upon to exclude AMI. Radiation of chest pain is an important symptom. With careful analysis, the electrocardiogram may yield a higher diagnostic sensitivity than is commonly accepted.     

Aortic dissection: a dreaded disease with many faces

Aortic dissection is a relatively uncommon but catastrophic illness classically thought to present with acute, sharp, chest pain with radiation to the back. However, aortic dissection can manifest in a number of different ways that include congestive heart failure, inferior myocardial infarction, stroke, focal pulse and neurologic deficits, abdominal pain, or acute renal failure. According to some studies, only about 80% of patients with type A dissection present with severe anterior chest pain, and only about 60% describe their pain as being sharp. Another series reports that treating clinicians fail to initially entertain the diagnosis of aortic dissection in up to 35% of cases. Many patients later found to have aortic dissection are initially suspected to have other conditions such as acute coronary syndrome, pericarditis, pulmonary embolism, or even cholecystitis. In this article we present a case of an unusual presentation of aortic dissection and a review of this condition.     

Mode of arrival does not predict myocardial infarction in patients who present to the ED with chest pain

Aims

This study aims to determine if patients who arrive by ambulance with a chief complaint of chest pain have a higher risk of myocardial infarction (MI) than those who arrive via alternate transportation.

Methods

All patients ages 18–99 who presented to an urban academic ED between January 2006 and July 2006 with a chief complaint that included “chest pain” were eligible for retrospective analysis. Patients who were transferred or who left without being seen or against medical advice were excluded. Myocardial infarction was defined as patients who were admitted and who had elevated troponin I or went urgently to catheterization laboratory and had >90% occlusion of a vessel, with a final clinical impression of MI.

Results

There were 690 visits for chest pain during the study period, representing 4% of total ED census. A total of 39 visits met exclusion criteria, and 37 patients had 52 repeat visits, leaving 599 unique patients included for analysis. Mean age was 48.8?±?1.4 years (SD 17.7), 44.6% were female, and 35 patients (5.8%) were diagnosed with MI. In all, 157 patients (26.2%) arrived via EMS. Patients who arrived by ambulance did not have a significant difference in rate of MI when compared with alternate transportation [7.0% vs. 5.4%, OR (95% CI) = 1.3 (0.6–2.7), p?=?0.469]. Only 31.4% (11/35) of patients who ultimately were diagnosed with MI arrived by ambulance.

Conclusion

We were unable to show a significant difference in rate of MI between patients who arrived via ambulance or private transportation. Equal consideration and urgency should be given to both types of patients when they arrive at the ED.     

Summary statistics for acute cardiac ischemia and chest pain visits to United States EDs, 1995-1996.

In this article we describe characteristics of emergency encounters for patients with a diagnosis of acute cardiac ischemia (ACI) and for patients with chest pain complaints. Data are from the National Hospital Ambulatory Medical Care Survey, which includes abstracts from the medical records of a national probability sample of visits to emergency departments (ED). Analysis was limited to records of patients 25 years of age and older with a diagnosis of either confirmed or suspected acute myocardial infarction (AMI) or unstable angina pectoris and records with a nontraumatic chest pain complaint. There was an estimated annual average of 1.2 million visits to EDs by patients 25 years and over with a diagnosis of ACI in 1995-1996, an average annual rate of 7.2 visits per 1,000 persons. Visit rates varied by patient's age, race, and gender. Chest pain was a complaint in three-fourths of all ACI visits. There were an estimated 4.6 million annual ED visits where in patients aged 25 years and older had complaints of nontraumatic chest pain, an average annual rate of 27.7 visits per 1,000 persons. ACI accounted for 11% of all chest pain visits, but the probability of the chest pain visit having an ACI diagnosis varied by patient's age and race. There remains a large amount of variation in treatment for suspected and confirmed AMI, and for patients presenting with chest pain to EDs.     

Acute myocardial infarction caused by coronary embolism from infective endocarditis

Background: Identifying an acute myocardial infarction caused by a non-atherosclerotic process can have consequences on the short- and long-term management of the disease. Case Reports: In the first case reported, a 39-year-old woman with a history of hypertension, diabetes, end-stage renal disease, deep vein thrombosis, and a recent hospitalization for staphylococcal bacteremia presented to the Emergency Department (ED) with acute onset of chest pain and shortness of breath. Her electrocardiogram (ECG) showed findings of an ST-segement elevation lateral wall acute myocardial infarction (AMI). The patient's condition worsened in the ED, and thrombolytic therapy was initiated. The patient subsequently had a coronary catheterization that illustrated an irregular mitral valve and abrupt occlusions in the left anterior descending artery, suggestive of coronary embolism from a mitral valve source. This patient was later treated with intravenous antibiotics and mitral valve replacement. In the second case reported, a 56-year-old man with a history of hypertension, diabetes, and end-stage renal disease presented to the ED with shortness of breath, fever, and chest pain. His ECG was significant for ST-segment elevation in the lateral leads, suggestive of an AMI. This patient had a history of positive blood cultures in a previous admission as well as an echocardiogram revealing an aortic valve vegetation. Given the high suspicion for an infective endocarditis causing an embolic event that in turn led to the myocardial infarction, thrombolytics were withheld in the ED and the patient was transported for coronary catheterization. The coronary angiogram demonstrated abrupt cutoffs at the distal left anterior descending artery and distal left posterior descending artery suggestive of an embolic occlusion of these vessels. He was subsequently treated with intravenous antibiotics and aortic valve replacement. Conclusions: These two cases illustrate the importance of broadening our differential in the causes of AMI. In these cases, the recognition of an embolic event from infective endocarditis as the cause of the acute coronary syndrome allowed physicians to direct their interventions to optimize the appropriate care for each patient.     

床旁即时超声心动图在急性心源性胸痛中的作用

胸痛为门急诊常见的主诉,其中急性心源性胸痛的病因主要为急性冠状动脉综合征、肺栓塞和主动脉夹层等,病情凶险,需快速准确的诊断和救治。床旁即时经胸超声心动图便捷,可通过观察心脏的结构和功能的异常,快速明确病因,在临床急性心源性胸痛的诊断中的作用越来越重要。     

Headache angina

The initial recognition of acute myocardial infarction at the time of the emergency department (ED) visit may be difficult in the absence of typical presentations such as chest pain, diaphoresis, and radiation tenderness. Headache angina, although reported in several instances in the past with variable patient outcomes, is still an uncommon phenomenon in patients with acute myocardial infarction. We report a patient with inferior myocardial infarction who presented to the ED with a complaint of severe headache and subsequent cardiogenic shock secondary to ventricular fibrillation.     

Does Gender Influence Emergency Department Management and Outcomes in Geriatric Abdominal Pain?

Prior studies have suggested gender-based differences in the care of elderly patients with acute medical conditions such as myocardial infarction and stroke, but it is unknown whether these differences are seen in the care of abdominal pain. The objective of this study was to examine differences in evaluation, management, and diagnoses between elderly men and women presenting to the Emergency Department (ED) with abdominal pain. For this observational cohort study, a chart review was conducted of consecutive patients aged 70 years or older presenting with a chief complaint of abdominal pain. Primary outcomes were care processes (e.g., receipt of pain medications, imaging) and clinical outcomes (e.g., hospitalization, etiology of pain, and mortality). Of 131 patients evaluated, 60% were women. Groups were similar in age, ethnicity, insurance status, and predicted mortality. Men and women did not differ in the frequency of medical (56% vs. 57%, respectively), surgical (25% vs. 18%, respectively), or non-specific abdominal pain (19% vs. 25%, respectively, p = 0.52) diagnoses. Similar proportions underwent abdominal imaging (62% vs. 68%, respectively, p = 0.42), received antibiotics (29% vs. 30%, respectively, p = 0.85), and opiates for pain (35% vs. 41%, respectively, p = 0.50). Men had a higher rate of death within 3 months of the visit (19% vs. 1%, respectively, p < 0.001). Unlike prior research in younger patients with abdominal pain and among elders with other acute conditions, we noted no difference in management and diagnoses between older men and women who presented with abdominal pain. Despite a similar predicted mortality and ED evaluation, men had a higher rate of death within 3 months.     

Differential diagnosis of the association of gastrointestinal symptoms and ST segment elevation,in the absence of chest pain

This is a review of the underlying causes of the association of ST segment elevation and gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and anorexia, in patients who do not have chest pain. The review was based on anecdotal reports in Googlescholar and Pubmed using the search terms, abdominal pain, nausea, vomiting, anorexia, ST elevation, myocardial infarction, and Takotsubo cardiomyopathy. Those patients who did not have acute myocardial infarction as the cause of the association of ST segment elevation and gastrointestinal symptoms were compared with counterparts with similar symptoms who had well authenticated acute myocardial infarction or Takotsubo cardiomyopathy as the underlying cause of ST segment elevation. The underlying causes of gastrointestinal symptoms which could be associated with ST segment elevation in the absence of either acute myocardial infarction or Takotsubo cardiomyopathy comprised pneumonia, pulmonary embolism, perforated gastric ulcer, intestinal obstruction, acute appendicitis, acute pancreatitis, acute cholecystitis, pheochromocytoma, bacterial meningitis, diabetic keto acidosis, and cannabis abuse. However, each of those disorders could also coexist either with acute myocardial infarction or with Takotsubo cardiomyopathy. The coexistence of ST segment elevation and gastrointestinal symptoms(without chest pain) was also documented in patients with esophageal perforation, mesenteric ischaemia, aortic dissection, Kounis syndrome, and in electrolyte disorders. In the context of presentation with gastroenterological symptoms but without concurrent chest pain, echocardiography appeared to be useful in distinguishing between “pseudo” myocardial infarction characterised by ST segment elevation in the absence of cardiac disease vs ST segment elevation attributable either to acute myocardial infarction or to Takotsubo cardiomyopathy.     

Gatekeepers: A Missed Opportunity for Safe Transport

Abstract. Objective : To assess whether contact with a health care provider or gatekeeper increases the use of an ambulance for patients with acute chest pain. Methods : A convenience sample of adults ≥:40 years of age presenting with a chief complaint of chest pain were interviewed by trained personnel regarding transport used to come to the ED. The study was performed at the ED of an urban university hospital. Patients with hemodynamic instability and those receiving thrombolytics or emergency angio-plasty were excluded. Patients were asked about access to a primary health care provider and contact with a provider regarding this ED visit, including instructions given for transportation. Results : Of the 450 interviewed patients, 42% arrived by ambulance. Those who had contact with a health care provider prior to the ED visit were less likely to come by ambulance than those without contact, 31% vs 51% (p < 0.001). Of the patients who had cardiac enzymes obtained to work up for their chest pain, 34% with health provider contact vs 57% without health provider contact arrived by ambulance (p < 0.001). Of those with acute myocardial infarction, 30% with health provider contact vs 66% without health provider contact came by a mbulance (p < 0.03). Patients who recalled transport instructions from their providers tended to follow those instructions. The majority of patients who recalled no specific transport instructions arrived by personal automobile. Conclusion : Of patients presenting to an ED for evaluation of chest pain, those who made contact with a health care provider were less likely to arrive via ambulance.     

Identifying Myocardial Ischemia due to Coronary Microvascular Dysfunction in the Emergency Department: Introducing a New Paradigm in Acute Chest Pain Evaluation

Chest pain stands as one of the most frequent patient presentations in the emergency department (ED). Despite established diagnostic algorithms for identifying several important causes of chest pain, such as acute myocardial infarction (AMI), aortic dissection, and pulmonary embolism, guidance on managing patients with recurrent chest pain, one of the top 3 reasons for repeated hospitalization in the United States, is less defined. The assessment of symptoms, serial ECG, and necrosis biomarkers plays a major role in patient management. Notably, the recently introduced high-sensitivity troponin T (hs-TnT) assay is helping to identify ischemia in patients previously undiagnosed by conventional testing. In Europe, with the use of this assay for over a decade, the identification of patients with AMI has substantially increased, particularly of patients with type 2 AMI, which is seen in the absence of atherosclerotic obstruction of the epicardial coronaries on angiography. Use of hs-TnT is in particular relevant in women, in whom the use of a sex-specific threshold for elevated hs-TnT has almost doubled the diagnosis of AMI. With the advent of the hs-TnT assay in the United States in 2017, a similar phenomenon is expected. Thus, it is important to learn from the European experience and to develop sex-specific nuanced algorithms for the evaluation of additional causes of myocardial ischemia/necrosis, such as coronary artery vasomotor disorders and coronary microvascular dysfunction. The latter has a high prevalence among symptomatic women presenting to the ED, a group in whom recurrent chest pain is common. This commentary describes the tools available for diagnosing epicardial- and non–epicardial-related myocardial ischemia in patients with recurrent chest pain in the ED setting. A sex-specific, nuanced approach applied to select groups of patients being observed in the ED has the potential to reduce admissions and to allow for the initiation of timely, appropriate medical treatment and outpatient follow-up in an at-risk population. The costs and availability of advanced diagnostics may pose some limitation to the widespread adoption of such protocols.     

The Evaluation of Cocaine-induced Chest Pain with Acute Myocardial Perfusion Imaging

OBJECTIVE: To use myocardial perfusion imaging to determine the etiology of cocaine-induced chest pain in patients without ECG evidence of acute cardiac ischemia. METHODS: The authors conducted a prospective study of consecutive consenting patients aged 18-70 years with cocaine-induced chest pain who reported cocaine use within three days and presented with a chief complaint of chest pain occurring within three hours and lasting longer than 15 minutes with a normal or nondiagnostic ECG. Patients were excluded if they had a clear-cut noncardiac cause of chest pain, ECG evidence of acute cardiac ischemia, history of myocardial infarction, pregnancy, or lactation, required immediate hospitalization, or were unable to consent. Patients were injected with Tc-99m tetrofosmin and imaged. Perfusion scans were independently read by two nuclear radiologists. Clinicians blinded to scan results determined patient disposition. Patients with abnormal scans were asked to return for follow-up resting scans. RESULTS: Fourteen patients were enrolled. Twelve of the 14 patients had chest pain at the time of Tc-99m tetrofosmin injection. Ten of the 14 [(71%) 95% CI = 48% to 95%] scans were normal or within normal limits. Four of the 14 [(29%) 95% CI = 5% to 52%] were abnormal. Of the four patients with abnormal scans, two had follow-up scans that demonstrated an irreversible perfusion abnormality, and two who did not return for follow-up reported no subsequent hospitalizations for acute cardiac ischemia. CONCLUSION: Perfusion imaging did not demonstrate reversible ischemia in most patients (12/14, 86%) with cocaine-induced chest pain without ECG evidence of ischemia. These results suggest that cocaine-induced chest pain in most patients without ECG evidence of ischemia is not due to acute ischemia.     

D-二聚体在急诊主动脉夹层早期诊断的临床应用

目的：探讨血浆D-二聚体水平在急性主动脉夹层中早期诊断的临床价值。方法：回顾性分析我院2011-05-2013-08因急诊胸痛24h内入院患者共285例,所有患者入院即抽血行全血D-二聚体快速测试,比较不同病因组D-二聚体水平。所有数据采用SPSS 16.0统计软件分析处理,计量资料采用珚x±s及中位数（M）、四分位数间距（QR）进行描述,各组间D-二聚体中位数的比较采用Kruskal-Wallis H检验,Nemenyi法进一步两两比较;绘制D-二聚体水平诊断急性主动脉夹层（AAD）的受试者工作曲线（ROC曲线）,分析D-二聚体鉴别急性主动脉夹层的敏感性、特异性、预测值和似然比（P〈0.05认为差异具有统计学意义）。结果：急性主动脉夹层组（AAD）和急性肺栓塞组（APE）血浆D-二聚体水平显著高于急性心肌梗死（AMI）、心绞痛、急性心包炎、急性胸膜炎及其他病因不明的急性胸痛病例组;AMI组D-二聚体水平大于心绞痛组（P〈0.01）;D-二聚体界值250μg/L鉴别诊断AAD的敏感度和阴性预测值均达到100%,随着D-二聚体水平的升高,诊断AAD的敏感性降低,特异性升高;低于500μg/L值能很好区分排除AAD,阴性预测值97.97%,对应阴性似然比0.02;在急性胸痛患者区分AAD诊断最佳临界点为982.5μg/L,受试者工作曲线下面积为0.972±0.010（95%CI,0.953 0.991）。结论：D-二聚体可作为急性胸痛患者中鉴别诊断主动脉夹层的方便指标。     

Should age be incorporated into the adult triage algorithm in the emergency department?

ObjectiveTo compare resource utilization and mortality between older and younger adult patients with similar ED chief complaints and ESI triage levels.MethodsThis was an observational study of consecutive adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with chest pain, abdominal pain, altered mental status, generalized weakness, or headache. Patients were categorized into 40–64, 65–79, and ≥ 80-year old groups. Mortality and utilization outcomes were compared between age groups through logistic regression models or Cox proportional hazards adjusting for ESI level and chief complaint. Odds ratios (OR) and hazard ratios (HR) were calculated with 95% confidence intervals (CI).ResultsA total of 9798 ED visits were included. As compared to younger adults (age 40–64), older adults, independently of ESI level and chief complaint, had higher ED laboratory use (OR 1.46 [CI 1.29, 1.66] for age 65–80; OR 1.33 [CI 1.15, 1.55] for age ≥ 80), ED radiology use (OR 1.40 [CI 1.26, 1.56]; OR 1.48 [CI 1.30, 1.69]), hospital admission (OR 1.56 [CI 1.42, 1.72]; OR 1.97 [CI 1.75, 2.21]), and ICU admission (OR 1.38 [CI 1.15, 1.65]; OR 1.23 [CI 0.99, 1.52]). Despite similar ESI and chief complaint, patients age 65–79 and ≥ 80 had higher 30-day mortality rates (HR 1.87 [CI 1.39 to 2.51] and 2.47 [CI 1.81 to 3.37], respectively).ConclusionsOlder adults with similar chief complaints and ESI levels than younger adults, have significantly higher ED resource use, hospitalization rates, and mortality.     

Evaluation of chest pain in the ED: factors affecting triage decisions

The emergency physician's (EP) fast and correct diagnosis of patients with chest pain is crucial for preventing inappropriate discharge and dire consequences. To determine which factors affect admission decisions in the ED, we studied epidemiologic characteristics of both discharged and admitted patients, and the percentage of discharged patients who returned to the ED with acute myocardial infarction. The study included 185 patients seen in the ED because of chest pain between July 1 and 31, 1997 (every third day not included). Ninety patients were admitted: 36.7% were admitted for "observation of chest pain" and 63.3% met the criteria for active coronary heart disease. A form was used to collect personal data, medical history, risk factors, clinical examination, electrocardiogram interpretation, laboratory data, and admittance decision. EPs' diagnosis of cardiac chest pain demonstrated a sensitivity of 93.4%, a specificity of 73.4%, and a positive predictive value of 63.3%. Sensitivity for diagnosing acute myocardial infarct was 100%, with no erroneous discharges. The EP's ability to integrate the medical history information, including risk factors and pain characteristics, had a marked influence on the admittance decision. Efforts to reduce missed diagnoses are warranted.     

Undiagnosed Takayasu's arteritis mimicking an acute aortic dissection

Takayasu's arteritis (TA) is a vasculitis involving the aorta and its branches. We report a case of undiagnosed TA that presented to the Emergency Department with a chief complaint of chest pain and signs consistent with an aortic dissection.     

Acute Aortic Regurgitation with Myocardial Infarction: An Important Clue for Aortic Dissection

Background

Aortic dissection is an important cause of acute chest pain that should be rapidly diagnosed, as mortality increases with each hour this condition is left untreated. The diagnosis can be challenging, especially if concomitant myocardial infarction is present. Echocardiography is an important tool for the differential diagnosis.

Objectives

To stress the importance of recognizing aortic regurgitation for the differentiation of myocardial infarction and aortic dissection.

Case Report

An 80-year-old woman was admitted to our hospital with chest pain that was diagnosed as inferior and lateral wall myocardial infarction based on electrocardiographic findings. The diagnosis was reevaluated when aortic regurgitation was detected on echocardiography. Closer inspection of the ascending aorta revealed a dissection flap as the cause of aortic regurgitation.

Conclusion

Detection of aortic regurgitation in a patient with myocardial infarction and normal valves should prompt the search for a possible aortic dissection, whether or not the dissection flap can be visualized.     

Role of "Ischemia modified albumin", a new biochemical marker of myocardial ischaemia, in the early diagnosis of acute coronary syndromes

Background: Diagnosis of cardiac ischaemia in patients attending emergency departments (ED) with symptoms of acute coronary syndromes is often difficult. Cardiac troponin (cTn) is sensitive and specific for the detection of myocardial damage but may not rise during reversible myocardial ischaemia. Ischemia Modified Albumin (IMA) has recently been shown to be a sensitive and early biochemical marker of ischaemia. Methods and Results: This study evaluated IMA in conjunction with ECG and cTn in 208 patients presenting to the ED within three hours of acute chest pain. At presentation, a 12-lead ECG was recorded and blood taken for IMA and cardiac troponin T (cTnT). Patients underwent standardised triage, diagnostic procedures, and treatment. Results of IMA, ECG, and cTnT, alone and in combination, were correlated with final diagnoses of non-ischaemic chest pain, unstable angina, ST segment elevation, and non-ST segment elevation myocardial infarction. In the whole patient group, sensitivity of IMA at presentation for an ischaemic origin of chest pain was 82%, compared with 45% of ECG and 20% of cTnT. IMA used together with cTnT or ECG, had a sensitivity of 90% and 92%, respectively. All three tests combined identified 95% of patients whose chest pain was attributable to ischaemic heart disease. In patients with unstable angina, sensitivity of IMA used alone was equivalent to that of IMA and ECG combined. Conclusions: IMA is highly sensitive for the diagnosis of myocardial ischaemia in patients presenting with symptoms of acute chest pain.