Initial Evaluation of Chest Pain

Improvement of Emergency Department Chest Pain Evaluation Using Hs-cTnT and a Risk Stratification Pathway

BACKGROUND

Chest pain is among the most common reasons for presentation to the emergency department (ED) worldwide. Additional studies on most cost-effective ways of differentiating serious vs. benign causes of chest pain are needed.

OBJECTIVES

Our study aimed to evaluate the effectiveness of a novel risk stratification pathway utilizing 5th generation high-sensitivity cardiac troponin T assay (Hs-cTnT) and HEART score (History, Electrocardiogram, Age, Risk factors, Troponin) in assessing nontraumatic chest pain patients in reducing ED resource utilization.

METHODS

A retrospective chart review was performed 6 months prior to and after the implementation of a novel risk stratification pathway that combined hs-cTnT with HEART score to guide evaluation of adult patients presenting with nontraumatic chest pain at a large academic quaternary care ED. Primary outcome was ED length of stay (LOS); secondary outcomes included cardiology consult rates, admission rates, number of ED boarders, and number of eloped patients.

RESULTS

A total of 1707 patients and 1529 patients were included pre- and postimplementation, respectively. Median overall ED LOS decreased from 317 to 286 min, an absolute reduction of 31 min (95% confidence interval 22-41 min), after pathway implementation (p < 0.001). Furthermore, cardiology consult rate decreased from 26.9% to 16.0% (p < 0.0001), rate of admission decreased from 30.1% to 22.7% (p < 0.0001), and number of ED boarders as a proportion of all nontraumatic chest pain patients decreased from 25.13% preimplementation to 18.63% postimplementation (p < 0.0001).

CONCLUSIONS

Implementation of our novel chest pain pathway improved numerous ED throughput metrics in the evaluation of nontraumatic chest pain patients.

A Heart Rate-Dependent Protocol of "One-Stop" Computed Tomography Angiography of Coronary Combined with Pulmonary Arteries Reduces the Dosages of Contrast Agent

Background:

The personalized, heart rate-dependent computed tomography angiography (CTA) protocol can reduce the use of contrast medium (CM) and the radiation dose. This is especially beneficial for patients with CTA of coronary combined with pulmonary arteries.

Purpose:

To evaluate the feasibility of low CM in one-stop coronary and pulmonary arterial CTA tailored by patients’ heart rate.

Material and Methods:

94 patients set to undergo CTA of coronary combined with pulmonary arteries with one-stop scans. Patients were prospectively randomized into two groups: For group A (n = 47), the timing of the scans was determined according to the patient’s HR using 30 mL CM; For group B (n = 47), in which the routine bolus tracking was applied by setting the ascending aortic threshold of 80 HU with 70 mL CM, scans were performed simultaneously.

Results:

Compared with group B, group A had slightly higher computed tomography (CT) value and image quality of pulmonary artery (CT value: group A 484.7HU; group B 457.9HU; t = 2.446, P = .016; image quality: χ2 = 8.292, P = .016), but in coronary artery wasn’t statistically different between two groups(image quality: χ2 = 2.516, P = .642).

Conclusion:

The heart rate-dependent CM injection protocol can greatly reduce the use of CM, simplify the work-flow, and may obtain comparable or even better image quality compared with the routine bolus tracking.

Higher Plasma Aldosterone Concentrations Are Associated With Elevated Risk of Aortic Dissection and Aneurysm: a Case-Control Study

BACKGROUND

Animal models demonstrate circulating aldosterone leads to aortic dissection and aneurysm, whereas data from humans are lacking. Therefore, we aimed to examine the associations of plasma aldosterone concentrations (PAC) with aortic dissection and aneurysm.

METHODS

We identified patients with aortic dissection and aneurysm with assessed PAC before disease onset from hospital-based electronic database and set as case group. Simultaneously, age and gender-matched cohort with PAC measurement whereas without aortic dissection and aneurysm were selected as control group using ratio of 1:4. Multi-variable logistic regression analysis was used to assess the relationship of PAC with aortic dissection and aneurysm.

RESULTS

Totally, 133 cases and 531 controls (all hypertensive) were enrolled between 2004 and 2021, with 77.9% men, mean age of 55.5 years and PAC of 13.9 ng/dL. Case group showed significantly higher PAC(14.51 versus 13.65 ng/dL, P=0.012) than did control group. In logistic regression analysis, higher PAC exhibited 1.68-fold higher odds (95% CI, 1.14-2.48, P=0.008) for presence of aortic dissection and aneurysm, significant in adjusted model (odds ratio, 1.69 [95% CI, 1.11-2.57], P=0.015). In stratified analysis, the association between the 2 was observed in women of all ages and in men with coronary artery disease. Sensitivity analysis by excluding those under interfering agents at PAC measurement and those with primary aldosteronism did not change the relationship of the 2.

CONCLUSIONS

Higher PAC is associated with the increased odd for aortic dissection and aneurysm in patients with hypertension, even in the absence of primary aldosteronism, implying that PAC might be a target for prevention.

High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update)

Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.

The diagnostic accuracy of the mediastinal width on supine anteroposterior chest radiographs with nontraumatic Stanford type A acute aortic dissection

Background

Nontraumatic Stanford type A acute aortic dissection is a life‐threatening condition; thus, the ability to make a precise diagnosis of nontraumatic Stanford type A acute aortic dissection is essential for the emergency physician. Several reports have shown that the mediastinal widening on a chest radiograph is useful for the diagnosis of nontraumatic Stanford type A acute aortic dissection; however, the exact cutoff value of the mediastinal width on plain radiographs is rarely defined.

Methods

A single‐center retrospective case‐control study was conducted between October 1, 2013, and March 31, 2015. We evaluated the maximal mediastinal width of the anteroposterior chest X‐ray at the level of the aortic knob in the supine position between patient groups with and without nontraumatic Stanford type A acute aortic dissection.

Results

We enrolled 72 patients (36 patients with nontraumatic Stanford type A acute aortic dissection and 36 patients without nontraumatic Stanford type A acute aortic dissection). The median mediastinal width of patients with nontraumatic Stanford type A acute aortic dissection was significantly larger than that of patients without nontraumatic Stanford type A acute aortic dissection (100.7 mm vs 77.7 mm, P < .01). The optimal cutoff level was 87 mm (sensitivity, 81%; specificity, 89%). Using multivariable logistic regression, the odds ratio of a mediastinal width of >87 mm for a diagnosis nontraumatic Stanford type A acute aortic dissection was 57.1 (95% confidence interval, 11.2‐290.2).

Conclusion

A mediastinal width of >87 mm showed high sensitivity in the diagnosis of probable nontraumatic Stanford type A acute aortic dissection.

Age and clinical outcomes in patients presenting with acute coronary syndromes

CONTEXT

Elderly patients have more cardiovascular risk factors and a greater burden of ischemic disease than younger patients.

AIMS

To examine the impact of age on clinical presentation and outcomes in patients presenting with acute coronary syndrome (ACS).

METHODS AND MATERIAL

Collected data from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2), which is a prospective multicenter study from six adjacent Arab Middle Eastern Gulf countries. Patients were divided into 3 groups according to their age: ≤50 years, 51-70 years and >70 years and their clinical characteristics and outcomes were analyzed. Mortality was assessed at one and 12 months.

STATISTICAL ANALYSIS USED

One-way ANOVA test for continuous variables, Pearson chi-square (X (2)) test for categorical variables and multivariate logistic regression analysis for predictors were performed.

RESULTS

Among 7930 consecutive ACS patients; 2755 (35%) were ≤50 years, 4110 (52%) were 51-70 years and 1065 (13%) >70 years old. The proportion of women increased with increasing age (13% among patients ≤50 years to 31% among patients > 70 years). The risk factor pattern varied with age; younger patients were more often obese, smokers and had a positive family history of CAD, whereas older patients more likely to have diabetes mellitus, hypertension, and dyslipidemia. Advancing age was associated with under-treatment evidence-based therapies. Multivariate logistic regression analysis after adjusting for relevant covariates showed that old age was independent predictors for re-ischemia (OR 1.29; 95% CI 1.03-1.60), heart failure (OR 2.8; 95% CI 2.17-3.52) and major bleeding (OR 4.02; 95% CI 1.37-11.77) and in-hospital mortality (age 51-70: OR 2.67; 95% CI 1.86-3.85, and age >70: OR 4.71; 95% CI 3.11-7.14).

CONCLUSION

Despite being higher risk group, elderly are less likely to receive evidence-based therapies and had worse outcomes. Guidelines adherence is highly recommended in elderly.

ST Elevation Myocardial Infarction in the elderly

Acute coronary syndromes (ACS) are the leading causes of death in the elderly. The suspicion and diagnosis of ACS in this age group is more difficult, since typical angina is less frequent. The morbidity and mortality is greater in older age patients presenting ACS. Despite the higher prevalence and greater risk, elderly patients are underrepresented in major clinical trials from which evidence based recommendations are formulated. The authors describe, in this article, the challenges in the diagnosis and management of ST elevation myocardial infarction in the elderly, and discuss the available evidence.

High-risk chief complaints I: chest pain--the big three

Chest pain is one of the most frequently seen chief complaints in patients presenting to emergency departments, and is considered to be a "high-risk" chief complaint. The differential diagnosis for chest pain is broad, and potential causes range from the benign to the immediately life-threatening. Although many (if not most) emergency department patients with chest pain do not have an immediately life-threatening condition, correct diagnoses can be difficult to make, incorrect diagnoses may lead to catastrophic therapies, and failure to make a timely diagnosis may contribute to significant morbidity and mortality. Several atraumatic "high-risk" causes of chest pain are discussed in this article, including myocardial infarction and ischemia, thoracic aortic dissection, and pulmonary embolism. Also included are brief discussions of tension pneumothorax, esophageal perforation, and cardiac tamponade.

Usefulness of three posterior chest leads for the detection of posterior wall acute myocardial infarction

A significant proportion of patients with myocardial infarction are missed upon initial presentation to the emergency department. The 12-lead electrocardiogram (ECG) has a low sensitivity for the detection of acute myocardial infarction, especially if the culprit lesion is in the left circumflex artery (LCA). This study was designed to evaluate the benefit of adding 3 posterior chest leads on top of the 12-lead ECG to detect ischemia resulting from LC disease, using a model of temporary balloon occlusion to produce ischemia. We studied 53 consecutive patients who underwent clinically indicated coronary interventions. At the time of coronary angiography, the balloon was inflated to produce complete occlusion of the proximal LCA. We recorded and analyzed the changes noted on the 15-lead ECG, which included 3 posterior leads in addition to the standard 12 leads. In response to acute occlusion of the LCA, the posterior chest leads showed more ST elevation than the other leads, and more patients had ST elevation in the posterior leads than in any other lead. The 15-lead ECG was able to detect>or=0.5 mm (74% vs 38%, p<0.0001) and >or=1 mm (62% vs 34%, p<0.0001) ST elevation in any 2 contiguous leads more frequently than the 12-lead ECG. In conclusion, the 15-lead ECG identified more patients with posterior myocardial wall ischemia because of temporary balloon occlusion of the LC than the 12-lead ECG. This information may enhance the detection of posterior MI in the emergency department and potentially facilitate early institution of reperfusion therapy.

Cardiovascular Risk in Women with Nonspecific Chest Pain

Evaluation of: Robinson JG, Wallace R, Limacher M et al.: Cardiovascular risk in women with non-specific chest pain (from the Women's Health Initiative hormone trials). Am. J. Cardiol. 102(6), 693–699 (2008). Chest pain is common, and often a specific cause fails to be diagnosed. There is particular concern that many women with a diagnosis of nonspecific chest pain (NSCP) may have atypical indications of coronary artery disease. Analysis of data from the Women's Health Initiative hormone therapy trials, amongst 24,834 postmenopausal women aged 50–79 years who were initially free of cardiovascular disease, found that NSCP was associated with a 139% (95% CI: 46–292%) increase in the risk of subsequent angina. Similar proportional increases in risk were found for cardiac surgery or interventions and nonfatal myocardial infarction. Thus, a diagnosis of NSCP in a woman, using current technology, does not rule out the possibility of increased coronary risk. It would be prudent to treat women with NSCP as being at a higher than average risk of cardiovascular disease

The triple work-up for emergency department patients with acute chest pain: how often does it occur?

OBJECTIVES

To measure the degree of overlap and diagnostic yield for evaluations of acute coronary syndrome (ACS), pulmonary embolism (PE), and aortic dissection (AD) among Emergency Department (ED) patients.

METHODS

We conducted a cross-sectional descriptive study of consecutive adult patients seen in the ED of a 78,000-annual-visit urban academic medical center. Patients who had received at least one of eight of the tests used in our ED to diagnose these three diseases were identified through three methods, and a final study population list was created. Overlap of evaluations and diagnostic yields were calculated by simple descriptive statistics.

RESULTS

Over a 2-week period, 626 patient encounters among 622 unique patients were identified. Among these 626 visits, 139 (22%) included diagnostic tests for more than one of the three diagnoses of interest. The majority of these multiple tests were for ACS plus PE (n = 121, 87% of all multiple tests), whereas a minority of patients received tests for ACS plus AD (n = 14, 10% of all multiple tests) or for the "triple work-up" of ACS plus PE plus AD (n = 4, 2.9% of all multiple tests).

CONCLUSION

Although the "triple work-up" evaluation for ACS, PE, and AD is relatively uncommon, a significant number of ED patients who are evaluated for at least one of these three major chest pain syndromes receive simultaneous testing for one of the others.

Circumferential Involvement of an Acute Type B Aortic Dissection: A Unique Case

A case of a 35-year-old woman with acute circumferential type B aortic dissection is presented. A review of the literature demonstrated that circumferential aortic dissection is limited to a small number of case reports and a small case series of type A lesions. This is the first report of a circumferential type B dissection. The case highlights the need to fully evaluate patients with acute aortic dissection and illustrates the unique data provided by transesophageal echocardiography and helical computed tomographic angiography.

Evaluation of the Elderly Patient with Acute Chest Pain

Chest pain is one of the most common and serious chief complaints. Geriatricians must be well versed in evaluating elderly patients who have chest pain. This article discusses the initial diagnostic evaluation of elderly patients with chest pain. Specific emphasis is placed on identifying acute coronary syndromes, aortic dissection, pulmonary embolism, and pericarditis with cardiac tamponade. By understanding the different presentations of these potentially life-threatening emergencies, the geriatrician will be better prepared to distinguish them from less dire conditions and to initiate prompt treatment.

Identifying Chest Pain Emergencies in the Primary Care Setting

The majority of patients presenting to a primary care physician with acute chest pain will have non-life-threatening etiologies. Nevertheless, catastrophic cause of chest pain such as ACS, AD, PE, esophageal perforation, and pericarditis must be considered in the differential diagnosis. Often, these deadly conditions have atypical clinical presentations that must be recognized. Furthermore, the physical examination can be deceptively benign in patients harboring a catastrophic etiology of chest pain. By identifying these atypical presentations, recognizing the utility of the physical examination, and understanding of the limitations of traditional diagnostic imaging, primary care physicians can effectively diagnose patients who have life-threatening cause of acute chest pain.