Lung ultrasound in internal medicine: A bedside help to increase accuracy in the diagnosis of dyspnea

BackgroundDyspnea is one of the most frequent causes of admission in Internal Medicine wards, leading to a sizeable utilization of medical resources.Study design and methodsThe role of bedside lung ultrasound (LUS) was evaluated in 130 consecutive patients (age: 81 ± 9 years), in whom blindly collected LUS results were compared with data obtained by clinical examination, medical history, blood analysis, and chest X-ray. Dyspnea etiology was classified as “cardiac” (n = 80), “respiratory” (n = 36) or “mixed” (n = 14), according to the discharge diagnosis (congestive heart failure either alone [n = 80] or associated with pneumonia [n = 14], pneumonia [n = 24], and obstructive disventilatory syndrome [n = 12]). An 8-window LUS protocol was applied to evaluate B-line distribution, “interstitial syndrome” pattern, pleural effusion and images of static or dynamic air bronchogram/focal parenchymal consolidation.ResultsThe presence of a generalized “interstitial syndrome” at the initial LUS evaluation allowed to discriminate “cardiac” from “pulmonary” Dyspnea with high sensitivity (93.75%; confidence intervals: 86.01%–97.94%) and specificity (86.11%; 70.50%–95.33%). Positive and negative predictive values were 93.76% (86.03%–97.94%) and 86.09% (70.47%–95.32%), respectively. Moreover, LUS diagnostic accuracy for the diagnosis of pneumonia was not inferior to that of chest X-ray.ConclusionsBedside LUS evaluation contributes with high sensitivity and specificity to the differential diagnosis of Dyspnea. This holds true not only in the emergency setting, but also in the sub-acute Internal Medicine arena. A wider use of this portable technique in our wards is warranted.     

An Acute Care for Elders (ACE) unit in the emergency department

BackgroundEvidence for Comprehensive Geriatric Assessment (CGA) in discrete units is now well accepted but in the emergency department setting is not as clear and may offer significant benefits.MethodsWe evaluated the implementation of a four-bedded Acute Care for Elders (ACE) unit in the emergency department. Three cohorts of patients were recruited in a prospective before and after evaluation.ResultsPatients in the ACE unit were more likely to be discharged immediately (17.1% vs. 1.4% “before” and 7.7% “after”, P < 0.0005). Access to specialty beds on the day of admission was significantly different (71% “before”, 69% ACE unit, 60% “after”, P = 0.019). Length of stay in a non-specialty bed was not reduced compared to the “before” group (1.0 days vs. 1.2 days, P = 0.09) but was compared to the “after” group (1.0 days vs. 1.6 days, P = 0.0001). Length of stay was not significantly different (12.2 days “before” vs. 12.7 days ACE unit, P = 0.78 or vs. 11.7 days “after”, P = 0.54). Seven and 30-day readmission, 12-month mortality, admission to residential care or living at home were not significantly different.ConclusionACE units in the emergency department can reduce admissions and offer immediate CGA without adverse outcomes for patients.     

Relation between serum B-type brain natriuretic peptide level and complexity & severity of coronary artery disease in non-ST elevation myocardial infarction

BackgroundNeurohumoral activation of the heart can be monitored by measurements of systemic levels of natriuretic peptides, such as BNP. Patients with non ST-elevation myocardial infarction (NSTEMI) with elevated BNP levels had an increased mortality rate when compared with those with lower levels. The SYNTAX score is a novel anatomical tool characterizing coronary vasculature and grades the complexity of coronary artery disease.Patients and methodsThe study included 58 patients with NSTEMI “Group I” (72.5%) and 22 patients as a control “Group II” (27.5%) with typical chest pain, and coronary angiography revealed healthy coronaries. Analysis of blood samples for troponin-I, CKMB, and BNP levels was performed within 24 h of hospital admission, all patients underwent echocardiographic examination to exclude systolic dysfunction. Both groups were referred to coronary angiography.ResultsThis study included 58 patients with NSTEMI “Group I” (72.5%) and 22 patients as a control “Group II” (27.5%), the serum level of BNP was significantly higher in patients with the NSTEMI “group I” (37.7 ± 32.06) than the control “group II” (1.82 ± 5.9) p value (0.0001). The levels of BNP were positively correlated with the LAD involvement in coronary angiography. There was a positive correlation between the serum level of BNP and number of coronary vessels involved (r = 0.75) and Degree of SYNTAX score (r = 0.78).ConclusionThere was a significant relationship between the serum level of BNP and number of coronary arteries involved and complexity of the lesions in NSTEMI as regards SYNTAX score.     

Takotsubo Syndrome in a Rheumatoid Arthritis Patient Under Tofacitinib: A Case Report

We describe a case of a 57-year-old white woman treated for rheumatoid arthritis (RA) with tofacitinib 10 mg daily (started one year ago) and prednisolone 5 mg daily. She presented to the emergency department with a tight squeezing chest pain and shortness of breath for 7 h and the clinical evaluation revealed regional systolic dysfunction of the left ventricle, mimicking a myocardial infarction, in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. All changes were transient and resolved completely within 4 days. The diagnosis of Takotsubo cardiomyopathy (TKM) was established. This is, as far as we know, the first report of a case of TKM in a RA patient taking tofacitinib. Although the association has not been previously described and the precise cause cannot be identified in this patient, the association with tofacitinib should be considered given the etiopathogenic rationale and the absence of any other identifiable cause.     

Suspected coronary artery disease and myocardial infarction with normal coronary angiography: A heterogeneous but benign condition?

IntroductionPrevious follow-up studies of patients with symptoms and/or non-invasive tests suggestive of ischemia or an acute coronary syndrome and a normal coronary angiogram have reported a good prognosis.ObjectivesThe aim of this study was to evaluate the clinical characteristics and outcome of a cohort of patients with suspected ischemic heart disease and normal coronary arteries.MethodsA clinical follow-up was performed of 607 patients (mean age 62 ± 11 years) with symptoms or non-invasive tests suggestive of ischemia (544) or myocardial infarction (63) and normal coronary angiography. The occurrence of major cardiac events or of readmission due to chest pain was recorded during a mean follow-up of 33.6 ± 9.5 months after angiography.ResultsPatients with myocardial infarction were older (65.4 ± 11.1 vs. 61.9 ± 10.7, p=0.05), and the majority were women (68.3%). Hypertension was reported by 65.5% of patients, diabetes by 17.9%, dyslipidemia by 58.6%, smoking by 14% and family history of coronary artery disease in 11%. During follow-up no patient died from cardiovascular causes; three patients (0.5%) suffered myocardial infarction and 50 (8.3%) had recurrent chest pain leading to emergency admission. Patients with myocardial infarction had more events (20.6%) than those referred for angiography due to symptoms and/or positive non-invasive tests for ischemia (7.4%) (log-rank chi-square test: 13.6, p<0.0005).ConclusionThe incidence of risk factors was high. Our data suggest that patients with a normal angiogram had a good prognosis in spite of their baseline clinical presentation. A significant number of patients showed persistence of symptoms.     

Prognostic implications of percutaneous coronary interventions performed according to the appropriate use criteria for coronary revascularization

ObjectivesTo assess the prognostic implication of the ACCF/AHA/SCAI appropriate use criteria (AUC) for coronary revascularization in a cohort of non-acute coronary syndrome patients.BackgroundThe AUC for coronary revascularization were developed in order to deliver high-quality care; however, the prognostic impact of these criteria remains undefined.MethodsConsecutive patients (n = 3817) undergoing elective percutaneous coronary intervention (PCI) at MedStar Washington Hospital Center since the 2009 AUC publication were retrospectively grouped according to AUC as an “Appropriate,” “Inappropriate,” or “Undetermined” indication for PCI. Outcomes to 1 year were compared.ResultsPCI was categorized as “Appropriate” in 47%, “Inappropriate” in 1.8% and as “Uncertain” in 51% of patients. “Appropriate” PCI patients had a higher prevalence of hypertension and diabetes but a lower prevalence of smoking. “Inappropriate” PCI involved the treatment of more complicated lesions, with lower rates of drug-eluting stent utilization. While there were no differences in procedural complications among the 3 groups, in-hospital major complications and outcomes were worse for “Inappropriate” PCI patients. The 30-day (3.2% vs. 7% vs. 4.1%, p = 0.32) and 1-year (13.1% vs. 11.8% vs. 15.3%, p = 0.43) major adverse cardiac event rates of the “Appropriate,” “Inappropriate,” and “Uncertain” PCI patients, respectively, were comparable. In multivariable analysis, the procedural appropriateness was not associated with either in-hospital or 1-year outcome.ConclusionsAt large, physicians practicing in tertiary centers adhere to the AUC when subjecting patients with non-acute coronary syndrome to revascularization. The present analysis did not demonstrate association between long-term outcome and procedure appropriateness according to the AUC.     

Simulation Curriculum Can Improve Medical Student Assessment and Management of Acute Coronary Syndrome During a Clinical Practice Exam

BackgroundIt has been noted that increased focus on learning acute care skills is needed in undergraduate medical curricula. This study investigated whether a simulation-based curriculum improved a senior medical student’s ability to manage acute coronary syndrome as measured during a clinical performance examination (CPX). The authors hypothesized that simulation training would improve overall performance when compared with targeted didactics or historical controls.MethodsAll 4th-year medical students (n = 291) over 2 years at the authors’ institution were included in this study. In the 3rd year of medical school, the “control” group received no intervention, the “didactic” group received a targeted didactic curriculum, and the “simulation” group participated in small group simulation training and the didactic curriculum. For intergroup comparison on the CPX, the authors calculated the percentage of correct actions completed by the student. Data are presented as mean ± standard deviation with significance defined as P < 0.05.ResultsThere was a significant improvement in overall performance with simulation versus both didactics and control (P < 0.001). Performance on the physical examination component was significantly better in simulation versus both didactics and control, as was for diagnosis: simulation versus both didactics and control (P < 0.02 for all comparisons).Conclusionssimulation training had a modest impact on overall CPX performance in the management of a simulated acute coronary syndrome. Additional studies are needed to evaluate how to further improve curricula regarding unstable patients.     

Time to shift from contemporary to high-sensitivity cardiac troponin in diagnosis of acute coronary syndromes

Early rule-in and rule-out of non-ST-segment elevation myocardial infarction (NSTEMI) is a challenge. In patients with inconclusive findings on ECG, cardiac biomarkers play a crucial role in the diagnosis. The introduction of the new high-sensitive cardiac troponin test (hs-TnI assay) has changed the landscape of NSTEMI diagnosis.The new hs-TnI assay can detect troponin values at a lower level compared with a contemporary cardiac troponin (cTn) assay. The hs-cTnI assay has a coefficient of variation of ≤10%, well below the 99th percentile value. It reduces the time to diagnose acute myocardial infarction from 6 h to 3 h. A recent study has demonstrated that hs-cTnI can further reduce the time to 1 h in 70% of all patients with chest pain.The European Society of Cardiology 2015 guidelines recommend including a second sample of hs-cTnI within 3 h of presentation This increases the sensitivity of the hs-TnI assay from 82.3% (at admission) to 98.2% and negative predictive value from 94.7% (at admission) to 99.4%. Combining the 99th percentile at admission with serial changes in troponin increases the positive predictive value to rule in acute coronary syndrome from 75.1% at admission to 95.8% after 3 h.The 2015 ESC Guidelines recommend the use of a rapid rule out protocol (0 h and 1 h) when hs-cTnI with a validated 0 to1 h algorithm is available.Training and displaying the clinical algorithm depicting the role of hs-TnI assay in acute cardiac care units and in EDs are an efficient way to deliver the new standard of care to patients. Compared with contemporary troponin assays, the hs-cTn assay accelerates the diagnostic pathway to 0–1 h, thus reducing the time for diagnosis of NSTEMI and hence, its management.     

Implementation of high sensitivity cardiac troponin T measurement in the emergency department

BackgroundWe examined the diagnostic performance of high sensitivity cardiac troponin T (cTnThs) measurement and its ability to predict risk in unselected patients presenting to the emergency department with acute chest pain.MethodsWe conducted a retrospective analysis of 137 consecutive patients with chest pain (age range, 66 ± 16 years; 64% male). A final diagnosis of acute myocardial infarction was made using the “old” (cTnT fourth-generation assay, ≥0.04 μg/L) or the “new” cutpoint (cTnThs ≥0.014 μg/L).ResultsThe adjudicated final diagnosis of acute myocardial infarction significantly increased from 20 to 35 patients (a 75% increase) and troponin-positive nonvascular cardiac chest pain from 10 to 30 (a 200% increase) using cTnThs. The number of patients with unstable angina or troponin-negative nonvascular cardiac chest pain significantly decreased (P <.05). Diagnostic performance of cTnThs levels at admission was significantly higher compared to cTnT levels (area under the curve [AUC] 0.85 vs AUC 0.70; P <.05). cTnThs levels below the detection limit (<0.003 μg/L) had a negative predictive value of 100% to exclude acute myocardial infarction. The event rate during 6 months of follow-up was low in patients with cTnThs levels <0.014 μg/L, while patients with cTnT levels ≥0.04 μg/L were at increased, and patients with cTnThs ≥0.014 μg/L and cTnT <0.04 μg/L at intermediate risk of death or recurrent myocardial infarction (P = .002). Risk was highest in chest pain patients with dynamic changes of cTnThs levels >30%.ConclusionThe introduction of cTnThs assay displays an excellent diagnostic performance for the workup of patients with chest pain at the time of their initial presentation. Even small increases of cTnThs indicate increased risk for death or myocardial infarction during follow-up.     

Le spasme coronaire lié à la dobutamine chez les patients avec des échocardiographies de stress faussement positives : prévalence et facteurs prédictifs

Background and objectiveDobutamine stress echocardiography (DSE) is being consistently used as an exercise-independent stress modality aimed at the detection of coronary artery disease (CAD) and the evaluation of myocardial ischemia. It may though occasionally induce coronary vasospasm. In this study, we aimed to evaluate the prevalence and predictors of dobutamine-related coronary spasm in patients without known CAD and false positive DSE (positive DSE but no significant coronary lesions on angiogram).MethodsThree thousand nine hundred and fifty-two patients referred to our echocardiography laboratory for DSE between January 2010 and May 2012 were prospectively investigated. Those with positive DSE underwent coronary angiograms with systematic methylergometrine intracoronary injection in case of absence of significant coronary stenosis or spontaneous occlusive coronary spasm. Patients with spontaneous occlusive coronary spasm or positive methylergometrine test but no significant stenoses were enrolled and compared with those with positive DSE but no coronary lesions nor spontaneous or induced spasm (“true” false positive DSE).ResultsTwenty-nine patients with DSE-related vasospasm (19.4% of positive DES without known CAD) were compared with 56 patients with no lesions and no spasm (“true” false positive DSE). They were more frequently smokers (72.4% vs 37.5%; P = 0.003); they had more frequently dyslipidemia (79.3% vs 43%; P = 0.001); they also had a larger ischemic area at peak DSE (3.4 segments vs 2.7 segments; P = 0.05). On multivariate analysis, dyslipidemia (HR = 10.7; 95% CI = [2.7–42.1]; P = 0.001) and active smoking (HR = 6.1; 95% CI = [1.7–21.1]; P = 0.004) were found to be independent predictors of spasm-related DSE rather than “true” false positive DSE.ConclusionDSE-related coronary spasm is present in a significant proportion of patients with erroneously labelled “false” positive DSE and should systematically be ruled out. Dyslipidemia and active smoking were independent predictors of spasm rather than “true” false positive DSE.     

Calidad asistencial en el hombro doloroso agudo: ¿qué aporta la ecografía musculoesquelética?

For the purpose of assessing the impact of ultrasound in patients with acute shoulder pain, we conducted an analysis of quality health care indicators: need for reevaluation of the pain, rate of referral to specialized medicine and length of time in the emergency department. We reviewed the 1,433 records of patients attended to between 2015 and 2016.Thirty days after the first examination, 90 patients (10.1%) had returned to the control group (56 through the emergency department and 34 because of the), whereas, in the ultrasound (US) group, 14 (2.5%) had returned at least once (12 through the emergency department and 2 because of the PCC) (P < .001). The rate of referral to specialized medicine in the control group was 36.5%, whereas in the US group it was 6.21% (P < .0001). The average length of stay was 94.5 (standard deviation [SD] 34.3) minutes in the control group and 105.4 (SD 40.1) minutes in the US group (P < .0001). Our results suggest that the practice of shoulder ultrasound improves health care quality in these patients, at the cost of a slight increase in health care time.     

Admission insulin resistance index in non diabetic patients with acute coronary syndrome; clinical and angiographic features

BackgroundThe clinical implication of insulin resistance has extended beyond diabetes mellitus to include ischemic heart disease, dyslipidemia, hypertension and features of metabolic syndrome. Non diabetic patients with acute coronary syndrome and elevated admission insulin resistance index (AIRI) may have certain clinical angiographic and therapeutic strategies.ObjectivesIt was aimed to illustrate the value of AIRI in non diabetic patients with acute coronary syndrome (ACS) and identify the angiographic CAD severity in relation to AIRI.Study designCross sectional study.Patients and methodsIncludes 120 non diabetic patients presenting with acute chest pain who were admitted to the Coronary Care Unit. Admission glucose and insulin concentration were measured and the AIRI were calculated. ECG was carried out and the cases were grouped as; unstable angina (UA) (40 cases) and acute myocardial infarction (AMI) (40 cases). They were compared to 40 cases of the stable angina (SA) group and the control group (40 cases). The studied cases were examined clinically stressing on the other criteria of insulin resistance syndrome. The following laboratory tests were undertaken including random plasma glucose, HBA1-c, lipid profile, cardiac enzymes (CK-MB, LDH, troponin T). The angiographic study was carried out for patients of each diseased group and 20 cases of the stable angina group.ResultsAIRI was significantly elevated in AMI (3.9 ± 0.1) and UA (3.01 ± 0.2) when compared to the group of SA and the control group. AIRI was significantly higher in AMI when compared to the UA group. Coronary angiography revealed one coronary vessel involvement in 10%, 20%, and 10% of SA, UA and AMI, respectively. While, two vessel involvement was detected in 0%, 30%, and 60% of SA, UA and AMI, respectively. Three coronary vessel disease was not detected in SA but was evident in 5% of UA and 30% of AMI. The relation of AIRI of the studied groups by the calculated Chi-square revealed a significant elevation of AIRI in AMI and UA. Cases with three vessel affection demonstrated higher AIRI.ConclusionElevated AIRI can predict coronary artery events in non diabetic patients with acute chest pain. Multiple coronary vessel involvement is common in such cases and suitable planned invasive therapeutic strategies have to be considered.     

Perte de capture par ischémie myocardique : à propos d’un cas

We report the case of a patient with pacemaker who presented chest pain during exercise followed by fainting. He has a history of arterial hypertension and diabetes. The initial examination was normal; the ventricular stimulation threshold was 1.125 volts (V) and cardiac enzymes were normal. Stress test has reproduced chest pain followed by loss of pacemaker capture and asystole. Coronary angiography showed a tight stenosis of the proximal anterior interventricular artery dilated by a drug-eluting stent. The control of stress test was normal. A stent thrombosis eight days later led to an acute coronary syndrome with recurrent syncope due to the loss of ventricular capture. The ventricular pacing threshold was then 2.25 V. After revascularization and stabilization of the patient's clinical status, this threshold returned to 1.125 V. This clinic case has confirmed that coronary artery disease could increase pacing threshold. It also highlights the usefulness of automatic capture algorithms in coronary patients. The stress test cannot only help to detect coronary artery disease but also allows the optimization of programming the pacemaker.     

Consenso mexicano sobre dolor torácico no cardiaco

IntroductionNon-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases.AimTo present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients.MethodsThree general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i) definitions, epidemiology, and pathophysiology; (ii) diagnosis, and (iii) treatment. The statements underwent 3 rounds of voting, utilizing the Delphi system. The final statements were those that reached > 75% agreement, and they were rated utilizing the GRADE system.Results and conclusionsThe final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4 weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.     

Relation between the GRACE score and severity of atherosclerosis in acute coronary syndrome

BackgroundPatients with non-ST-elevation acute coronary syndrome are heterogeneous in terms of clinical presentation and immediate- and long-term risk of death or non-fatal ischemic events. The aim of the present study was to evaluate the relationship between the Global Registry of Acute Coronary Events (GRACE) score and severity of coronary artery disease angiographically evaluated by Gensini score in patients with non-ST-elevation acute coronary syndrome.MethodsA total of 245 patients with non-ST-elevation acute coronary syndrome were enrolled to the study. Based on the GRACE risk score classification system, the patients were divided into low- (n = 97, 39.6%), intermediate- (n = 84, 34.3%), and high- (n = 64, 26.1%) risk groups. All patients underwent coronary angiography within five days after admission.ResultsThe Gensini scores were 26 ± 29 in the low-risk group, 29 ± 19 in the intermediate-risk group, and 38 ± 23 in the high-risk group (p = 0.016). The low-risk group was significantly different from the high-risk group (p = 0.013), and the difference from the intermediate-risk group almost reached significance. Normal, noncritical, one and two, or multivessel disease were identified in 15 (6.1%), 31 (12.7%), 75 (30.6%), and 124 (50.6%) patients, respectively. The prevalence of multivessel disease was 28% in the low-risk group, 30% in the intermediate-risk group, and 42% in the high-risk group. The high-risk group was significantly different from the low-risk group (p < 0.01).ConclusionOur study demonstrates that the GRACE score has significant value for assessing the severity and extent of coronary artery stenosis in patients with non-ST-elevation acute coronary syndrome.     

Typical takotsubo cardiomyopathy in suspected ST elevation myocardial infarction patients admitted for primary percutaneous coronary intervention

AimTakotsubo cardiomyopathy (TCM) is increasingly being recognised in patients admitted with suspected acute coronary syndrome, as access to angiography and echocardiography is much quicker than before. We aimed to analyse the prevalence of typical TCM in patients admitted for primary percutaneous coronary intervention (PPCI) with suspected ST elevation myocardial infarction (STEMI) to a single tertiary centre in United Kingdom.MethodsAll patients admitted to our unit with suspected STEMI from September 2009 to November 2011 were included for analysis.ResultsOf the 1875 patients admitted, 17 patients (all female) with mean age of 69 ± 11.9 yrs were identified to have clinical features of typical TCM, thus giving an overall prevalence of 0.9% in PPCI admissions (3.2% prevalence in women). The admission ECG showed ST elevation in 14 patients (82%) and 3 had LBBB (18%). In the 16 patients who had raised hs Troponin (normal range < 14), the mean level was 921 ± 668 (median 778, range 110 to 2550) ng/L. Two patients survived cardiac arrest and one had apical thrombus on presentation. Left ventricular function was severely impaired (EF ≤ 30%) in 2 patients, whilst it was moderately impaired (EF 31–50%) in others. During a mean follow-up period of 22 ± 7 months (range 8–36 months), there was no mortality or recurrence.ConclusionThis is the first observational study to report the prevalence of typical TCM in patients admitted for PPCI in “real-world” practice. Though this condition is not benign during the acute episode, there is a good survival outcome if managed appropriately during the acute phase.     

Use of multislice CT for the evaluation of emergency room patients with chest pain: The so‐called “Triple rule‐out”

Recent advances in computed tomography (CT) technology have made high resolution noninvasive coronary angiograms possible. Multiple studies involving over 2,000 patients have established that coronary CT angiography (CCTA) is highly accurate for delineation of the presence and severity of coronary atherosclerosis. The high negative predictive value (>95%) found in these studies suggests that CCTA is an attractive option for exclusion of coronary artery disease in properly selected emergency department patients with acute chest pain. CT is also a well established and accurate tool for the diagnosis of acute aortic dissection and pulmonary embolism. Recent technical developments now permit acquisition of well‐opacified images of the coronary arteries, thoracic aorta and pulmonary arteries from a single CT scan. While this so called “triple‐rule out” scan protocol can potentially exclude fatal causes of chest pain in all three vascular beds, the attendant higher radiation dose of this method precludes its routine use except when there is sufficient support for the diagnosis of either aortic dissection or pulmonary embolism. This article provides an overview of CCTA, and reviews the clinical evidence supporting the use of this technique for triage of patients with acute chest pain. © 2008 Wiley‐Liss, Inc.     

Two-year prognosis of acute coronary syndrome during the first wave of the coronavirus disease 2019 pandemic

BackgroundThe first wave of the coronavirus disease 2019 pandemic significantly changed behaviour in terms of access to healthcare.AimTo assess the effects of the pandemic and initial lockdown on the incidence of acute coronary syndrome and its long-term prognosis.MethodsPatients admitted for acute coronary syndrome from 17 March to 6 July 2020 and from 17 March to 6 July 2019 were included. The number of admissions for acute coronary syndrome, acute complication rates and 2-year rates of survival free from major adverse cardiovascular events or death from any cause were compared according to the period of hospitalization.ResultsIn total, 289 patients were included. We observed a 30 ± 3% drop in acute coronary syndrome admissions during the first lockdown, which did not recover in the 2 months after it was lifted. At 2 years, there were no significant differences in the combined endpoint of major adverse cardiovascular events or death from any cause between the different periods (P = 0.34). Being hospitalized during lockdown was not predictive of adverse events during follow-up (hazard ratio 0.87, 95% confidence interval 0.45–1.66; P = 0.67).ConclusionsWe did not observe an increased risk of major cardiovascular events or death at 2 years from initial hospitalization for patients hospitalized during the first lockdown, adopted in March 2020 in response to the coronavirus disease 2019 pandemic, potentially as a result of the lack of power of the study.     

The value of human heart-type fatty acid binding protein in diagnosis of patients with acute chest pain

BackgroundThe aim was to determine the efficacy of heart-type fatty acid-binding protein (H-FABP) compared with routinely myoglobin (MYO), creatine kinase-MB (CK-MB) and cardiac troponin-I (cTn-I) in the early diagnosis of acute myocardial infarction (AMI) in patients presenting with acute chest pain.Methods and resultsThe patients were classified as AMI (n = 22), unstable angina (UA, n = 20) and non-cardiac chest pain (NCCP, n = 15) within 3 h and 6 h of acute chest pain according to the American College/European Society of Cardiology; and normal healthy subjects (controls, n = 10). Blood H-FABP levels were measured by ELISA and compared with cTn-I, CK-MB and MYO in all subjects. The diagnostic sensitivity, specificity and receiver operating characteristic (ROC) curve were evaluated. Serum H-FABP, MYO, CK-MB and cTn-I were significantly higher in AMI more than the UA, NCCP (non-AMI) and control groups within 6 h. However, Serum H-FABP, MYO and CK-MB were significantly elevated within 0–3 h and extend more within 3–6 h in AMI versus non-AMI. The cutoff value of H-FABP in AMI was 21.85 ng/ml within 3 h, and has diagnostic sensitivity (81.8%) equal to that of CK-MB and cTn-I but superior to that of MYO (72.7%). However, H-FABP has higher specificity (88.2%) equal to that of MYO but superior to that of CK-MB and cTn-I. This trend extends to within 6 h as well. Moreover, ROC curve areas for H-FABP were significantly higher (p < 0.05) than other biomarkers <6 h after the onset of chest pain.ConclusionH-FABP can be used as a sensitive biomarker for myocardial injury in early stage.     

Electrocardiography as a predictor of left main or three-vessel disease in patients with non-ST segment elevation acute coronary syndrome

IntroductionAcute coronary syndrome remains the leading cause of morbidity and mortality worldwide. It will continue to rise as the prevalence of patients with obesity and diabetes increases. Patients with non-ST segment elevation acute coronary syndrome had a bad prognosis in patients with left main ± three vessel diseases, so early identification of these patients by electrocardiography if ST segment elevation in lead aVR ?0.5 m and maximal QRS duration of ?90 ms is important for the selection of optimal treatment.Materials and methodsThe study was designed as a multicenter cross-sectional study that was conducted on 150 patients presenting with non-ST segment elevation acute coronary syndromes, 80 patients had non-ST segment elevation myocardial infarction and 70 patients had unstable angina in the period between January 2009 till January 2010. All patients had full history, clinical examination, laboratory investigations including lipid profile, blood glucose, cardiac Troponin T and renal function, also electrocardiography and coronary angiography was done to prove the diagnosis. ECG was analyzed to assess the degree of ST segment elevation in aVR, ST segment depression in other leads and the maximal QRS was analyzed. Coronary angiography was done to all patients with detection of the presence of left main 50% stenosis at least with or without other three significant coronary vessels showing 70% stenosis or more to be included in 67 patients in group I. Group II include 83 patients with normal coronaries or significant stenosis in one or two vessels.ResultsLeft main coronary stenosis with or without three significant coronary vessel stenosis occurs in 67 patients (44.7%) in group I vs. 83 patients (55.3%) in group II (i.e. without left main disease or three vessel disease). The mean age of the patients 59 ± 9 years which was not significant in both the groups (P > 0.05). The following also were not significant gender, smoking, dyslipidemia, renal impairment, hypertension and positive family history. Diabetes was considered significant in 44 patients (65.7%) in group I in comparison to 34 patients (41%) in group II (P < 0.003). Positive Troponin T was also significant in group I in 47 patients (70.1%) vs. 33 patients (39.8%) in group II. ST segment elevation ?0.5 mm in lead AVR is significant in group I in 52 patients (77.6%) vs. 29 patients (34.9%) in group II (P < 0.001). ST segment depression ?0.5 mm in leads other than aVR is significant in group I in 56 patients (83.6%) vs. 41 patients (49.4%) in group II (P < 0.001). The presence of QRS duration > 90 ms in the admission ECG was significant in group I in 45 patients (67.2%) vs. 16 patients (19.3%) in group II (P < 0.001).ConclusionST-segment elevation in lead aVR ?0.5 mm and QRS duration ?90 ms are good electrocardiographic predictors of left main or three vessel disease in patients with non-ST segment elevation acute coronary syndrome.