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Background: Cardiovascular disease is the most common reason of mortality and morbidity all-over the world and is the major complication of diabetes. Diabetes mellitus (DM) has reached epidemic proportions worldwide and the consequences of its diagnosis are as severe as a diagnosis of coronary artery disease (CAD). Females are more likely to develop atypical symptoms of coronary CAD than males later in life. Imaging of deformation by two-dimensional speckle-tracking echocardiography (2DSTE) has developed as a highly effective method for quantification of the function of myocardium. This research aimed to evaluate the accuracy of diagnosis using speckle tracking for prediction of the existence or absence of severe CAD in diabetic female with acute chest pain by using two-dimensional echocardiography. Methods: This study is a cohort prospective research which was carried out at the department of cardiology, Tanta University Hospitals and National Heart Institute from the duration of October 2019 to September 2020 on 60 diabetic female patients above 18 years old with acute chest pain may be prolonged for > 20 minutes or transient, changes in ECG in the form of depression of ST segment and/or inversion of T wave (ECG may be normal) and cardiac biomarkers (troponin and CKMB) may be elevated or normal. Results: 2D speckle tracking was good predictor for multi-vessels disease with 95% total accuracy, then for single vessels disease with 85% total accuracy and finally for double vessel disease stenosis with 80% accuracy as shown in table. Among Non-STEMI group, 2D speckle tracking was good predictor for multi-vessels disease with 95% total accuracy, then for single vessels disease with 80% total accuracy and finally for double vessel disease stenosis with 75% accuracy as shown in table. Conclusions: We found that speckle tracking is effective in predicting presence of CAD in diabetic female patients had acute chest pain and in prediction of affected vessels depending on the distribution of affected segments in longitudinal strain by GLS. In addition, it can be used as non-invasive test for patients with acute coronary syndrome.
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Objective:To assess the application of three risk stratification scoring systems in evaluation and management of patients with acute chest pain.Methods:Patients with chest pain who visited the emergency department of Affiliated Hospital of Jining Medical University from February 2021 to April 2021 were recruited. The risk stratification evaluation was performed with EMPACT, HEART-Pathway and EDACS-ADP scoring systems. The primary endpoint was the major adverse events (MAE) within 30 days.The application values of three scales in identifying high-risk chest pain were evaluated.Results:A total of 628 patients with acute chest pain were enrolled, and 92 of them(14.95%) had MAE within 30 days. The scores of three scales were all positively correlated with MAE occurrence, while the EMPACT score had the highest correlation( r=0.41, P<0.001). ROC curve analysis showed that the area under the curve (AUC) of EMPACT score, HEART score and EDACS for predicting MAE within 30 days was 0.834(95% CI:0.790-0.878), 0.763(95% CI:0.710-0.817) and 0.635(95% CI:0.578-0.691), respectively. When the cut-off value was 9.5, the Yorden index of EMPACT score was the highest (0.561). Since all the scoring systems used integers, the EMPACT score of 10 was the threshold to distinguish low-risk chest pain from high-risk chest pain. The sensitivity of EMPACT, HEART-Pathway and EDACS-ADP scores in identifying high-risk chest pain patients was 0.707, 0.576 and 0.783, and the specificity of them was 0.854, 0.882 and 0.509, respectively. Conclusion:The EMPACT score has a good risk stratification ability, and it can be used for identifying patients with acute chest pain.
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Objective:To explore the application value of evaluation and management of patients with acute chest pain in China (EMPACT) score in risk stratification for patients with acute chest pain.Methods:According to the methods of prospective cohort study, 548 patients with chest pain in the Affiliated Hospital of Jining Medical University from February to April 2021 were selected. The risk stratification was performed according to EMPACT score. The primary endpoint was the major adverse events (MAE) within 30 d, including death from all causes, acute myocardial infarction (AMI), emergency revascularization, cardiac arrest, cardiogenic shock and other life-threatening situations that need urgent attention. The receiver operating characteristic (ROC) curve was used to evaluate the predictive value of EMPACT score for MAE.Results:Among the 548 patients, 75 cases had MAE within 30 d (MAE group), and the incidence of MAE was 13.7%; 473 cases did not occur MAE (non-MAE group). The EMPACT score in MAE group was significantly higher than that in non-MAE group: 8 (12, 18) scores vs. 5 (2, 8) scores, and there was statistical difference ( Z = 8.94, P<0.01). Spearman correlation analysis result showed that EMPACT score was positively correlated with MAE ( r = 0.38, P<0.01). ROC curve analysis result showed that the area under the curve of EMPACT score in prediction within 30 d MAE was 0.820 (95% CI 0.770 to 0.871), the cut-off value was 9.5 scores (since all the scoring systems were integers, the cut-off value was 10 scores), the sensitivity was 88.6%, and the specificity was 60.0%. Conclusions:The EMPACT score has a good risk stratification capability to achieve safe and effective triage of acute chest pain.
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@#This clinical pathway for the diagnosis and risk stratification of patients presenting with acute chest pain, including acute coronary syndromes, provides recommendations and algorithms for clinicians to diagnose, risk stratify, and manage acute chest pain in adult patients. The writing committee reviewed existing international and local guidelines. Modifications to the algorithm following face-to-face and virtual meetings resulted in expert decisions written as recommendations and presented in a flow diagram format. The USTH Chest Pain Pathway provides guidance based on current guidelines and recommendations on assessing and evaluating acute chest pain, tailored to local needs and institution-specific facilities. We recommend its use to ensure quality patient care in the hospital.
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Objective:To explore the value of growth differentiation factor 15 (GDF15) in the early diagnosis of acute chest pain.Methods:A total of 96 patients with acute chest pain admitted to the Emergency Department of Hainan Hospital of PLA General Hospital from January to November 2020 were retrospectively collected. The sex, age, troponin T, creatine kinase, creatine kinase isoenzyme, GDF15 and B-type natriuretic peptide of patients within 30 min after admission were recorded, and the differences of each index in different groups were compared. ROC curve was drawn to evaluate the diagnostic value of GDF15 and TNT/BNP in acute coronary syndrome (ACS). The Gensini score, left ventricular ejection fraction, length of stay in hospital and the number of stents were calculated, and the correlation between these indexes and GDF15 concentration was evaluated.Results:The general trend of acute chest pain was more male than female (72.92% vs. 27.08%) , the oldest group was the UA group (64.67 ± 13.87) years old , the youngest group was cardiac arrest group (47.29 ± 9.99) years old . There were higher rates of hypertension in the STEMI group, NSTEMI group and UA group, and none of the groups showed significant advantage in diabetes. The GDF15 concentration was higher in ACS related chest pain group [(2.360 ± 1.710) ng/mL vs. (1.380 ± 1.040) ng/mL, P<0.01]. The area under the Receiver Operating Characteristic Curve (AUC) of GDF15 combined with TNT was up to 0.863. GDF15 concentration was negatively correlated with ejection fraction, positively correlated with Gensini score, positively correlated with the number of stents implanted, and positively correlated with the length of hospital stay. Conclusions:GDF15 is valuable in the diagnosis and prognosis of acute chest pain. The combination of GDF15 and TNT can improve the diagnostic rate of ACS.
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Objective To evaluate the predictive value of HEART and GRACE scores for risk stratification and 30-day major adverse cardiovascular events (MACE) in patients with acute chest pain in emergency department.Methods This is a prospective observational study.Patients with acute chest pain aged 18 years or older who were first diagnosed in our emergency department were enrolled from January 1,2016 to September 1,2017.The clinical data were collected,and HEART and GRACE scores were calculated.All causes of MACE in each patient were followed up for 30 days.Results This study included 1004 patients with acute chest pain for analysis.Finally this study enrolled 600 patients with an age range of 20-98 years (mean 63.28±15.47 years),351 males (58.5％) and 249 females (41.5％).The age,past history (smoking,coronary heart disease and diabetes),GRACE score and HEART score in MACE patients were significantly higher than those in non-MACE patients (P＜0.05).The area under the ROC curve of HEART and GRACE scores were 0.817 (95％ CI 0.771-0.863) and 0.739 (95％ CI:0.687-0.791),respectively.The percent of patients with 30-day MACE with GRACE score and HEART score were 6.2％ vs 4.1％ in low-risk stratification,19.7％ vs 15.1％ in medium-risk stratification,and 35.1％ vs 56.5％ in high-risk stratification,respectively.Conclusions The HEART score is superior to the GRACE score in predicting 30-day MACE in patients with acute chest pain in emergency department.
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Objective To evaluate the diagnostic value of A-F mnemonic performed by sonographers with limited experience in patients with acute chest pain. Methods This was a prospective observational study. Bedside cardiac ultrasound for patients with chest pain was performed by six sonographers with limited experience using A-F mnemonic, evaluating indexes including aortic dissection(A), both ventricles (B), regional wall motion abnormality (RWMA), left ventricular ejection fraction (LVEF) ≤ 50％ (C ,contractility), dimensions (D), pleural and pericardial effusion (E) and further abnormalities (F). Afterwards, experienced cardiac sonographers performed the same examinations, and the difference in the time of ultrasound examination was calculated. The diagnosis of experienced sonographers were referred as the control group, and kappa test was applied to analyze the sensitivity, specificity, positive predictive value and negative predictive value. Results There were 245 cases eligible for study, and 20 cases were excluded. Finally 225 cases of acute chest pain were included in the analysis, containing 158 fatal chest pain and 67 low-risk chest pain. The experienced sonographers diagnosed 20 cases of ascending aortic dissection, 5 cases of right ventricular dilatation, 72 cases of RWMA, 12 cases of LVEF ≤ 50％, 45 cases of left ventricular dilatation, 6 cases of hydropericardium, and 6 cases of other abnormalities. The consistency between beginners and experienced sonographers were as follows:completely same (hydropericardium, Kappa=1.000), highly consistent (ascending aortic dissection, Kappa=0.853, right ventricular dilatation, Kappa=0.931, and other abnormalities, Kappa=0.829), moderately consistent (RWMA, Kappa=0.768, LVEF ≤ 50％, Kappa=0.713 and left ventricular dilatation, Kappa=0.766). The sensitivity and negative predictive value of RWMA and LVEF ≤ 50％ and the positive predictive value of left ventricular dilatation in the beginner sonographers were lower than those in the experienced sonographers. Conclusions A-F mnemonic was a simple and practical way for the beginner sonographers to perform bedside cardiac ultrasound. It was of significant value in making correct diagnosis of most acute chest pain patients and providing quick and reliable information for clinicians.
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[Objective]To investigate the effect of GRACE scores on prediction of 30-day cardiovascular adverse events in acute chest pain patients.[Methods]A prospective,observational analysis was conducted in the patients with acute chest pain in Emergency Department(ED)from January 1,2016 through April 1,2016.Data including characteris-tics and GRACE scores were collected.All causes leading to MACE were followed up at 30th day after the onset of acute chest pain.[Results]Among a total of 209 patients presenting with acute chest pain enrolled in this study,110 were male (52.63%)and 99 were female(47.37%).The range of age was 20-98years old,and mean age was(65.28±16.85)years old.During follow-up period,12 patients had MACE,2 patients died in ED,3 patients died in hospital,6 patients died out of hospital,and 1 person was diagnosed with myocardial infarction. When compared with non-MACE group,factors including age,BMI,hospitalized patient number,and number of patients admitted in CCU as well as GRACE scores, were significantly higher in MACE group(P<0.05). The predictive ROC curve area of GRACE scores in 30-day MACE was 0.819(0.735 to 0.902). The optimal sensitivity and specificity were 0.92 and 0.65,respectively. The probability of 30-day cardiovascular adverse events in various GRACE score risk stratification was 0.95%(low-risk),6.67%(medi-um-risk),and 18.92%(high-risk),respectively.[Conclusion]The GRACE score was a useful predictor to the occur-rence of 30-day cardiovascular adverse events in acute chest pain patients.
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Objective To evaluate the performance of D-dimer in the differential diagnosis between acute aortic dissection (AAD)with elevated troponin-I(TNI)and acute myocardial infarction (AMI) in patients with acute chest pain diseases with elevated TNI.Methods The data of the 547 patients complaining acute chest pain who were diagnosed as acute myocardial infarction by thoracic and abdominal aorta CTA examination from January 2013 to September 2015 were analyzed.The comparison of data of D-dimer mass concentration and the general clinical information between 44 patients diagnosed as AAD with elevated TNI and without other underlying diseases which could cause increase in D-dimer mass concentration(AAD with elevated TNI group) and 50 patients diagnosed as acute myocardial infarction confirmed by using coronary angiography(AMI group) were carried out.Results Compared with AMI group,in the AAD with elevated TNI group,the type of Stanford A was 38 cases, accounting for 86.4%;the proportion of the patients with a history of hypertension was higher, and the average age was younger;the D-dimer mass concentration levels and the positive ratio of the D-dimer test were much higher[11.27 μg/mL(3.95,20)μg/mL vs.0.28 μg/mL(0.22,0.40)μg/mL,P<0.01;100%vs.14%,P<0.01.The area under the ROC curve to diagnosis of the AAD with elevated TNI was 0.997,and the optimal diagnostic threshold was 1.095 μg/mL.When the D-dimer mass concentration level was 1.095 μg/mL,the sensitivity,specificity,positive predictive value(PPV),negative predictive value(NPV),positive likelihood ratio(PLR),negative likelihood ratio(NLR)were 97.7%,98%,97.7%,98%,48.86,and 0.02,respctively.When the D-dimer mass concentration level was 0.5 μg/mL,which meant the D-dimer test was positive,the sensitivity,specificity,PPV,NPV,PLR,NLR were 100%,86%,86.3%,100%,7.14,and 1.16,respctively.Conclusion D-dimer is helpful to the differential diagnosis between the AAD with elevated TNI and the AMI in acute chest pain patients with elevated TNI.
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Objective To explore the HEART risk score in predicting 30-day major adverse cardiovascu-lar events (MACE)for the patients presenting to Emergency Department (ED) with acute chest pain. Methods Patients presented in our ED with acute chest pain were enrolled from January,2016 to April,2016. All cause MACE of each patient were followed up at 30 days by Health insurance information management System and call . Results Total 209 patients were enrolled(mean age 65.28 ± 16.85 years;52.63%male). The age,hypertension, ratio of ACS,SpO2,in-patient number HEART score in MACE subject were significantly higher than that in non MACE patients(P<0.05). The blood pressure at admission of MACE patients was significantly decrease than that in non MACE patients(P<0.05). The MACE within 30 days was 5.74%. The respective areas under the curve (AUC)for 30-day MACE(95% CI)was 0.908(0.846 ~ 0.974). The percent of patients with 30-day MACE with HEART scores between 0% and 3,4 ~ 6,and 7 ~ 10 was 0%,2.5%,and 27%,respectively. Conclusion HEART score can be simple,rapid and accurate prediction of emergency department of patients with acute chest pain within 30 days of MACE,effective elimination of low-risk patients with MACE,it plays a very important role for disease assessment and diagnosis and treatment process in emergency department.
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Objective To describe the general characteristics of patients with acute chest pain in order to analyze factors associated with patients’utilization of emergency medical services (EMS).Methods A total of 747 eligible patients with acute chest pain admitted to emergency department of Qilu Hospital were consecutively enrolled from October 2014 to April 2015.Clinical data including demographic features, mode of arrival,past medical history,risk factors,symptoms and signs were collected prospectively by using standardized case report form.Univariate and multivariate analyses were carried out to investigate the association between the decision to use EMS and related factors including demographic features,past medical history,risk factors,symptoms and signs.Results Of the total 747 eligible patients,414 (55.4%)were male ,and the mean age was (57.2 ± 15.8)year;333 (44.6%)were female,and the mean age was (61.7 ±14.9)year.Of them,171 (22.9%)patients used EMS,and 143 chest pain patients with more than 75 years old were more inclined to use EMS (P <0.01),whereas 152 patients in 65 -75 years age group accounted for the lowest proportion of using EMS.Men were more inclined to use EMS than women (P <0.05),and 483 patients with typical chest pain used more EMS than patients with atypical chest pain (P <0.05);Of them,356 patients with a history of hypertension and 54 patients with a history of cerebral infarction were more inclined to use EMS (P <0.05 and P <0.01,respectively).Multivariate logistic regression analysis showed that male,older than 75 years,history of cerebral infarction were independent factors associated with EMS use (P <0.05).Conclusions This study indicated that only less than one-third of emergency department visits with acute chest pain decide to use EMS when symptoms occurred. Factors including male,older than 75 years,and a history of cerebral infarction were associated with more use of EMS.In order to promote patient asking for EMS timely,more work should be done.
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Awareness of pitfalls in common clinical symptoms is important. Not all patients with ACS presents with chest pains (beware of patients presenting with syncope, diaphoresis, dyspnoea, pain upper back, etc.). In a breathless patient, anxiety and other psychiatric conditions should only be considered as the diagnosis after careful exclusion of other life threatening causes: metabolic acidosis, partially occluded upper airway, bronchospasm, and pulmonary embolism. In a patient with headaches, intracranial haemorrhage, meningitis/ encephalitis, and brain mass lesion need to be considered in the differential diagnosis. The elderly patient presenting with acute abdominal pain will require FPs to maintain a high index of suspicion for potential life threatening causes. Possible causes of serious backache are ACS, AD, AAA, and spinal cord compression. In the wounded patient, there is a need to determine the medical condition that may have resulted in the patient’s injury, and patient’s risk profile is as important as the wound profile for correct management. In the pregnant patient, dyspnea can be due to pulmonary embolism, or heart failure; placenta abruption from abdominal injury may not have the classical triad of pain, tenderness or vaginal bleeding.
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Awareness of pitfalls in common clinical symptoms is important. Not all patients with ACS presents with chest pains (beware of patients presenting with syncope, diaphoresis, dyspnoea, pain upper back, etc.). In a breathless patient, anxiety and other psychiatric conditions should only be considered as the diagnosis after careful exclusion of other life threatening causes: metabolic acidosis, partially occluded upper airway, bronchospasm, and pulmonary embolism. In a patient with headaches, intracranial haemorrhage, meningitis/ encephalitis, and brain mass lesion need to be considered in the differential diagnosis. The elderly patient presenting with acute abdominal pain will require FPs to maintain a high index of suspicion for potential life threatening causes. Possible causes of serious backache are ACS, AD, AAA, and spinal cord compression. In the wounded patient, there is a need to determine the medical condition that may have resulted in the patient’s injury, and patient’s risk profile is as important as the wound profile for correct management. In the pregnant patient, dyspnea can be due to pulmonary embolism, or heart failure; placenta abruption from abdominal injury may not have the classical triad of pain, tenderness or vaginal bleeding.
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In modern times a lot of advances have been made in the treatment of Cardiac diseases and it is not uncommon to come across patients who are leading almost a normal life even after having a “Triple / Quadruple” by pass. On the other side modern dietary practices and sedentary lifestyles are responsible for the increased incidence of coronary heart diseases1. Recently many states have introduced emergency response services like ‘108’ services in Andhra Pradesh. This has made some improvements to the emergency care and it is now possible to successfully manage even more number of these cardiac emergencies. In this article every attempt has been made by keeping in mind the limited knowledge of a practicing Dental Surgeon regarding the definitive management of coronary events and the presentation has been designed in such a way that it can be easily adopted and followed by a general dental practitioner
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BACKGROUND: A diagnosis of coronary artery disease (CAD) in the early phase of acute chest pain is often difficult in an emergency department (ED) due to the lower sensitive ECG and delayed expression of the cardiac necrosis markers. Ischemia modified albumin (IMA) has recently been reported to be an early sensitive biochemical marker of ischemia. The aim of this study was to evaluate the diagnostic value of IMA in patients with suspected CAD and less sensitive ECG/delayed cardiac necrosis markers. METHODS: 100 consecutive patients (mean age: 5413 years, male: 66%) presenting to the ED with suspected CAD and chest pain within 6 hours of chest pain were enrolled in this study. An ECG check and blood sampling for IMA and CK-MB, cardiac troponin-T (TnT) were done within 1 hour at the ED. The diagnosis of CAD was based upon the clinical findings, results of serial ECG/TnT and coronary angiography. The ideal cutoff value of IMA for CAD was calculated by the Receiver Operator Characteristic (ROC) curve analysis. RESULTS: CAD including acute coronary syndrome was diagnosed in 69/100 (69%). The optimum diagnostic cutoff point for the IMA levels in these study populations was found by ROC analysis to be 99.5 U/mL. The ROC curve area for the IMA test was 0.901 (95% confidential interval, 0.840-0.961, p=0.001). The IMA levels >99.5 U/mL demonstrated a sensitivity of 86%, specificity of 81%, positive predictive value of 90% and negative predictive value of 74% for the diagnosis of CAD. The combination of IMA-ECG-CKMB/TnT increased the sensitivity for detecting ischemia to 94%, with a negative predictive value of 85%. IMA is a highly sensitive with a high negative predictive value, and might improve the utility of standard biomarkers for CAD. CONCLUSIONS: IMA might be a useful ischemic marker of coronary artery disease in patients presenting within 6 hours after the onset of chest pain.
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Humans , Male , Acute Coronary Syndrome , Biomarkers , Chest Pain , Coronary Angiography , Coronary Artery Disease , Coronary Vessels , Diagnosis , Electrocardiography , Emergencies , Emergency Service, Hospital , Ischemia , Necrosis , ROC Curve , Sensitivity and Specificity , Thorax , Troponin TABSTRACT
OBJECTIVE: To evaluate diagnostic role of echocardiography in the patients of acute chest pain with nonspecific ECG findings we have performed prospective study. SUBJECT AND METHOD: 79 out of 101 consecutive patients presenting to the emergency room with symtoms suggestive of acute coronary syndrome (ACS) without diagnostic ECG change were studied. Presence and score of regional wall motion abnormality (RWMA) were assessed according to the American Society of Echocardiography guideline (16 segment model) by two-dimensional echocardiography within 4 hours after arrival. The diagnosis of acute myocardial infarction (AMI) was confirmed by serial myocardial enzyme assay retrospectively. RESULTS: Of the 28 patients with RWMA, 13 (46%) had non-Q AMI, 8 (28%) had unstable angina, 3 (11%) had posterior AMI. Of the 51 patients with normal wall motion, 10 had gastroesophageal disease, 9 had variant angina, 3 had psychologic disease, 1 had aortic dissection and 1 had hypertrophic cardiomyopathy. Thus, Presence of RWMA by echocardiography had a sensitivity of 49% and a specificity of 88% for diagnosis of ACS. In 21 ACS patients with RWMA, regional wall motion score was significantly higher in AMI than in unstable angina (3.1+/-1.8 vs 1.0+/-2.2, p<0.05). As for the significant coronary artery stenosis, there was a higher incidence of multivessel disease in the patients with RWMA (64%). CONCLUSION: RWMA by two-dimensional echocardiography in the emergency room is not a sensitive but a specific technique to diagnose ACS patient with nonspecific ECG change, especially in posterior AMI and non-Q AMI.