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Cardiac chest pain best practice

James E Andruchow, Peter A Kavsak, Andrew D McRae
This article synthesizes current best evidence for the evaluation of patients with suspected acute coronary syndrome (ACS) using high-sensitivity troponin assays, enabling physicians to effectively incorporate them into practice. Unlike conventional assays, high-sensitivity assays can precisely measure blood cardiac troponin concentrations in the vast majority of healthy individuals, facilitating the creation of rapid diagnostic algorithms. Very low troponin concentrations on presentation accurately rule out acute myocardial infarction (AMI) and enable the discharge of approximately 20% of patients after a single test, whereas an additional 30%-40% of patients can be safely discharged after short-interval serial sampling in as little as 1 or 2 hours...
February 2018: Canadian Journal of Cardiology
Brit Long, Alex Koyfman
BACKGROUND: Chest pain is a common presentation to the emergency department (ED), though the majority of patients are not diagnosed with acute coronary syndrome (ACS). Many patients are admitted to the hospital due to fear of ACS. OBJECTIVE: Our aim was to investigate controversies in low-risk chest pain evaluation, including risk of missed ACS, stress test, and coronary computed tomography angiography (CCTA). DISCUSSION: Chest pain accounts for 10 million ED visits in the United States annually...
December 2016: Journal of Emergency Medicine
Brit Long, Alex Koyfman
BACKGROUND: Chest pain accounts for 10% of emergency department (ED) visits annually, and many of these patients are admitted because of potentially life-threatening conditions. A substantial percentage of patients with chest pain are at low risk for a major cardiac adverse event (MACE). OBJECTIVE: We investigated controversies in the evaluation of patients with low-risk chest pain, including clinical scores, decision pathways, and shared decision-making. DISCUSSION: ED patients with chest pain who have negative biomarker results and nonischemic electrocardiograms are at low risk for MACE...
January 2017: Journal of Emergency Medicine
Ingvild Billehaug Norum, Vidar Ruddox, Thor Edvardsen, Jan Erik Otterstad
BACKGROUND: Patients evaluated for acute and chronic chest pain comprise a large, heterogeneous group that often provides diagnostic challenges. Although speckle tracking echocardiography (STE) has proved to have diagnostic value in acute coronary syndrome it is not commonly incorporated in everyday practice. The purpose of the present systematic review was to assess the diagnostic accuracy of left ventricular (LV) longitudinal function by STE to predict significant coronary artery stenosis (CAD+) or not (CAD-) verified by coronary angiography in patients with chest pain suspected to be of cardiac ischemic origin...
July 25, 2015: BMC Medical Imaging
U Bellbhudder, J C Stanfliet
BACKGROUND: Chest pain is a frequent presenting symptom and is a diagnostic challenge. Recent recommendations state that high-sensitivity cardiac troponin assays are the only biochemical test required in the diagnosis of acute coronary syndrome (ACS) and that other biomarkers such as myoglobin or creatine kinase (CK)-MB isoform are not indicated. OBJECTIVE: To establish whether clinician ordering in the setting of suspected ACS was in keeping with recent recommendations...
April 2014: South African Medical Journal, Suid-Afrikaanse Tydskrif Vir Geneeskunde
Joy Victor, Mangalore Amith Shenoy, Sameer Chadha, Felix Yang, Gerald Hollander, Jacob Shani
SESSION TITLE: Cardiovascular CasesSESSION TYPE: Case ReportsPRESENTED ON: Saturday, March 22, 2014 at 04:15 PM - 05:15 PMINTRODUCTION: Paroxysmal supraventricular tachycardia (PSVT) following blunt cardiac injury (BCI) is rare but reported in the literature. AV nodal reentrant tachycardia (AVNRT) is the commonest form of PSVT encountered in clinical practice. We present a unique case of AVNRT after a blunt chest trauma with concomitant pulmonary embolism. CASE PRESENTATION: An 18 year-old Hispanic man with no significant past medical history presented to the emergency room with two hours of palpitations after sustaining a hard blow to the left mid-sternum while playing basketball...
March 1, 2014: Chest
Yalcin Velibey, Aliriza Erbay, Enver Ozkurt, Emrah Usta, Filiz Akin
A 62-year old patient with a history of chronic anemia associated with malabsorption secondary to short gut syndrome, experienced acute chest pain the second hour after the transfusion of a crossmatch-compatible erythrocyte suspension. His electrocardiogram (ECG) revealed widespread ST-segment depressions and he had an elevated troponin level. Laboratory findings and physical examination did not indicate the presence of immunological or non-immunological blood transfusion reactions. Cardiac catheterization was performed and showed angiographically non-obstructive, atherosclerotic plaques and the absence of vasospasm or thrombus formation...
April 2014: Transfusion and Apheresis Science
Alexandra Wise, Christopher Annus
Arrhythmias (abnormal heartbeats) are common but can be life threatening. Symptoms can be severe and include palpitations, dizziness, blackouts, breathlessness and even chest pain. These can be highly distressing for patients, causing them severe anxiety and depression if they are not well supported. Early diagnosis is essential to reduce mortality and improve quality of life--the most common arrhythmia--atrial fibrillation--can cause a stroke if left untreated or inadequately treated. While sudden cardiac death is less common in a young person, it is usually due to an inherited cardiac condition that has resulted in a critical arrhythmia...
July 31, 2013: Nursing Times
William A Parsonage, Louise Cullen, John F Younger
Chest pain is a common reason for presentation in hospital emergency departments and general practice. Some patients presenting with chest pain to emergency departments and, to a lesser extent, general practice will be found to have a life-threatening cause, but most will not. The challenge is to identify those who do in a safe, timely and cost-effective manner. An acute coronary syndrome cannot be excluded on clinical grounds alone. In patients with ongoing symptoms of chest pain, without an obvious other cause, ST-segment-elevation myocardial infarction should be excluded with a 12-lead electrocardiogram at the first available opportunity...
July 8, 2013: Medical Journal of Australia
(no author information available yet)
One of the longest running debates in cardiology is about the best reperfusion therapy for patients with evolving acute myocardial infarction (MI). Percutaneous transluminal coronary angioplasty (ANGIOPLASTY) is a surgical treatment to reopen a blocked coronary artery to restore blood flow. It is a type of percutaneous (through-the-skin) coronary intervention (PCI) also known as balloon angioplasty. When performed on patients with acute myocardial infarction, it is called primary angioplasty. Primary angioplasty is an alternative to thrombolysis, clot-dissolving drug therapy, for patients with acute MI associated with ST-segment elevation (STEMI), a change recorded with an electrocardiogram (ECG) during chest pain...
2004: Ontario Health Technology Assessment Series
Tobias Reichlin, Christian Schindler, Beatrice Drexler, Raphael Twerenbold, Miriam Reiter, Christa Zellweger, Berit Moehring, Ronny Ziller, Rebeca Hoeller, Maria Rubini Gimenez, Philip Haaf, Mihael Potocki, Karin Wildi, Cathrin Balmelli, Michael Freese, Claudia Stelzig, Heike Freidank, Stefan Osswald, Christian Mueller
BACKGROUND: High-sensitivity cardiac troponin (hs-cTn) assays seem to improve the early diagnosis of acute myocardial infarction (AMI), but it is unknown how to best use them in clinical practice. Our objective was to develop and validate an algorithm for rapid rule-out and rule-in of AMI. METHODS: A prospective multicenter study enrolling 872 unselected patients with acute chest pain presenting to the emergency department. High-sensitivity cardiac troponin T (hs-cTnT) was measured in a blinded fashion at presentation and after 1 hour...
September 10, 2012: Archives of Internal Medicine
Jonathan B Finkel, Gregary D Marhefka
Every year more than 500,000 patients present to the emergency department with cocaine-associated complications, most commonly chest pain. Many of these patients undergo extensive work-up and treatment. Much of the evidence regarding cocaine's cardiovascular effects, as well as the current management of cocaine-associated chest pain and acute coronary syndromes, is anecdotally derived and based on studies written more than 2 decades ago that involved only a few patients. Newer studies have brought into question many of the commonly held theories and practices regarding the etiology, diagnosis, and treatment of this common clinical scenario...
December 2011: Mayo Clinic Proceedings
James P Earls, Richard D White, Pamela K Woodard, Suhny Abbara, Michael K Atalay, J Jeffrey Carr, Linda B Haramati, Robert C Hendel, Vincent B Ho, Udo Hoffman, Arfa R Khan, Leena Mammen, Edward T Martin, Anna Rozenshtein, Thomas Ryan, Joseph Schoepf, Robert M Steiner, Charles S White
Imaging is valuable in determining the presence, extent, and severity of myocardial ischemia and the severity of obstructive coronary lesions in patients with chronic chest pain in the setting of high probability of coronary artery disease. Imaging is critical for defining patients best suited for medical therapy or intervention, and findings can be used to predict long-term prognosis and the likely benefit from various therapeutic options. Chest radiography, radionuclide single photon-emission CT, radionuclide ventriculography, and conventional coronary angiography are the imaging modalities historically used in evaluating suspected chronic myocardial ischemia...
October 2011: Journal of the American College of Radiology: JACR
J George, D Jack, G Mackle, T S Callaghan, L Wei, C C Lang, E Dow, A D Struthers
OBJECTIVE: To evaluate the prognostic value of high-sensitivity troponin T (hs-cTnT) in patients who present to General Practitioners (GPs) with non-acute chest pain. DESIGN, SETTING AND PATIENTS: A total of 625 patients who were referred by their GPs to a regional Rapid Access Chest Pain Clinic in Tayside, Scotland were consented and recruited. Diamond-Forrester pretest probability of coronary artery disease (CAD) was used to select patients with intermediate and high-pretest probability...
February 2012: QJM: Monthly Journal of the Association of Physicians
T C Collyer, H C Reynolds, E Truyens, L Kilshaw, T Corcoran
BACKGROUND: Increasing numbers of older patients prescribed clopidogrel are presenting for urgent hip fracture surgery. Best practice for the management of clopidogrel therapy is unknown, although delays to surgery are associated with increased mortality. We investigated the influence of perioperative management of clopidogrel therapy on in-hospital cardiac morbidity and transfusion in this population. METHODS: Retrospective review of all patients aged >60 yr, admitted to a single centre with hip fractures between June 2005 and November 2008...
December 2011: British Journal of Anaesthesia
I Ramasamy
Owing to their higher risk for cardiac death or ischemic complications, patients with acute coronary syndrome (ACS) must be identified from other causes of chest pain. Patients with acute coronary syndrome are divided into categories based on their electrocardiogram; those with new ST-segment elevation and those who present with ST-segment depression. The subgroups of patients with ST-segment elevation are candidates for immediate reperfusion, while fibrinolysis appears harmful for those with non-ST elevation myocardial infarction...
July 15, 2011: Clinica Chimica Acta; International Journal of Clinical Chemistry
Maria P Bonomini, Pedro D Arini, Max E Valentinuzzi
BACKGROUND: Allometry, in general biology, measures the relative growth of a part in relation to the whole living organism. Using reported clinical data, we apply this concept for evaluating the probability of ventricular fibrillation based on the electrocardiographic ST-segment deviation values. METHODS: Data collected by previous reports were used to fit an allometric model in order to estimate ventricular fibrillation probability. Patients presenting either with death, myocardial infarction or unstable angina were included to calculate such probability as, VFp = δ + β (ST), for three different ST deviations...
2011: Biomedical Engineering Online
Stefan Bösner, Jörg Haasenritter, Annette Becker, Konstantinos Karatolios, Paul Vaucher, Baris Gencer, Lilli Herzig, Monika Heinzel-Gutenbrunner, Juergen R Schaefer, Maren Abu Hani, Heidi Keller, Andreas C Sönnichsen, Erika Baum, Norbert Donner-Banzhoff
BACKGROUND: Chest pain can be caused by various conditions, with life-threatening cardiac disease being of greatest concern. Prediction scores to rule out coronary artery disease have been developed for use in emergency settings. We developed and validated a simple prediction rule for use in primary care. METHODS: We conducted a cross-sectional diagnostic study in 74 primary care practices in Germany. Primary care physicians recruited all consecutive patients who presented with chest pain (n = 1249) and recorded symptoms and findings for each patient (derivation cohort)...
September 7, 2010: CMAJ: Canadian Medical Association Journal, Journal de L'Association Medicale Canadienne
Troy Madsen, Michael Mallin, Joseph Bledsoe, Philip Bossart, Virgil Davis, Christopher Gee, Erik Barton
BACKGROUND: Recent research has noted low rates of compliance among ED chest pain patients referred for outpatient stress testing. The practice at our institution, a 39,000 visits per year emergency department (ED), is to place chest pain patients considered low risk for acute coronary syndrome in an observation unit for serial biomarker testing and provocative cardiac testing. Our objective was to determine the rates of positive stress tests among this group and to extrapolate from this the potential missed positive stress tests if these patients were referred instead for outpatient stress testing...
September 2009: Critical Pathways in Cardiology
L Sharples, V Hughes, A Crean, M Dyer, M Buxton, K Goldsmith, D Stone
OBJECTIVES: To assess the acceptability and feasibility of functional tests as a gateway to angiography for management of coronary artery disease (CAD), the ability of diagnostic strategies to identify patients who should undergo revascularisation, patient outcomes in each diagnostic strategy, and the most cost-effective diagnostic strategy for patients with suspected or known CAD. DESIGN: A rapid systematic review of economic evaluations of alternative diagnostic strategies for CAD was carried out...
December 2007: Health Technology Assessment: HTA
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