Evaluation of acute chest pain: Evolving paradigm of coronary risk scores and imaging

Risk Stratification of Acute-Onset Chest Pain: SVEAT Score Versus HEART and TIMI Scores

Introduction Acute chest pain is a frequently encountered symptom in the emergency department. Despite the availability of various chest pain risk scores, their effectiveness in identifying low-risk patients suitable for safe and early discharge is inadequate. Moreover, clinical data collected at the initial stage, which has valuable discriminatory ability, is often underutilized. This study aims to assess the effectiveness of the Symptoms, history of Vascular disease, ECG, Age, and Troponin I (SVEAT) score in predicting major adverse cardiovascular events (MACE) in acute-onset chest pain, compared with the pre-existing History, ECG, Age, Risk factors, and Troponin I (HEART) and Thrombolysis In Myocardial Infarction (TIMI) scores. Methodology This prospective study utilizing non-probability convenience sampling was conducted in the emergency medicine department of a tertiary care hospital in Rawalpindi, Pakistan, for a period of five months from July 2022 to November 2022. The study included patients aged >45 years who presented primarily with chest pain lasting for at least five minutes but less than 24 hours and with a lack of acute ECG changes indicative of ST-elevation acute coronary syndrome (STE-ACS). Patients who were hemodynamically unstable were excluded. All patients were assessed for the calculation of SVEAT, TIMI, and HEART scores. All patients were followed for a period of 30 days to assess the incidence of MACE. Results A total of 60 patients were included. The mean age was 61.5±9.1 years while 31 (51.7%) patients were females. Diabetes was the most prevalent comorbidity (n=32; 53.3%). Regarding MACE, nine (15%) patients developed ACS and underwent percutaneous coronary intervention (PCI). Two patients (3.3%) experienced heart failure. Six (10%) patients also underwent PCI in the absence of ACS while two (3.3%) patients developed sudden cardiac death. Area-under-curve (AUC) values were determined for SVEAT (0.843; 95%CI: 0.74-0.94), TIMI (0.742; 95%CI: 0.62-0.86), and HEART scores (0.840; 95%CI: 0.74-0.94). A cut-off level of 3.5 SVEAT points obtained a sensitivity of 63.2% and specificity of 75.6% in predicting 30-day MACE. Conclusion SVEAT score potentially lacks the appropriate sensitivity level to predict a significant number of major adverse cardiovascular events compared to contemporary risk stratification scores. Therefore, the SVEAT criteria need re-evaluation as a screening tool for risk assessment in acute chest pain.

Spontaneous spleen rupture mimicking non-specific thoracic pain: A rare case in physiotherapy practice

BACKGROUND

The prevalence of Thoracic Pain (TP) is estimated to be low compared to other common musculoskeletal disorders such as nonspecific low back pain (LBP). Notably, compared to LBP, TP or referral pain to the thoracic area potentially may involve serious pathologies. Visceral referral of pain may present to the thoracic spine or anteriorly in the abdomen or chest. Rupture of the spleen in the absence of trauma or previously diagnosed disease is rare and rarely documented in emergency medicine literature. The incidence of red flags are higher in the thoracic area in comparison to the lumbar or cervical regions, but TP can also be of musculoskeletal origin and for this reason it is important to assess the origin of pain.

CASE DESCRIPTION

This case report describes the clinical history, evaluation and management of a 60-year-old complaining of upper thoracic, bilateral shoulder, and right upper quadrant abdominal pain. The patient's clinical findings from a physiotherapist's assessment led to a referral to a physician to explore a potential non-musculoskeletal origin. A splenectomy was required due to a non-traumatic rupture of the spleen. After 20 days of hospitalization from the surgery, the patient returned to all normal activities of daily living.

DISCUSSION AND CONCLUSION

The purpose of this current case report is to describe the clinical reasoning of a physiotherapist screening a patient who presented with thoracic pain due to a spontaneous rupture of the spleen, that resulted in a referral to another health practitioner.

Predictive Value of the HEART Score Combined with Hypersensitive C-Reactive Protein for 30 d Adverse Cardiovascular Events in Patients with Acute Chest Pain

Purpose

This study aimed to explore the predictive value of the HEART score combined with hypersensitive C-reactive protein (hs-CRP) for 30 d major adverse cardiovascular events (MACEs) in patients with acute chest pain.

Methods

103 patients with acute chest pain admitted to the emergency department of our hospital from May 2020 to May 2022 were selected as the study subjects. The patients' HEART score and plasma hs-CRP level were recorded. The patients were followed up for 30 d to observe whether MACE occurred.

Results

Among 103 patients with acute chest pain, MACE occurred in 8 cases within 30 d of follow-up, and the probability of MACE was 7.76%. There was a statistically significant difference in 30 d MACE risk among patients with different HEART score stratification (P < 0.05). The age, HEART score, and hs-CRP levels of patients in the MACE group were higher than those in the non-MACE group (P < 0.05). The HEART score and the hs-CRP level were independent risk factors for 30 d MACE in patients with acute chest pain (P < 0.05). The AUC of the HEART score combined with hs-CRP in the occurrence of 30 d MACE in patients with acute chest pain was 0.901, which was significantly higher than 0.720 and 0.758 of single detection.

Conclusion

The HEART score combined with hs-CRP can better predict the occurrence of 30 d MACE in patients with acute chest pain.

Coronary CT angiography and serum biomarkers are potential biomarkers for predicting MACE at three-months and one-year follow-up

Aims

To assess the prognostic value of coronary computed tomography angiography (CTA) and serum biomarkers for the prediction of major adverse cardiac events (MACE) at three-month and one-year follow-ups.

Methods and Results

A total of 720 patients with acute chest pain and normal electrocardiography (ECG) were included in the prospective cohort study. These patients received both coronary CTA screening and serum biomarkers testing, followed by three-month and one-year follow-ups for the occurrence of major adverse cardiac events (MACE). The primary outcome was the occurrence of MACE, which is defined as acute coronary syndrome (ACS), nonfatal MI, and all-cause mortality. The MACE rate was 17.8% (128 cases) and 25.2% (182 cases) at three-months and one-year follow-up. ApoB/apoA1(OR = 7.45, P < 0.001) and the number of atherosclerotic vessels (OR = 2.86, P < 0.001) were independent predictors for MACE at the three-month follow-up, so were apoB/apoA1 (OR = 5.23, P = 0.003), Serum amyloid protein A (SAA, OR = 1.04, P < 0.001) and the number of atherosclerotic vessels (OR = 2.54, P < 0.001) at the one-year follow-up. While apoB/apoA1 suggested its sensitivities of 84% for predicting MACE at three-month follow-ups, the number of atherosclerotic vessels had 81% specificity at one-year follow-up.

Conclusions

Among patients with acute chest pain and normal ECG, apoB/apoA1, SAA and the number of atherosclerotic vessels are the most powerful predictors of MACE at three-month and one-year follow-ups.

Desempenho Diagnóstico da Angiotomografia Computadorizada e da Avaliação Seriada de Troponina Cardíaca Sensível em Pacientes com Dor Torácica e Risco Intermediário para Eventos Cardiovasculares

Fundamento

A angiotomografia coronária (ATC) tem sido usada para avaliação de dor torácica principalmente em pacientes de baixo risco, e poucos dados existem com pacientes em risco intermediário.

Objetivo

Avaliar o desempenho de medidas seriadas de troponinas sensíveis e de ATC em pacientes de risco intermediário.

Métodos

Um total de 100 pacientes com dor torácica, TIMI score 3 ou 4 e troponina negativa foram prospectivamente incluídos. Todos os pacientes foram submetidos à ATC, e aqueles com obstruções ≥ 50% foram encaminhados à cineangiocoronariografia. Pacientes com lesões < 50% recebiam alta hospitalar, receberam alta e foram contatados 30 dias depois por telefonema para avaliação dos desfechos clínicos. Os desfechos foram hospitalização, morte, e infarto agudo do miocárdio em 30 dias. A comparação entre os métodos foi realizada pelo teste de concordância kappa. O desempenho das medidas de troponina e da ATC na detecção de lesões coronárias significativas e desfechos clínicos foi calculado. Os resultados foram considerados estatisticamente significativos quando p <0,05.

Resultados

Estenose coronária ≥ 50% na ATC foi encontrada em 38% dos pacientes e lesões coronárias significativas na angiografia coronária foram encontradas em 31 pacientes. Dois eventos clínicos foram observados. A análise de concordância Kappa mostrou baixa concordância entre as medidas de troponina e ATC na detecção de lesões coronárias significativas (kappa = 0,022, p = 0,78). O desempenho da ATC para detectar lesões coronárias significativas na angiografia coronária ou para prever eventos clínicos em 30 dias foi melhor que as medidas de troponina sensível (acurácia de 91% versus 60%).

Conclusão

ATC teve melhor desempenho que as medidas seriadas de troponina na detecção de doença coronariana significativa em pacientes com dor torácica e risco intermediário para eventos cardiovasculares.

Current Role of Computed Tomography in the Evaluation of Acute Coronary Syndrome

This review article provides an overview regarding the role of computed tomography (CT) in the evaluation of acute chest pain (ACP) in the emergency department (ED), focusing on characteristic CT findings.