WorldWideScience

Sample records for atypical chest pain

  1. An Atypical Cause of Atypical Chest Pain

    Directory of Open Access Journals (Sweden)

    Ahmad Zaheen

    2014-01-01

    Full Text Available The present report describes a case involving a 57-year-old HIV-positive man who presented with acute retrosternal chest pain accompanied by 24 h of fever. Septic arthritis of the manubriosternal joint was diagnosed based on magnetic resonance imaging findings in addition to Staphylococcus aureus bacteremia. To the authors’ knowledge, the present case is only the 12th reported case of manubriosternal septic arthritis, and the first in an HIV-positive patient. Early diagnosis and treatment can circumvent the need for surgical intervention. Based on the present case report and review of the literature, the authors summarize the epidemiology, appropriate imaging and suggestions for antibiotic therapy for this rare presentation.

  2. Atypical chest pain: evidence of intercostobrachial nerve sensitization in Complex Regional Pain Syndrome.

    Science.gov (United States)

    Rasmussen, Jennifer W; Grothusen, John R; Rosso, Andrea L; Schwartzman, Robert J

    2009-01-01

    Atypical chest pain is a common complaint among Complex Regional Pain Syndrome (CRPS) patients with brachial plexus involvement. Anatomically, the intercostobrachial nerve (ICBN) is connected to the brachial plexus and innervates the axilla, medial arm and anterior chest wall. By connecting to the brachial plexus, the ICBN could become sensitized by CRPS spread and become a source of atypical chest pain. To evaluate the sensitivity of chest areas in CRPS patients and normal controls. Prospective investigation of pressure algometry in chest areas to determine chest wall sensitivity. CRPS patients and normal controls volunteered to participate in our study. Each individual was examined to meet inclusion criteria. Patients' report of chest pain history was collected from every participant. Pressure algometry was used to measure pressure sensitivity in the axilla, anterior axillary line second intercostal space, mid-clavicular third rib, mid-clavicular tenth rib, and midsternal. Each of these measurements were compared to an intra-participant abdominal measure to control for an individuals generalized sensitivity. The ratios of chest wall sensitivities were compared between CRPS patients and normal controls. A history of chest pain was reported by a majority (94%) of CRPS patients and a minority (19%) of normal controls. CRPS patients reported lifting their arm as a major initiating factor for chest pain. To pressure algometry, the ratios of CRPS patients were significantly greater than control subjects (pCRPS patients than normal controls. The ICBN could be the source of this sensitization by CRPS spread from the brachial plexus.

  3. Non-Cardiac Chest Pain

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    ... it: “atypical chest pain, chest pain of undetermined origin, unexplained chest pain, functional chest pain, soldier’s heart, ... Return to Top GI Health Centers Colorectal Cancer Hepatitis C Inflammatory Bowel Disease Irritable Bowel Syndrome Obesity ...

  4. Atypical Chest Pain: An Unusual Presentation of Spinal Metastasis due to Penile Carcinoma

    Directory of Open Access Journals (Sweden)

    Sarah Pywell

    2016-01-01

    Full Text Available Spinal metastases may present in a myriad of ways, most commonly back pain with or without neurology. We report an unusual presentation of isolated atypical chest pain preceding metastatic cord compression, secondary to penile carcinoma. Spinal metastasis from penile carcinoma is rare with few cases reported. This unusual presentation highlights the need for a heightened level of clinical suspicion for spinal metastases as a possible cause for chest pain in any patients with a history of carcinoma. The case is discussed with reference to the literature.

  5. Chest Pain

    Science.gov (United States)

    ... or tightness in your chest Crushing or searing pain that radiates to your back, neck, jaw, shoulders, and one or both arms Pain that lasts ... com. Accessed Sept. 6, 2017. Yelland MJ. Outpatient evaluation of the adult with chest pain. https://www.uptodate.com/contents/search. Accessed Sept. ...

  6. Atypical Chest Pain in the Elderly: Prevalence, Possible Mechanisms and Prognosis

    Directory of Open Access Journals (Sweden)

    Chung-Lieh Hung

    2010-03-01

    Full Text Available Acute chest pain is a major complaint quite commonly presented at emergency departments. A differential diagnosis of acute chest pain includes various disease entities, including some life-threatening disorders. Of these, acute coronary syndrome garners much clinical attention and forms a specific disease that includes a critical ST-segment elevation myocardial infarction and a less severe form of non-ST-segment elevation myocardial infarction and unstable angina. As an urgent and life-threatening disease leading to a high morbidity and mortality, accurate diagnosis of acute coronary syndrome remains a clinical challenge. Efficient management of this syndrome may rely on a quick yet accurate diagnosis. A high misdiagnosis rate and inappropriate discharge rate for acute coronary syndrome are still observed, especially in the elderly population, owing to a higher prevalence of atypical symptoms presented in this group. Moreover, the existence of high comorbidities in the elderly population makes effective clinical approach complicated. A delay in the identification and treatment may lead to worse outcomes in this patient population. The underlying pathophysiology and exact mechanisms are various. Patient evaluation strategies are currently being developed, as are new diagnostic facilities aimed at preparing physicians for urgent intervention in a more cost-effective manner.

  7. [Chest pain].

    Science.gov (United States)

    Horn, Benedikt

    2015-01-01

    Chest pain in ambulatory setting is predominantly not heart-associated. Most patients suffer from muskuloskeletal or functional (psychogenic) chest pain. Differential diagnosis covers aortic dissection, rib-fracture, shingles, GERD, Tietze-Syndrome, pulmonary embolism, pleuritis, pneumothorax, pleurodynia and metastatic disease. In most cases history, symptoms and signs allow a clinical diagnosis of high pretest-probability.

  8. Severe Hypoplasia of Posterior Mitral Valve Leaflet Presented with Atypical Chest Pain: A Case Report

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    Afsoon Fazlinezhad

    2016-02-01

    Full Text Available Introduction Absence of the posterior mitral leaflet is usually fatal for fetus in utero. Although hypoplasia of the posterior mitral leaflet is usually present in children with symptomatic mitral regurgitation, it is usually evident in a few cases of asymptomatic adults. We decided to introduce a rare case with hypoplasia of the posterior mitral valve leaflet associated with aortic stenosis. Case Presentation A 24-year-old man was admitted with a history of atypical chest pain. The patient had a normal psychophysical growth. The physical examination showed 4/6 mid- systolic ejection murmurs over the left sternal border. Chest roentgenogram was normal and the electrocardiogram showed sinus rhythm with mild LVH. Meanwhile, the echocardiography revealed severe elongated sail- like anterior leaflet and hypoplasia of the posterior mitral leaflet with moderate valvular aortic stenosis. MR grade was mild due to the complete coverage of anterior mitral leaflet. Moreover, LV function and pulmonary arterial pressure were reported normal. Conclusions This abnormality was tolerated since adulthood and mitral regurgitation was gradually developed due to annulus dilation. Therefore, the posterior mitral leaflet did not have a significant impact on mitral valve performance.

  9. Atypical Chest Pain in the Elderly: Prevalence, Possible Mechanisms and Prognosis

    OpenAIRE

    Hung, Chung-Lieh; Hou, Charles Jia-Yin; Yeh, Hung-I; Chang, Wen-Han

    2010-01-01

    Acute chest pain is a major complaint quite commonly presented at emergency departments. A differential diagnosis of acute chest pain includes various disease entities, including some life-threatening disorders. Of these, acute coronary syndrome garners much clinical attention and forms a specific disease that includes a critical ST-segment elevation myocardial infarction and a less severe form of non-ST-segment elevation myocardial infarction and unstable angina. As an urgent and life-threat...

  10. Comparison of Prediction Between TIMI (Thrombolysis in Myocardial Infarction) Risk Score and Modified TIMI Risk Score in Discharged Patients From Emergency Department With Atypical Chest Pain

    OpenAIRE

    Abbasnezhad, Mohsen; Soleimanpour, Hassan; Sasaie, Mohamadreza; EJ Golzari, Samad; Safari, Saeid; Soleimanpour, Maryam; Mehdizadeh Esfanjani, Robab

    2014-01-01

    Background: Chest pain is one of the most common causes of the admission to the emergency departments. It, however, can be due to numerous diseases some of which are life threatening. Objectives: In the current study, we evaluated the prognostic value of TIMI (Thrombolysis in Myocardial Infarction) and Modified TIMI risk scores to stratify the risk for patients with atypical chest pain being discharged from the emergency department. Patients and Methods: In a prospective-analytic study, we co...

  11. [Chest pain units or chest pain algorithm?].

    Science.gov (United States)

    Christ, M; Dormann, H; Enk, R; Popp, S; Singler, K; Müller, C; Mang, H

    2014-10-01

    A large number of patients present to the emergency department (ED) for evaluation of acute chest pain. About 10-15% are caused by acute myocardial infarction (MI), and over 50% of cases are due to noncardiac reasons. Further improvement for chest pain evaluation appears necessary. What are current options to improve chest pain evaluation in Germany? A selective literature search was performed using the following terms: "chest pain", "emergency department", "acute coronary syndrome" and "chest pain evaluation". A working group of the German Society of Cardiology published recommendations for infrastructure, equipment and organisation of chest pain units in Germany, which should be separated from the ED of hospitals and be under the leadership of a cardiologist. A symptom-based decision for acute care would be preferable if all differential diagnoses of diseases could be managed by one medical specialty: However, all four main symptoms of patients with acute MI (chest pain, acute dyspnea, abdominal pain, dizziness) are also caused by diseases of different specialties. Evaluation and treatment of acute chest pain by representatives of one specialty would lead to over- or undertreatment of affected patients. Therefore we suggest a multidisciplinary evaluation of patients with acute chest pain including representatives of emergency and critical care physicians, cardiologists, internists, geriatricians, family physicians, premedics and emergency nurses. Definition of key indicators of performance and institutionalized feedback will help to further improve quality of care.

  12. Comparison of Prediction Between TIMI (Thrombolysis in Myocardial Infarction) Risk Score and Modified TIMI Risk Score in Discharged Patients From Emergency Department With Atypical Chest Pain.

    Science.gov (United States)

    Abbasnezhad, Mohsen; Soleimanpour, Hassan; Sasaie, Mohamadreza; Golzari, Samad Ej; Safari, Saeid; Soleimanpour, Maryam; Mehdizadeh Esfanjani, Robab

    2014-02-01

    Chest pain is one of the most common causes of the admission to the emergency departments. It, however, can be due to numerous diseases some of which are life threatening. In the current study, we evaluated the prognostic value of TIMI (Thrombolysis in Myocardial Infarction) and Modified TIMI risk scores to stratify the risk for patients with atypical chest pain being discharged from the emergency department. In a prospective-analytic study, we collected data from 1020 patients with atypical chest pain enrolled to the study. All eligible patients were visited by the emergency medicine residents who were trained for this study. Based on the criteria in both systems, the emergency medicine attending decided on either discharging or hospitalizing patients. Patients were allocated into 2 equal groups randomly. In order to predict the opposing accidents in 30 days (coronary revascularization, myocardial infarction, and all-cause death) TIMI risk scores and Modified TIMI risk scores were assessed based on TIMI risk score (0 or 1) and Modified TIMI risk score (0 or 1). No significant difference could be observed between both groups regarding demographic characteristics, ejection fraction, left ventricle hypertrophy, TRS criteria, risk factors and the history of coronary artery stenosis. None of the atypical chest pain patients discharged based on TIMI and modified TIMI risk scores experienced any adverse events. The results obtained from this study support the idea that the TIMI and modified TIMI risk scores might be valuable tools that could be used to stratify the risk of patients with atypical chest pain in the emergency department.

  13. Chest pain

    Science.gov (United States)

    ... pain. The pain may spread to the arm, shoulder, jaw, or back. A tear in the wall of the aorta, the large blood vessel that takes blood from the heart to the rest of the body ( aortic dissection ) causes sudden, severe ...

  14. Acute chest pain.

    Science.gov (United States)

    Jindal, Atul; Singhi, Sunit

    2011-10-01

    Chest pain is a worrisome symptom that often causes parents to bring their child to emergency department(ED) for evaluation. In the majority of cases, the etiology of the chest pain is benign, but in one-fourth of the cases symptoms are distressing enough to cause children to miss school. The clinician's primary goal in ED evaluation of chest pain is to identify serious causes and rule out organic pathology. The diagnostic evaluation includes a thorough history and physical examination. Younger children are more likely to have a cardiorespiratory source for their chest pain, whereas an adolescent is more likely to have a psychogenic cause. Children having an organic cause of chest pain are more likely to have acute pain, sleep disturbance due to pain and associated fever or abnormal examination findings, whereas those with non-organic chest pain are more likely to have pain for a longer duration. Chest radiograph is required in some, especially in patients with history of trauma . In children, myocardial ischemia is rare, thus routine ECG is not required on every patient. However, both pericarditis and myocarditis can present with chest pain and fever. Musculoskeletal chest pain, such as caused by costochondritis and trauma, is generally reproducible on palpation and is exaggerated by physical activity or breathing. Pneumonia with or without pleural effusion, usually presents with fever and tachypnea; chest pain may be presenting symptom sometimes. In asthmatic children bronchospasm and persistent coughing can lead to excess use of chest wall muscles and chest pain. Patients' who report acute pain and subsequent respiratory distress should raise suspicion of a spontaneous pneumothorax or pneumomediastinum. ED management includes analgesics, specific treatment directed at underlying etiology and appropriate referral.

  15. Chest Pain: First Aid

    Science.gov (United States)

    ... angina with any of the following signs and symptoms, it may indicate a more serious condition, such as a heart attack: Pain in your arms, neck, jaw, shoulder or back accompanying chest pain Nausea Fatigue Shortness ...

  16. [Musculoskeletal-related chest pain].

    Science.gov (United States)

    Sturm, C; Witte, T

    2017-01-01

    Approximately 10-50% of chest pains are caused by musculoskeletal disorders. The association is twice as frequent in primary care as in emergency admissions. This article provides an overview of the most important musculoskeletal causes of chest pain and on the diagnostics and therapy. A selective search and analysis of the literature related to the topic of musculoskeletal causes of chest pain were carried out. Non-inflammatory diseases, such as costochondritis and fibromyalgia are frequent causes of chest pain. Inflammatory diseases, such as rheumatoid arthritis, spondyloarthritis and systemic lupus erythematosus are much less common but are more severe conditions and therefore have to be diagnosed and treated. The diagnostics and treatment often necessitate interdisciplinary approaches. Chest pain caused by musculoskeletal diseases always represents a diagnosis by exclusion of other severe diseases of the heart, lungs and stomach. Physiotherapeutic and physical treatment measures are particularly important, including manual therapy, transcutaneous electrical stimulation and stabilization exercises, especially for functional myofascial disorders.

  17. Chest pain and behavior in suspected coronary artery disease.

    Science.gov (United States)

    Young, L D; Barboriak, J J; Anderson, A J

    1988-01-01

    This study assessed behavioral activity, dietary and emotional variables among patient cohorts with angina pectoris, atypical chest pain, and no chest pain in whom coronary disease is suspected. Questionnaire responses of 3,899 employed male patients at the time of coronary arteriography were analyzed. Patients with angina pectoris had high levels of coronary-prone and neurotic attitudes, and fatigue variables including feeling unrested on awakening, easy fatiguability, reducing activity at work and arriving home tired. Atypical chest pain patients showed coronary-prone and neurotic attitudes similar to the angina pectoris group but had less coronary occlusion and lower levels of fatigue variables. Compared to the other groups, atypical chest pain patients were more likely to skip breakfast and showed a trend to eat fast. These findings suggest that including assessment of activity levels, fatiguability, eating behavior, neurotic traits and coronary-prone attitudes at time of coronary arteriography can have some limited value for patients with chest pain who may seek cardiac treatment but could benefit from alternative approaches.

  18. Evaluation of an Australian chest pain assessment unit.

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    Sonigra, A; Lawlor, J; Roberts, L

    2012-12-01

    In order to mitigate the risk of missing atypical or low probability presentations of acute coronary syndromes (ACS), many hospitals have designated resources specifically for the assessment of chest pain. This study aims to evaluate the introduction of a chest pain assessment unit (CPAU) in a North Queensland hospital. Information on admission status, diagnosis, procedures, length of stay and chest pain representation rates was obtained for patients presenting with chest pain to the emergency department (ED) at The Townsville Hospital in the 2.5 years prior to the introduction of a CPAU in March 2007 (n = 6665). This was compared with information on chest pain patients (n = 7885) presenting to the ED in the 2.5 years after it opened. The CPAU resulted in a reduction in the percentage of 'missed' cases of ACS. The rate of people who represented with chest pain at 3 months and who ultimately received an ACS diagnosis reduced from 1.9% to 1.4%. There was an increased rate of apparently appropriate angiograms from 6.7% to 9.4% of chest pain admissions. The admission rate of ED chest pain presentations was stable as was the median length of stay (1.14-1.16 days). A relative decrease in the proportion of admitted patients diagnosed with ACS compared with those with unspecified chest pain was observed. The implementation of a CPAU at The Townsville Hospital resulted in improved care of those presenting to the ED with chest pain. Further Australian CPAU evaluations are recommended. © 2012 The Authors; Internal Medicine Journal © 2012 Royal Australasian College of Physicians.

  19. Atypical temporomandibular joint pain: a case report.

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    Widmer, Charles G; Wold, Courtney C; Stoll, Ethan M; Dolwick, M Franklin

    2014-12-01

    Atypical temporomandibular joint (TMJ) pain can consist of an unusual intensity, location or set of pain descriptors that do not match what is traditionally observed for TMJ capsular pain, disc displacements or arthritic conditions. Presented in this case report is an atypical pain report regarding a unilateral TMJ pain as the chief complaint. An overview of typical vs atypical TMJ pain is also reviewed to highlight unusual signs and symptoms so that the clinician can identify these atypical presentations and pursue further diagnostic approaches. Copyright © 2014 Elsevier Inc. All rights reserved.

  20. A rhythmic chest pain

    Directory of Open Access Journals (Sweden)

    Lorenzo Cristoni

    2013-11-01

    Full Text Available A middle-aged man with a history of ischemic heart disease presented at the emergency department having had a forty-minute long precordial pain at home and with an electrocardiogram showing a wide complex tachycardia with left bundle branch block shaped QRS. While preparing for urgent electrical cardioversion, the physician practiced a carotid sinus massage which helped to i unveil the supraventricular origin of the arrhythmia (by slowing down heart frequency and thus displaying p waves previously hidden and ii to exclude that the aberrancy was the expression of a transmural ischemia, thanks to the narrowing of the QRS complex. The final diagnosis was atrial tachycardia. The patient consequently received amiodarone IV and was discharged in normal sinus rhythm. We emphasize the importance of correctly diagnosing any rhythm disorder before administering the treatment, if the patient’s clinical condition permits it, in order to ensure the best treatment in urgency and the most appropriate prophylaxis.

  1. Evaluation and Management of Chest Pain in the Elderly.

    Science.gov (United States)

    Gupta, Rohit; Munoz, Robert

    2016-08-01

    Geriatric patients are at increased risk for serious morbidity and mortality from life-threatening causes of chest pain. This article covers 5 life-threatening causes of chest pain in the elderly: acute coronary syndrome, aortic dissection, pulmonary embolism, pneumothorax, and esophageal rupture. Atypical presentations, frailty, and significant comorbidities that characterize the elderly make the diagnosis and treatment of these already complicated conditions even more complicated. The emergency provider must be vigilant and maintain a low threshold to test. When a diagnosis is made, treatment must be aggressive. The elderly benefit from optimal care. Copyright © 2016 Elsevier Inc. All rights reserved.

  2. Examination of musculoskeletal chest pain

    DEFF Research Database (Denmark)

    Brunse, Mads Hostrup; Stochkendahl, Mette Jensen; Vach, Werner

    2010-01-01

    using a standardized examination protocol, (2) to determine inter-observer reliability of single components of the protocol, and (3) to determine the effect of observer experience. Eighty patients were recruited from an emergency cardiology department. Patients were eligible if an obvious cardiac or non......-cardiac diagnosis could not be established at the cardiology department. Four observers (two chiropractors and two chiropractic students) performed general health and manual examination of the spine and chest wall. Percentage agreement, Cohen's Kappa and ICC were calculated for observer pairs (chiropractors...... and students) and all. Musculoskeletal chest pain was diagnosed in 45 percent of patients. Inter-observer kappa values were substantial for the chiropractors and overall (0.73 and 0.62, respectively), and moderate for the students (0.47). For single items of the protocol, the overall kappa ranged from 0...

  3. Chest pain in focal musculoskeletal disorders

    DEFF Research Database (Denmark)

    Stochkendahl, Mette Jensen; Christensen, Henrik Wulff

    2010-01-01

    The musculoskeletal system is a recognized source of chest pain. However, despite the apparently benign origin, patients with musculoskeletal chest pain remain under-diagnosed, untreated, and potentially continuously disabled in terms of anxiety, depression, and activities of daily living. Several...... overlapping conditions and syndromes of focal disorders, including Tietze syndrome, costochondritis, chest wall syndrome, muscle tenderness, slipping rib, cervical angina, and segmental dysfunction of the cervical and thoracic spine, have been reported to cause pain. For most of these syndromes, evidence...

  4. Acute neck pain, an atypical presentation of subarachnoid haemorrhage

    OpenAIRE

    Ahmed, Julian; Blakeley, Chris; Sakar, Ramy; Aktar, Khalida; Hashemi, Kambiz

    2007-01-01

    Subarachnoid haemorrhage can be a massively debilitating condition with long‐term repercussions. The “classic” presentation of sudden‐onset severe headache normally raises suspicions. However, if the presentation is atypical, the diagnosis may be missed. We report on a 52‐year‐old man who presented with a 1‐day history of progressively worsening right‐sided neck pain spreading to the chest with associated symptoms of autonomic dysfunction. After initial stabilisation, the patient's Glasgow Co...

  5. Coronary CT angiography in acute chest pain

    OpenAIRE

    Nikhil Goyal; Arthur Stillman

    2017-01-01

    Coronary computed tomographic angiography has become a reliable diagnostic tool in the evaluation of patients with chest pain. Studies have shown this modality to be accurate and safe when compared with conventional methods of assessing patients with chest pain. We review the recent developments with coronary computed tomographic angiography and devote particular attention toward its application to triage patients in the emergency department.

  6. Chest pain evaluation in the emergency department.

    Science.gov (United States)

    Foy, Andrew J; Filippone, Lisa

    2015-07-01

    Chest pain is a common complaint in the emergency department. Recognition of chest pain symptoms and electrocardiographic changes consistent with acute coronary syndrome (ACS) can lead to prompt initiation of goal-directed therapy. Cardiac troponin testing confirms the diagnosis of acute myocardial infarction, but does not reveal the mechanism of injury. When patients with chest pain rule out for ACS the use of advanced, noninvasive testing has not been found to be associated with better patient outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.

  7. Angina - when you have chest pain

    Science.gov (United States)

    ... gov/ency/patientinstructions/000088.htm Angina - when you have chest pain To use the sharing features on ... discusses how to care for yourself when you have angina. Signs and Symptoms of Angina You may ...

  8. Utility of the Diamond-Forrester Classification in Stratifying Acute Chest Pain in an Academic Chest Pain Center.

    Science.gov (United States)

    Hamburger, Robert F; Spertus, John A; Winchester, David E

    2016-06-01

    Because the Diamond-Forrester (DF) model is predictive of obstructive coronary artery disease (CAD), it is often used to risk stratify acute chest pain patients. We sought to further evaluate the clinical utility of the DF model within a chest pain evaluation center. Consecutive patients with chest pain and no known CAD or evidence of active ischemia were asked to participate in a prospective registry. Patients were classified based on cardiovascular risk factors, age, and DF classification. We compared data from the emergency department course, Duke Activity Status Index (DASI) and Seattle Angina Questionnaire (SAQ), hospitalization rates, and results of testing between patients with typical angina and all others. Multivariate logistic regression was also used to assess for predictors of CAD by computed tomography coronary angiography (CTCA) or positive exercise treadmill testing (ETT). Among 209 patients, 163 had atypical/noncardiac and 46 had typical chest pain. The SAQ and DASI scores were lower in the typical chest pain group (indicating more severe impairment), which were not statistically significantly different. There were no significant differences in risk factors or the results of CTCA, ETT, or cardiac catheterization. In the regression analysis, SAQ score, DASI score, and DF classification were not predictive of CAD by CTCA. Worsening angina frequency scores on the SAQ were marginally associated with positive ETT (OR, 1.04; P=0.04). In a contemporary low-risk acute chest pain population, typical angina, as defined by the DF classification, was not predictive of CAD or useful for identifying patients with higher symptom burden.

  9. Atypical odontalgia: phantom tooth pain.

    Science.gov (United States)

    Bates, R E; Stewart, C M

    1991-10-01

    The findings in 30 cases diagnosed as atypical odontalgia are presented. The clinical characteristics of these cases are compared with other cases reported in the literature. Three cases are described in detail. Patient understanding and treatment with tricyclic antidepressants are discussed together with medication side effects and interactions. The importance of deferring invasive procedures is emphasized.

  10. Tuberculous spondylitis presenting as severe chest pain

    Directory of Open Access Journals (Sweden)

    Martha A. Kaeser

    2012-04-01

    Full Text Available This case report describes a 32-year-old male who presented to an emergency department with severe chest pain and a history of cough, fever, night sweats, loss of appetite and weight. Chest radiography revealed a left upper lobe consolidation and multiple compression deformities in the thoracic spine. Magnetic resonance imaging demonstrated significant kyphosis and vertebral plana at two thoracic levels. Anterior compression of the spinal cord and adjacent soft tissue masses were also noted.

  11. Tuberculous spondylitis presenting as severe chest pain.

    Science.gov (United States)

    Kaeser, Martha A; Kettner, Norman W; Albastaki, Usama; Kotb, Hossam Ahmed; Eldesouky, Ibrahim M A; Pierre-Jerome, Claude

    2012-03-30

    This case report describes a 32-year-old male who presented to an emergency department with severe chest pain and a history of cough, fever, night sweats, loss of appetite and weight. Chest radiography revealed a left upper lobe consolidation and multiple compression deformities in the thoracic spine. Magnetic resonance imaging demonstrated significant kyphosis and vertebral plana at two thoracic levels. Anterior compression of the spinal cord and adjacent soft tissue masses were also noted.

  12. [Atypical odontalgia - a little known phantom pain].

    Science.gov (United States)

    Türp, J C

    2001-02-01

    Atypical odontalgia (AO) was described in the dental literature more than 200 years ago, and it is included in most taxonomies and textbooks of pain. Nonetheless, it remains one of the most frequently misdiagnosed intraoral pain conditions. Due to similarities with phantom pain, AO is also referred to as "phantom tooth pain". AO is characterized by persistent throbbing pain in or around a former or present permanent tooth (preferably molars and premolars). Clinical and radiographic examination, however, does not reveal any organic cause of the pain. The complaints associated with AO usually begin after deafferentiation of primary afferent trigeminal nerve fibers, e. g., after pulp extirpation, apicectomy, or extraction of a tooth. AO is a diagnosis by exclusion. Patients and dentists must be aware of the fact that the therapeutic options are limited. AO is primarily managed with topically or systemically administered pharmacological agents. Unnecessary and harmful procedures around teeth and jaws must be avoided by all means. A concept was recently proposed which aims to unify a group of four types of orofacial pain under the term "idiopathic orofacial pain" (Woda & Pionchon 1999, 2000). These pain conditions - AO, atypical facial pain, burning mouth syndrome ("stomatodynia"), and subgroups of temporomandibular disorders ("idiopathic facial arthromyalgia") - are characterized by unknown etiology, but common clinical characteristics. It is to be hoped that the suggested classification will stimulate reflection on these enigmatic orofacial pain disorders.

  13. Evaluation and treatment of musculoskeletal chest pain.

    Science.gov (United States)

    Ayloo, Amba; Cvengros, Teresa; Marella, Srimannarayana

    2013-12-01

    This article summarizes the evaluation and treatment of musculoskeletal causes of chest pain. Conditions such as costochondritis, rib pain caused by stress fractures, slipping rib syndrome, chest wall muscle injuries, fibromyalgia, and herpes zoster are discussed, with emphasis on evaluation and treatment of these and other disorders. Many of these conditions can be diagnosed by the primary care clinician in the office by history and physical examination. Treatment is also discussed, including description of manual therapy and exercises as needed for some of the conditions. Copyright © 2013 Elsevier Inc. All rights reserved.

  14. Misdiagnosed Chest Pain: Spontaneous Esophageal Rupture

    Science.gov (United States)

    Inci, Sinan; Gundogdu, Fuat; Gungor, Hasan; Arslan, Sakir; Turkyilmaz, Atila; Eroglu, Atila

    2013-01-01

    Chest pain is one of themost common complaints expressed by patients presenting to the emergency department, and any initial evaluation should always consider life-threatening causes. Esophageal rupture is a serious condition with a highmortality rate. If diagnosed, successful therapy depends on the size of the rupture and the time elapsed between rupture and diagnosis.We report on a 41-year-old woman who presented to the emergency department complaining of left-sided chest pain for two hours. PMID:27122690

  15. Atypical Odontalgia (Phantom Tooth Pain)

    Science.gov (United States)

    ... nerves or a portion of the brain that processes pain sensation. It is important to recognize this ... The information contained in this monograph is for educational purposes only. Prepared by D Falace and the ...

  16. Clinical images. Atypical midcycle pain.

    LENUS (Irish Health Repository)

    Alsinnawi, Mazen

    2012-01-31

    A 16-year-old female presented with acute-onset abdominal pain and an initial diagnosis of midcycle pain. Subsequent pelvic ultrasound and diagnostic laparoscopy showed a large mass in the pouch of Douglas. The patient underwent a laparotomy and excision of a mass from a loop of jejunum. This case highlights the difficulties in diagnostic differentiation relating to large pelvic masses in young females.

  17. Risk stratification in chest pain patients

    NARCIS (Netherlands)

    Poldervaart, J.M.

    2016-01-01

    Yearly, a total of approximately 200,000 patients in The Netherlands present to the emergency department with chest pain. Only 20% of these patients will have an acute coronary syndrome (ACS), and need prompt admission and treatment. However, differentiating between ACS and other, mostly

  18. The Interdisciplinary Management of Acute Chest Pain.

    Science.gov (United States)

    Bruno, Raphael R; Donner-Banzhoff, Norbert; Söllner, Wolfgang; Frieling, Thomas; Müller, Christian; Christ, Michael

    2015-11-06

    Acute chest pain of non-traumatic origin is a common reason for presentation to physician's offices and emergency rooms. Coronary heart disease is the cause in up to 25% of cases. Because acute chest pain, depending on its etiology, may be associated with a high risk of death, rapid, goal-oriented management is mandatory. This review is based on pertinent articles and guidelines retrieved by a selective search in PubMed. History-taking, physical examination, and a 12-lead electrocardiogram (ECG) are the first steps in the differential diagnostic process and generally allow the identification of features signifying a high risk of lifethreatening illness. If the ECG reveals ST-segment elevation, cardiac catheterization is indicated. The timedependent measurement of highly sensitive troponin values is a reliable test for the diagnosis or exclusion of acute myocardial infarction. A wide variety of other potential causes (e.g., vascular, musculoskeletal, gastroenterologic, or psychosomatic) must be identified from the history if they are to be treated appropriately. Elderly patients need special attention. Acute chest pain is a major diagnostic challenge for the physician. Common errors are traceable to non-recognition of important causes and to an inadequate diagnostic work-up. Future studies should be designed to help optimize the interdisciplinary management of patients with chest pain.

  19. Chest pain: Coronary CT in the ER

    NARCIS (Netherlands)

    E. Maffei (Erica); S. Seitun (Sara); A.I. Guaricci (Andrea); F. Cademartiri (Filippo)

    2016-01-01

    textabstractCardiac CT has developed into a robust clinical tool during the past 15 years. Of the fields in which the potential of cardiac CT has raised more interest is chest pain in acute settings. In fact, the possibility to exclude with high reliability obstructive coronary artery disease (CAD)

  20. Quick identification of acute chest pain patients study (QICS)

    NARCIS (Netherlands)

    Willemsen, Hendrik M.; de Jong, Gonda; Tio, Rene A.; Nieuwland, Wybe; Kema, Ido P.; van der Horst, Iwan C. C.; Oudkerk, Mattijs; Zijlstra, Felix

    2009-01-01

    Background: Patients with acute chest pain are often referred to the emergency ward and extensively investigated. Investigations are costly and could induce unnecessary complications, especially with invasive diagnostics. Nevertheless, chest pain patients have high mortalities. Fast identification

  1. [Persistent idiopathic facial pain and atypical odontalgia].

    Science.gov (United States)

    Gaul, Charly; Ettlin, Dominik; Pfau, Doreen B

    2013-01-01

    The terms 'persistent idiopathic facial pain' (PIFP) and 'atypical odontalgia' (AO) are currently used as exclusion diagnoses for chronic toothache and chronic facial pain. Knowledge about these pain conditions in medical and dental practices is of crucial importance for the prevention of iatrogenic tissue damage by not-indicated invasive interventions, such as endodontic treatment and tooth extraction. In the present paper, etiology and pathogenesis, differential diagnostic criteria, and diagnostic approaches will be explained and relevant therapeutic principles will be outlined. Copyright © 2013. Published by Elsevier GmbH.

  2. Epipericardial fat necrosis as a cause of acute chest pain

    OpenAIRE

    Shah, Ankit H.; Bogale, Vivek; Hurst, David; dePrisco, Gregory

    2016-01-01

    Acute chest pain is one of the most common reasons for presentation to the emergency department. Although most etiologies of chest pain are easy to clinically ascertain with routine history, physical, and laboratory examinations, we present an important benign cause of acute chest pain that may mimic acute coronary syndrome.

  3. Uncommon Etiology of Chest Pain: Pulmonary Sequestration

    Directory of Open Access Journals (Sweden)

    Haider, Asghar

    2013-11-01

    Full Text Available Chest pain is a common presenting symptom in the emergency department. After ruling out emergent causes, emergency physicians need to identify and manage less commonly encountered conditions. Pulmonary sequestration (PS is a rare congenital condition involving pulmonary parenchyma. In PS, a portion of non-functional lung tissue receives systemic blood supply from an anomalous artery. While most individuals with PS present in early life with symptoms of difficulty feeding, cyanosis, and dyspnea, some present later with recurrent pneumonia, hemoptysis, or productive cough. In this report, we present a case of PS in an adult with acute onset pleuritic chest pain. [West J Emerg Med. 2013;14(6:638–639.

  4. Patients' opinions of acute chest pain care: a qualitative evaluation of Chest Pain Units.

    Science.gov (United States)

    Johnson, Maxine; Goodacre, Steve; Tod, Angela; Read, Susan

    2009-01-01

    This paper is a report of a study to explore the experiences of individuals receiving Chest Pain Unit care and routine Emergency Department care for acute chest pain. Chest Pain Units were established in the United States of America with the aim of reducing admissions and costs, whilst improving quality of life and care satisfaction. Trials showed these units to be safe and practical; however, there was a need to establish whether Chest Pain Units could be cost-effective in the United Kingdom, and whether use of a nurse-led protocol could be acceptable to patients. We carried out 26 semi-structured interviews in 2005-2006 with patients across seven trial Chest Pain Units in the United Kingdom (14 in intervention sites and 12 in control sites) to explore issues that patients considered were important in their care experiences, and to develop possible explanations for the main trial outcomes. We analysed transcripts using the Framework approach to identify themes relating to care experiences. Differences in care experiences were more distinct between individual sites than between control and intervention sites. Satisfaction with care was high overall. Interactions with healthcare professionals, in particular specialist nurses, were valued in terms of reassurance, calming effect and competence. Indications for care improvement concerned information-giving about investigations, diagnosis, and self-care advice. Patients with non-cardiac causes needed to feel more supported after discharge. Differences between modes of care may not coincide with identified trial outcomes. Qualitative methods can identify aspects of care that improve patient acceptability. The specialist nurse role appears particularly important in providing satisfactory individualized chest pain care.

  5. [Statistical evaluation of potential mistakes and malpractice in a Chest Pain Unit].

    Science.gov (United States)

    Coppola, A; Soto, M; Baldini, E; Suppa, M; Colzi, M; Scarpellini, M G

    2013-01-01

    The Chest Pain Unit (CPU) of Policlinico Umberto I, established in 2008, is charged with the management of patients with non-traumatic chest pain transferred from the Emergency Department and aims at: a) an early recognition of patients at high risk of acute coronary syndrome (ACS), in order to perform a primary PCI within 90 minutes; b) an early diagnosis of patients at low risk of ACS in order to discharge them in a short time, and c) the diagnostic performance of clinical tests in patients at intermediate risk of ACS in order to identify those who require either a new PCI or a coronary artery bypass graft (CABG). The purpose is to avoid malpractice which could even imply the risk of legal conflicts. We evaluated the total number of admissions to the Emergency Department of Policlinico Umberto I in the period 2010-2011 and selected the patients with non-traumatic chest pain and acute coronary syndrome. In the Chest Pain Unit, patients with non-traumatic chest pain or ACS were recruited through a) the use of the Chest Pain Score to define the typicality or atypicality of chest pain; b) the stratification of the risk of ACS using the modified Braunwald Score; and c) the stratification of patients at intermediate or high risk of ACS using the GRACE ACS Model in order to perform a PCI. In the period 2010-2011, 603 patients were admitted to the CPU with non-traumatic chest pain. Of them, 15.75% (95) were diagnosed with atypical chest pain; 27.03% (163) with chronic stable angina pectoris; 9.3% (56) received a diagnosis of chronic heart failure and 47.92% (289) suffered from non ischemic cardiovascular disease. Other 124 subjects were admitted to the CPU with a diagnosis of ACS, but only in 91.93% of the cases such diagnosis was confirmed, whereas for the remaining 8.06% was discarded. On the whole, 54.2% (394) of the 727 patients admitted to the CPU with non-traumatic chest pain and acute coronary syndrome showed a low cardiovascular risk; 30.12% (219) were at

  6. Intrathoracic splenosis presenting as persistent chest pain.

    Science.gov (United States)

    Fukuhara, Shinichi; Tyagi, Samuel; Yun, Jaime; Karpeh, Martin; Reyes, Angelo

    2012-09-07

    Thoracic splenosis is a rare entity resulting from splenic and diaphragmatic injury. Patients remain asymptomatic, and surgical intervention is not indicated in the majority of cases. We report a case of a 50-year-old male with a history of splenectomy due to a gunshot wound 30 years previously who presented with vague, progressively worsening chest pain. He was found to have a large intrathoracic splenosis. Unique features of our patient include the presence of symptoms, the significant interval growth of the splenic tissue, and the unprecedented size of the mass, which we believe to be the largest among those previously described.

  7. Intrathoracic splenosis presenting as persistent chest pain

    Directory of Open Access Journals (Sweden)

    Fukuhara Shinichi

    2012-09-01

    Full Text Available Abstract Thoracic splenosis is a rare entity resulting from splenic and diaphragmatic injury. Patients remain asymptomatic, and surgical intervention is not indicated in the majority of cases. We report a case of a 50-year-old male with a history of splenectomy due to a gunshot wound 30 years previously who presented with vague, progressively worsening chest pain. He was found to have a large intrathoracic splenosis. Unique features of our patient include the presence of symptoms, the significant interval growth of the splenic tissue, and the unprecedented size of the mass, which we believe to be the largest among those previously described.

  8. An Unusual Cause of Precordial Chest Pain

    Directory of Open Access Journals (Sweden)

    Sevket Ozkaya

    2013-01-01

    Full Text Available Extraskeletal chondrosarcoma in anterior mediastinum is very rare. A 45-year-old male patient was admitted to the hospital with precordial chest pain. A large and well-shaped mass in the anterior mediastinum was seen radiologically, and there was a clearly compression of the heart by the mass. The lesion was totally resected, and extraskeletal mediastinal chondrosarcoma was histopathologically diagnosed. We aimed to present and discuss the radiologic, clinic, and histopathologic features of unusual presentation of extraskeletal chondrosarcoma in a case.

  9. An under recognized cause of chest pain

    Directory of Open Access Journals (Sweden)

    Unnikrishnan Ponnamma Kunjan Pillai

    2012-01-01

    Full Text Available Aortic intramural hematoma (IMH is related to but is pathologically distinct from aortic dissection. In this potentially lethal entity, there is hemorrhage into the aortic media in the absence of an intimal tear. With recent advances in imaging techniques, IMH is now increasingly recognized. The limited data available suggest that the clinical course of IMH mimics that of acute aortic dissection, and mortality rates are similar. Physicians need to be cognizant regarding this entity when they are evaluating chest pain. Here we report a case of IMH, in a 63-year-old female, which was managed conservatively.

  10. Clinical decision aids for chest pain in the emergency department: identifying low-risk patients

    Directory of Open Access Journals (Sweden)

    Alley W

    2015-11-01

    Full Text Available William Alley, Simon A Mahler Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA Abstract: Chest pain is one of the most common presenting complaints in the emergency department, though only a small minority of patients are subsequently diagnosed with acute coronary syndrome (ACS. However, missing the diagnosis has potential for significant morbidity and mortality. ACS presentations can be atypical, and their workups are often prolonged and costly. In order to risk-stratify patients and better direct the workup and care given, many decision aids have been developed. While each may have merit in certain clinical settings, the most useful aid in the emergency department is one that finds all cases of ACS while also identifying a substantial subset of patients at low risk who can be discharged without stress testing or coronary angiography. This review describes several of the chest pain decision aids developed and studied through the recent past, starting with the thrombolysis in myocardial infarction (TIMI risk score and Global Registry of Acute Coronary Events (GRACE scores, which were developed as prognostic aids for patients already diagnosed with ACS, then subsequently validated in the undifferentiated chest pain population. Asia-Pacific Evaluation of Chest Pain Trial (ASPECT; Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins (ADAPT; North American Chest Pain Rule (NACPR; and History, Electrocardiogram, Age, Risk factors, Troponin (HEART score have been developed exclusively for use in the undifferentiated chest pain population as well, with improved performance compared to their predecessors. This review describes the relative merits and limitations of these decision aids so that providers can determine which tool fits the needs of their clinical practice setting. Keywords: chest pain, decision aid, risk score, acute coronary syndrome

  11. Pontine Infarct Presenting with Atypical Dental Pain: A Case Report.

    Science.gov (United States)

    Goel, Rajat; Kumar, Sanjeev; Panwar, Ajay; Singh, Abhishek B

    2015-01-01

    Orofacial pain' most commonly occurs due to dental causes like caries, gingivitis or periodontitis. Other common causes of 'orofacial pain' are sinusitis, temporomandibular joint(TMJ) dysfunction, otitis externa, tension headache and migraine. In some patients, the etiology of 'orofacial pain' remains undetected despite optimal evaluation. A few patients in the practice of clinical dentistry presents with dental pain without any identifiable dental etiology. Such patients are classified under the category of 'atypical odontalgia'. 'Atypical odontalgia' is reported to be prevalent in 2.1% of the individuals. 'Atypical orofacial pain' and 'atypical odontalgia' can result from the neurological diseases like multiple sclerosis, trigeminal neuralgia and herpes infection. Trigeminal neuralgia has been frequently documented as a cause of 'atypical orofacial pain' and 'atypical odontalgia'. There are a few isolated case reports of acute pontine stroke resulting in 'atypical orofacial pain' and 'atypical odontalgia'. However, pontine stroke as a cause of atypical odontalgia is limited to only a few cases, hence prevalence is not established. This case is one, where a patient presented with acute onset atypical dental pain with no identifiable dental etiology, further diagnosed as an acute pontine infarct on neuroimaging. A 40 years old male presented with acute onset, diffuse teeth pain on right side. Dental examination was normal. Magnetic resonance imaging(MRI) of the brain had an acute infarct in right pons near the trigeminal root entry zone(REZ). Pontine infarct presenting with dental pain as a manifestation of trigeminal neuropathy, has rarely been reported previously. This stresses on the importance of neuroradiology in evaluation of atypical cases of dental pain.

  12. Staphylococcus aureus sternal osteomyelitis: a rare cause of chest pain

    Directory of Open Access Journals (Sweden)

    Kaur M

    2015-10-01

    Full Text Available Chest pain is a common presenting symptom with a broad differential. Life-threatening cardiac and pulmonary etiologies of chest pain should be evaluated first. However, it is critical to perform a thorough assessment for other sources of chest pain in order to limit morbidity and mortality from less common causes. We present a rare case of a previously healthy 45 year old man who presented with focal, substernal, reproducible chest pain and Staphylococcus aureus bacteremia who was later found to have primary Staphylococcus aureus sternal osteomyelitis.

  13. Non-invasive imaging in acute chest pain syndromes.

    Science.gov (United States)

    Sechtem, Udo; Achenbach, Stephan; Friedrich, Matthias; Wackers, Frans; Zamorano, José L

    2012-01-01

    This review has the purpose of informing the reader about the current use of imaging techniques in patients presenting with acute chest pain to the emergency department. We will focus on three aspects of managing the patient with acute chest pain: Imaging to increase the number of correct diagnoses in the acute situation; Imaging to rule out other than coronary causes of chest pain; Use of imaging for risk stratification once myocardial infarction has been ruled out in the CPU. Special emphasis is given to how these management aspects are discussed in current guidelines on the management of patients with acute chest pain or acute coronary syndrome.

  14. Association between paroxysmal trigeminal neuralgia and atypical facial pain.

    Science.gov (United States)

    Juniper, R P; Glynn, C J

    1999-12-01

    Paroxysmal trigeminal neuralgia and atypical facial pain are both fairly common conditions that produce pain in the face of different character. Trigeminal neuralgia is sharp and shooting, brought on by facial movement, change of temperature and by touching the face at a specific point (the trigger point). Atypical facial pain is dull and unrelenting and its site is ill-defined. Trigeminal neuralgia is generally more common in older people, and affects women slightly more than men, and atypical facial pain generally affects younger people, with women predominating. The pains should never be confused. We have noticed that many patients with trigeminal neuralgia have additional symptoms of atypical facial pain and so we reviewed the records of the Pain Relief Unit retrospectively. Of the 83 patients identified with trigeminal neuralgia where records were adequate, 35 (42%) also had atypical facial pain. Five of these had developed it before the onset of trigeminal neuralgia and could be examples of pretrigeminal neuralgia. There were eight patients in the series with multiple sclerosis, of whom two also had atypical facial pain. There seemed to be no relationship between the development of atypical facial pain and the interventions used to treat trigeminal neuralgia. It is important that both conditions are identified and treated individually.

  15. Computer Assisted Diagnosis of Chest Pain. Adjunctive Treatment Protocols

    Science.gov (United States)

    1984-07-30

    physical etiology for chest pain. Disorders that present with epigastric pain such as gastritis , peptic ulcer, pancreatitis, and cholelithiasis may...shaking chills seen in bacterial pneumonia. TREATMENT: The treatment of pneumonia consists of bed rest, hydration, adequate nutrition , an

  16. Clinical decision aids for chest pain in the emergency department: identifying low-risk patients

    OpenAIRE

    Alley W; Mahler SA

    2015-01-01

    William Alley, Simon A Mahler Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA Abstract: Chest pain is one of the most common presenting complaints in the emergency department, though only a small minority of patients are subsequently diagnosed with acute coronary syndrome (ACS). However, missing the diagnosis has potential for significant morbidity and mortality. ACS presentations can be atypical, and their workups are often prolonged and costly. ...

  17. [Angina-like chest pain and exertional esophageal ph monitoring].

    Science.gov (United States)

    Romand, F; Vincent, E; Potier, V; Claudel, N; Galoo, E; Desbaumes, J

    1999-03-01

    Spontaneous chest pain attacks are uncommon during 24-hour esophageal pH monitoring in patients suffering from angina-like chest pain suspected to be acid-related. The aim of this study was to assess the diagnostic value of exertional esophageal pH monitoring and to prove that exercise testing induces chest pain and gastro-esophageal reflux and therefore improves symptomatic correlation study. Forty three patients suffering from angina-like chest pain underwent treadmill exercise testing during a 24-hour esophageal pH monitoring. Symptom analysis was made using the symptom-association probability described by Weusten. During the 24-hour pH monitoring, 10 patients (23%) had a pathologic esophageal acid exposure, 20 (46%) experienced chest pain and 3 (7%) had a symptom association probability > 95%. During the exercise testing on a treadmill, 19 patients (44%) had gastro-esophageal reflux, and 14 (32%) experienced chest pain, coinciding with a gastro-esophageal reflux in 8 (19%). After exercise testing, the symptom-association probability analysis was significantly changed in 9 patients (21%), > 95% in 6 patients (14%). Exercise testing on a treadmill induces chest pain episodes during a 24-hour esophageal pH monitoring and therefore improves symptomatic correlation study in patients suffering from angina-like chest pain.

  18. Approach to chest pain and acute myocardial infarction | Pandie ...

    African Journals Online (AJOL)

    Patient history, physical examination, 12-lead electrocardiogram (ECG) and cardiac biomarkers are key components of an effective chest pain assessment. The first priority is excluding serious chest pain syndromes, namely acute coronary syndromes (ACSs), aortic dissection, pulmonary embolism, cardiac tamponade and ...

  19. Clinical decision aids for chest pain in the emergency department: identifying low-risk patients

    Science.gov (United States)

    Alley, William; Mahler, Simon A

    2015-01-01

    Chest pain is one of the most common presenting complaints in the emergency department, though only a small minority of patients are subsequently diagnosed with acute coronary syndrome (ACS). However, missing the diagnosis has potential for significant morbidity and mortality. ACS presentations can be atypical, and their workups are often prolonged and costly. In order to risk-stratify patients and better direct the workup and care given, many decision aids have been developed. While each may have merit in certain clinical settings, the most useful aid in the emergency department is one that finds all cases of ACS while also identifying a substantial subset of patients at low risk who can be discharged without stress testing or coronary angiography. This review describes several of the chest pain decision aids developed and studied through the recent past, starting with the thrombolysis in myocardial infarction (TIMI) risk score and Global Registry of Acute Coronary Events (GRACE) scores, which were developed as prognostic aids for patients already diagnosed with ACS, then subsequently validated in the undifferentiated chest pain population. Asia-Pacific Evaluation of Chest Pain Trial (ASPECT); Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins (ADAPT); North American Chest Pain Rule (NACPR); and History, Electrocardiogram, Age, Risk factors, Troponin (HEART) score have been developed exclusively for use in the undifferentiated chest pain population as well, with improved performance compared to their predecessors. This review describes the relative merits and limitations of these decision aids so that providers can determine which tool fits the needs of their clinical practice setting. PMID:27147894

  20. Diagnostic Evaluation of Nontraumatic Chest Pain in Athletes.

    Science.gov (United States)

    Moran, Byron; Bryan, Sean; Farrar, Ted; Salud, Chris; Visser, Gary; Decuba, Raymond; Renelus, Deborah; Buckley, Tyler; Dressing, Michael; Peterkin, Nicholas; Coris, Eric

    This article is a clinically relevant review of the existing medical literature relating to the assessment and diagnostic evaluation for athletes complaining of nontraumatic chest pain. The literature was searched using the following databases for the years 1975 forward: Cochrane Database of Systematic Reviews; CINAHL; PubMed (MEDLINE); and SportDiscus. The general search used the keywords chest pain and athletes. The search was revised to include subject headings and subheadings, including chest pain and prevalence and athletes. Cross-referencing published articles from the databases searched discovered additional articles. No dissertations, theses, or meeting proceedings were reviewed. The authors discuss the scope of this complex problem and the diagnostic dilemma chest pain in athletes can provide. Next, the authors delve into the vast differential and attempt to simplify this process for the sports medicine physician by dividing potential etiologies into cardiac and noncardiac conditions. Life-threatening causes of chest pain in athletes may be cardiac or noncardiac in origin, which highlights the need for the sports medicine physician to consider pathology in multiple organ systems simultaneously. This article emphasizes the importance of ruling out immediately life threatening diagnoses, while acknowledging the most common causes of noncardiac chest pain in young athletes are benign. The authors propose a practical algorithm the sports medicine physician can use as a guide for the assessment and diagnostic work-up of the athlete with chest pain designed to help the physician arrive at the correct diagnosis in a clinically efficient and cost-effective manner.

  1. Postpartum Pneumomediastinum: An Uncommon Cause for Chest Pain

    Directory of Open Access Journals (Sweden)

    Vladimir Revicky

    2010-01-01

    Full Text Available This case report refers to a 32-year-old primiparous woman with a mild asthma, who had a normal vaginal delivery in a birthing pool and developed an acute postpartum chest pain due to pneumomediastinum and subcutaneous chest emphysema. After 72 hours of observation, she was discharged home without any residual symptoms.

  2. Chest Pain Units: A Modern Way of Managing Patients with Chest Pain in the Emergency Department

    OpenAIRE

    Bassan Roberto

    2002-01-01

    It is estimated that 5 to 8 million individuals with chest pain or other symptoms suggestive of myocardial ischemia are seen each year in emergency departments (ED) in the United States 1,2, which corresponds to 5 to 10% of all visits 3,4. Most of these patients are hospitalized for evaluation of possible acute coronary syndrome (ACS). This generates an estimated cost of 3 - 6 thousand dollars per patient 5,6. From this evaluation process, about 1.2 million patients receive the diagnosis of a...

  3. Outpatient diagnosis of acute chest pain in adults

    National Research Council Canada - National Science Library

    McConaghy, John R; Oza, Rupal S

    2013-01-01

    .... The initial goal in patients presenting with chest pain is to determine if the patient needs to be referred for further testing to rule in or out acute coronary syndrome and myocardial infarction...

  4. Chest CT examinations in patients presenting with acute chest pain: a pictorial review.

    Science.gov (United States)

    Hammer, Sebastiaan; Kroft, Lucia J; Hidalgo, Alberto L; Leta, Ruben; de Roos, Albert

    2015-12-01

    Acute chest pain (ACP) is one of the most common presenting symptoms at the emergency department. The differential diagnosis is vast. To exclude life-threatening causes, radiologists encounter an increasing amount of thoracic computed tomography (CT) examinations including CT angiography of the heart and great vessels. The dual- and triple-rule CT examinations are currently implemented in clinical practice. We retrospectively identified chest CT examinations in the setting of acute chest pain in our hospitals and collected a variety of common and uncommon cases. In this pictorial essay, we present the most educative cases from patients who presented with acute chest pain in the emergency department of our hospitals and for whom a thoracic CT was ordered. When aortic emergencies, acute coronary syndrome, and pulmonary embolism are excluded, these cases may help the radiologist to suggest alternative diagnoses in the diagnostic challenge of acute chest pain. Teaching Points • The number of chest CT examinations for ACP is increasing.• Chest CT examinations may help suggesting alternative diagnosis in ACP.• Radiologists should be aware of the differential diagnosis of ACP.

  5. Treatment of atypically-localized cavernous hemangioma in abdomen with atypical pain

    Directory of Open Access Journals (Sweden)

    Mehmet Ilhan

    2016-01-01

    Conclusion: Cavernous hemangiomas of the liver rarely require treatment. Surgery is one of the options in selected cases and abdominal pain is one of the indications. In patients complaining from persistent abdominal pain, if intraabdominal atypical-localized mass was seen in examinations, hemangioma should be remembered in differential diagnosis.

  6. Quick identification of acute chest pain patients study (QICS

    Directory of Open Access Journals (Sweden)

    van der Horst Iwan CC

    2009-06-01

    Full Text Available Abstract Background Patients with acute chest pain are often referred to the emergency ward and extensively investigated. Investigations are costly and could induce unnecessary complications, especially with invasive diagnostics. Nevertheless, chest pain patients have high mortalities. Fast identification of high-risk patients is crucial. Therefore several strategies have been developed including specific symptoms, signs, laboratory measurements, and imaging. Methods/Design The Quick Identification of acute Chest pain Study (QICS will investigate whether a combined use of specific symptoms and signs, electrocardiography, routine and new laboratory measures, adjunctive imaging including electron beam (EBT computed tomography (CT and contrast multislice CT (MSCT will have a high diagnostic yield for patients with acute chest pain. All patients will be investigated according a standardized protocol in the Emergency Department. Serum and plasma will be frozen for future analysis for a wide range of biomarkers at a later time point. The primary endpoint is the safe recognition of low-risk chest pain patients directly at presentation. Secondary endpoint is the identification of a wide range of sensitive predictive clinical markers, chemical biomarkers and radiological markers in acute chest pain patients. Chemical biomarkers will be compared to quantitative CT measurements of coronary atherosclerosis as a surrogate endpoint. Chemical biomarkers will also be compared in head to head comparison and for their additional value. Discussion This will be a very extensive investigation of a wide range of risk predictors in acute chest pain patients. New reliable fast and cheap diagnostic algorithm resulting from the test results might improve chest pain patients' prognosis, and reduce unnecessary costs and diagnostic complications.

  7. Cardiac CT angiography for evaluation of acute chest pain.

    Science.gov (United States)

    Lee, Nam Ju; Litt, Harold

    2016-01-01

    Chest pain is the second most common emergency department (ED) presentation in the United States. Cardiac computed tomography angiography (CCTA) now plays an important role in the evaluation of patients with suspected acute coronary syndrome in the ED setting. In this article, we review the available techniques focused on the use of CCTA to evaluate patients fosr coronary atherosclerosis for timely triage of acute chest pain.

  8. Chest Pain Units: A Modern Way of Managing Patients with Chest Pain in the Emergency Department

    Directory of Open Access Journals (Sweden)

    Roberto Bassan

    2002-08-01

    Full Text Available It is estimated that 5 to 8 million individuals with chest pain or other symptoms suggestive of myocardial ischemia are seen each year in emergency departments (ED in the United States 1,2, which corresponds to 5 to 10% of all visits 3,4. Most of these patients are hospitalized for evaluation of possible acute coronary syndrome (ACS. This generates an estimated cost of 3 - 6 thousand dollars per patient 5,6. From this evaluation process, about 1.2 million patients receive the diagnosis of acute myocardial infarction (AMI, and just about the same number have unstable angina. Therefore, about one half to two thirds of these patients with chest pain do not have a cardiac cause for their symptoms 2,3. Thus, the emergency physician is faced with the difficult challenge of identifying those with ACS - a life-threatening disease - to treat them properly, and to discharge the others to suitable outpatient investigation and management.

  9. Embolized prostatic brachytherapy seeds mimicking acute chest pain syndromes

    Directory of Open Access Journals (Sweden)

    Nirmal Guragai

    2017-01-01

    Full Text Available A 59-year-old male with a history of nonobstructive coronary artery disease, diabetes mellitus, hypertension, and prostate cancer presented to the hospital with 1-day history of pleuritic chest pain. Initial workup for acute coronary event was unremarkable. Chest X-ray revealed multiple small radial densities which were linear and hyperdense, consistent with embolization of metallic seeds to the pulmonary circulation. The patient was noted to have had radioactive metallic seeds implanted for prostate cancer 6 months ago. Diagnosis of pulmonary embolization of prostatic seeds is challenging as they frequently present with chest pain mimicking acute coronary syndromes.

  10. Acute fatal chest pain: optimized procedure in emergency department.

    Science.gov (United States)

    Yang, Yang; Zhang, Wei; Peng, Ming; Tong, Lianying; Lin, Shouyu

    2013-01-01

    To explore the diagnostic procedure of acute fatal chest pain in emergency department (ED) in order to decrease the misdiagnosis rate and shorten the definite time to diagnosis. The ultimate aim is to rescue the patients timely and effectively. Three hundreds and two patients (56.9 ± 11.8 Years, 72% men) complained with acute chest pain and chest distress presenting to our ED were recruited. They were divided into two groups according to visiting time (Group I: from October 2010 to March 2011, Group II: from October 2011 to March 2012). The misdiagnosis rate, definite time for diagnosis and medical expense were analyzed. Patients of Group I were diagnosed by initial doctors who made their diagnosis according to personal experience in outpatient service or rescue room in ED. While patients of Group II were all admitted to rescue room and were diagnosed and rescued according to the acute chest pain screening flow-process diagram. Differences inter-group was compared. The misdiagnosis rate of fatal chest pain in Group I and Group II was 6.8% and 0% respectively, and there was statistic difference (P=0.000). The definite time to diagnosis was 65.3 min and 40.1 min in control and Group II respectively, the difference had statistic significance (P=0.000). And the mean cost for treatment was 787.5/124.5 ¥/$ and 905.5/143.2 ¥/$ respectively, and there was statistic difference too (P=0.012). Treating emergency patients with acute chest pain according to the acute chest pain screening flow-process diagram in rescue room will decrease misdiagnosis apparently, and it can also shorten the definite time to correct diagnosis. It has a remarkable positive role in rescuing patients with acute chest pain timely and effectively.

  11. Fast track evaluation of patients with acute chest pain: experience in a large-scale chest pain unit in Israel.

    Science.gov (United States)

    Beigel, Roy; Oieru, Dan; Goitein, Orly; Chouraqui, Pierre; Feinberg, Micha S; Brosh, Sella; Asher, Elad; Konen, Eli; Shamiss, Ari; Eldar, Michael; Hod, Hanoch; Or, Jacob; Matetzky, Shlomi

    2010-06-01

    Many patients present to the emergency department with chest pain. While in most of them chest pain represents a benign complaint, in some patients it underlies a life-threatening illness. To assess the routine evaluation of patients presenting to the ED with acute chest pain by means of a cardiologist-based chest pain unit using different noninvasive imaging modalities. We evaluated the records of 1055 consecutive patients who presented to the ED with complaints of chest pain and were admitted to the CPU. After an observation period and according to the decision of the attending cardiologist, patients underwent myocardial perfusion scintigraphy, multidetector computed tomography, or stress echocardiography. The CPU attending cardiologist did not prescribe non-invasive evaluation for 108 of the 1055 patients, who were either admitted (58 patients) or discharged (50 patients) after an observation period. Of those remaining, 444 patients underwent MDCT, 445 MPS, and 58 stress echocardiography. Altogether, 907 patients (86%) were discharged from the CPU. During an average period of 236 +/- 223 days, 25 patients (3.1%) were readmitted due to chest pain of suspected cardiac origin, and only 8 patients (0.9%) suffered a major adverse cardiovascular event. Utilization of the CPU enabled a rapid and thorough evaluation of the patients' primary complaint, thereby reducing hospitalization costs and occupancy on the one hand and avoiding misdiagnosis in discharged patients on the other.

  12. 'Chest pain typicality' in suspected acute coronary syndromes and the impact of clinical experience.

    Science.gov (United States)

    Carlton, Edward W; Than, Martin; Cullen, Louise; Khattab, Ahmed; Greaves, Kim

    2015-10-01

    Physicians rely upon chest pain history to make management decisions in patients with suspected acute coronary syndromes, particularly where the diagnosis is not immediately apparent through electrocardiography and troponin testing. The objective of this study was to establish the discriminatory value of "typicality of chest pain" and the effect of clinician experience, for the prediction of acute myocardial infarction and presence of significant coronary artery disease. This prospective single-center observational study was undertaken in a UK General Hospital emergency department. We recruited consecutive adults with chest pain and a nondiagnostic electrocardiogram, for whom the treating physician determined that delayed troponin testing was necessary. Using their own clinical judgment, physicians recorded whether the chest pain described was typical or atypical for acute coronary syndrome. Physicians were defined as "experienced" or "novice" according to postgraduate experience. Acute myocardial infarction was adjudicated using a high-sensitivity troponin (hs-cTn) assay, whereas coronary artery disease was adjudicated angiographically. Overall, 912 patients had typicality of chest pain assessed, of whom 114/912 (12.5%) had an acute myocardial infarction and 157/912 (17.2%) underwent angiography. In patients undergoing angiography, 90/157 (57.3%) had hs-cTn elevation, of whom 60 (66.7%) had significant coronary artery disease. Sixty-seven of 157 (42.7%) patients had angiography without hs-cTn elevation; of these, 31 (46.2%) had significant coronary artery disease. For the diagnosis of acute myocardial infarction, chest pain typicality had an area under the curve (AUC) of 0.54 (95% confidence interval [CI], 0.49-0.60). For the prediction of significant coronary artery disease with hs-cTn elevation AUC: 0.54 (95% CI, 0.40-0.67), and without hs-cTn elevation AUC: 0.45 (95% CI, 0.31-0.59). When assessed by experienced physicians, specificity for the diagnosis of acute

  13. [Fast track chest pain pathway in emergency department].

    Science.gov (United States)

    Nallet, O; Ketata, N; Ferrier, N; Marcaggi, X

    2016-11-01

    Acute chest pain is a common reason of consultation in the emergency department. The difficulty lies in discriminating patients with acute coronary syndrome or other life-threatening conditions from those non-cardiovascular, non-life-threatening chest pain. Only 15 to 25 % of patients with acute chest pain actually have acute coronary syndrome. Algorithms using high sensitivity troponin at admission and a second assessment 1 or 3hours later are validated to "rule in" or "rule out" the diagnosis of non ST-elevation myocardial infarction. This may reduce the delay for the diagnosis translating into shorter stay in the emergency department. Those algorithms must be interpreted in the context of clinical and ECG criteria. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

  14. Case of chest pain in a young man.

    Science.gov (United States)

    Gupta, Ankit; Palkar, Atul Vijay; Narwal, Priya

    2018-01-12

    A young man with a history of smoking presented with acute-onset chest pain after lifting weights. He also noticed a change in his voice, tightness in his neck and difficulty breathing. A chest radiograph showed soft tissue emphysema in the neck. A CT scan of the chest revealed moderate amount of pneumomediastinum tracking into the neck and down to the diaphragm. He was haemodynamically stable and had no hypoxia or dysphagia. He was monitored for 48 hours and discharged home after resolution of his symptoms. A chest radiograph repeated after 6 weeks was normal. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

  15. Approach to chest pain and acute myocardial infarction

    African Journals Online (AJOL)

    clinician is to rapidly and accurately diagnose potentially serious acute chest pain syndromes (Table 1), before turning attention to acute and chronic conditions that may also carry risk for mortality and morbidity, e.g. pneumonia, stable coronary artery disease (CAD), pericarditis, valvular heart disease, lung malignancies ...

  16. Development of quality metrics for ambulatory pediatric cardiology: Chest pain.

    Science.gov (United States)

    Lu, Jimmy C; Bansal, Manish; Behera, Sarina K; Boris, Jeffrey R; Cardis, Brian; Hokanson, John S; Kakavand, Bahram; Jedeikin, Roy

    2017-12-01

    As part of the American College of Cardiology Adult Congenital and Pediatric Cardiology Section effort to develop quality metrics (QMs) for ambulatory pediatric practice, the chest pain subcommittee aimed to develop QMs for evaluation of chest pain. A group of 8 pediatric cardiologists formulated candidate QMs in the areas of history, physical examination, and testing. Consensus candidate QMs were submitted to an expert panel for scoring by the RAND-UCLA modified Delphi process. Recommended QMs were then available for open comments from all members. These QMs are intended for use in patients 5-18 years old, referred for initial evaluation of chest pain in an ambulatory pediatric cardiology clinic, with no known history of pediatric or congenital heart disease. A total of 10 candidate QMs were submitted; 2 were rejected by the expert panel, and 5 were removed after the open comment period. The 3 approved QMs included: (1) documentation of family history of cardiomyopathy, early coronary artery disease or sudden death, (2) performance of electrocardiogram in all patients, and (3) performance of an echocardiogram to evaluate coronary arteries in patients with exertional chest pain. Despite practice variation and limited prospective data, 3 QMs were approved, with measurable data points which may be extracted from the medical record. However, further prospective studies are necessary to define practice guidelines and to develop appropriate use criteria in this population. © 2017 Wiley Periodicals, Inc.

  17. Cardiovascular Conditions in the Observation Unit: Beyond Chest Pain.

    Science.gov (United States)

    Gaddy, Jeremiah D; Davenport, Kathleen T P; Hiestand, Brian C

    2017-08-01

    The first emergency department observation units (EDOUs) focused on chest pain and potential acute coronary syndromes. However, most EDOUs now cover multiple other conditions that lend themselves to protocolized, aggressive diagnostic and therapeutic regimens. In this article, the authors discuss the management of 4 cardiovascular conditions that have been successfully deployed in EDOUs around the country. Copyright © 2017 Elsevier Inc. All rights reserved.

  18. The occurrences of chest pains and frequent coughing among ...

    African Journals Online (AJOL)

    This study aimed at establishing occurrences of chest pains and frequent coughing among different classes of residents within Selebi Phikwe, Botswana where there are on going nickel-copper (Ni-Cu) mining and smelting activities. Through the administration of questionnaires and structured questions to 600 individuals, ...

  19. Cardiac computed tomography in patients with acute chest pain

    NARCIS (Netherlands)

    K. Nieman (Koen); U. Hoffmann (Udo)

    2015-01-01

    textabstractThe efficient and reliable evaluation of patients with acute chest pain is one of the most challenging tasks in the emergency department. Coronary computed tomography (CT) angiography may play a major role, since it permits ruling out coronary artery disease with high accuracy if

  20. Non-Acute Coronary Syndrome Anginal Chest Pain

    Science.gov (United States)

    Agarwal, Megha; Mehta, Puja K.; Merz, C. Noel Bairey

    2010-01-01

    Anginal chest pain is one of the most common complaints in the outpatient setting. While much of the focus has been on identifying obstructive atherosclerotic coronary artery disease (CAD) as the cause of anginal chest pain, it is clear that microvascular coronary dysfunction (MCD) can also cause anginal chest pain as a manifestation of ischemic heart disease (IHD), and carries an increased cardiovascular risk. Epicardial coronary vasospasm, aortic stenosis, left ventricular hypertrophy, congenital coronary anomalies, mitral valve prolapse and abnormal cardiac nociception can also present as angina of cardiac origin. For non-acute coronary syndrome (ACS) stable chest pain, exercise treadmill testing (ETT) remains the primary tool for diagnosis of ischemia and cardiac risk stratification; however, in certain subsets of patients, such as women, ETT has a lower sensitivity and specificity for identifying obstructive CAD. When combined with an imaging modality, such as nuclear perfusion or echocardiography testing, the sensitivity and specificity of stress testing for detection of obstructive CAD improves significantly. Advancements in stress cardiac magnetic resonance imaging (MRI) enables detection of perfusion abnormalities in a specific coronary artery territory, as well as subendocardial ischemia associated with MCD. Coronary computed tomography angiography (CCTA) enables visual assessment of obstructive CAD, albeit with a higher radiation dose. Invasive coronary angiography (CA) remains the gold standard for diagnosis and treatment of obstructive lesions that cause medically refractory stable angina. Furthermore, in patients with normal coronary angiograms, the addition of coronary reactivity testing (CRT) can help diagnose endothelial dependent and independent microvascular dysfunction. Life-style modification and pharmacologic intervention remains the cornerstone of therapy to reduce morbidity and mortality in patients with stable angina. This review focuses on

  1. Rethinking cocaine-associated chest pain and acute coronary syndromes.

    Science.gov (United States)

    Finkel, Jonathan B; Marhefka, Gregary D

    2011-12-01

    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. However, there continues to be a paucity of prospective, randomized trials addressing this topic as it relates to clinical outcomes. We searched PubMed for English-language articles from 1960 to 2011 using the keywords cocaine, chest pain, coronary arteries, myocardial infarction, emergency department, cardiac biomarkers, electrocardiogram, coronary computed tomography, observation unit, β-blockers, benzodiazepines, nitroglycerin, calcium channel blockers, phentolamine, and cardiomyopathy; including various combinations of these terms. We reviewed the abstracts to confirm relevance, and then full articles were extracted. References from extracted articles were also reviewed for relevant articles. In this review, we critically evaluate the limited historical evidence underlying the current teachings on cocaine's cardiovascular effects and management of cocaine-associated chest pain. We aim to update the reader on more recent, albeit small, studies on the emergency department evaluation and clinical and pharmacologic management of cocaine-associated chest pain. Finally, we summarize recent guidelines and review an algorithm based on the current best evidence.

  2. ANMCO-SIMEU Consensus Document: in-hospital management of patients presenting with chest pain

    OpenAIRE

    Zuin, Guerrino; Parato, Vito Maurizio; Groff, Paolo; Gulizia, Michele Massimo; Di Lenarda, Andrea; Cassin, Matteo; Cibinel, Gian Alfonso; Del Pinto, Maurizio; Di Tano, Giuseppe; Nardi, Federico; Rossini, Roberta; Ruggieri, Maria Pia; Ruggiero, Enrico; Scotto di Uccio, Fortunato; Valente, Serafina

    2017-01-01

    Abstract Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. However, the evaluation of acute chest pain remains challenging, despite many new insights over the past two decades. The percentage of patients presenting to the emergency departments because of acute chest pain appears to be increasing. Nowadays, there are two essential chest pain-related issues: (i) the missed diagnoses of acute co...

  3. Clinical application of cardiac computed tomography: implications for chest pain assessment

    OpenAIRE

    Nasis, Arthur

    2017-01-01

    Chest pain is a common and potentially life-threatening symptom that represents a global health and economic challenge. The prompt and accurate evaluation of chest pain has considerable implications for patient morbidity and mortality as well as on health care economics, however accurate identification of the aetiology of a patient’s chest pain is associated with many diagnostic challenges and potential pitfalls. Most current diagnostic strategies for chest pain focus on the detection of acut...

  4. Acute chest pain in a patient with a non-strangulated hiatal hernia

    OpenAIRE

    Alexander John Scumpia; Megan Elizabeth Dekok; Daniel Michael Aronovich; Gurpaul Bajwa; Randy Barros; Randy Katz; Jordan Ditchek

    2015-01-01

    Acute chest pain resulting in spontaneous idiopathic hemomediastinum is a rare, potentially life-threatening occurrence. Acute chest pain is a common chief complaint of patients, accounting for 2.4%–6.0% of adult emergency room visits. The clinician's differential diagnoses for acute chest pain rarely include complications of hiatal hernias. An 83-year-old male presented with acute chest pain and was emergently diagnosed with hemomediastinum secondary to spontaneous gastric mesenteric vessel ...

  5. Outcomes in patients with chest pain evaluated in a chest pain unit: the chest pain evaluation in the emergency room study cohort.

    Science.gov (United States)

    Cullen, Michael W; Reeder, Guy S; Farkouh, Michael E; Kopecky, Stephen L; Smars, Peter A; Behrenbeck, Thomas R; Allison, Thomas G

    2011-05-01

    Limited data exist on the long-term outcomes of patients who undergo evaluation in a chest pain unit (CPU). Our study included patients with chest pain at intermediate risk for acute cardiovascular events enrolled in the CHEER study. The primary outcome included a composite of death, myocardial infarction, acute heart failure, stroke, and out-of-hospital cardiac arrest. The secondary outcome included a composite of cardiovascular death, myocardial infarction, acute heart failure, stroke, revascularization, and unstable angina. Data were obtained through a medical record review. We compared outcomes between groups randomized to the CPU versus admission, those admitted from the CPU versus dismissed home, and those who were admitted versus dismissed home after a cardiac stress test in the emergency department. The final analysis included 407 patients. Median surveillance length was 5.5 years. No differences in the primary outcome or secondary outcome existed between patients randomized to the CPU versus admitted to hospital (21.6% vs 20.2% and 29.9% vs 33.0%, respectively, P > .05 for all comparisons). Patients admitted from the CPU had higher rates of the secondary outcome (adjusted hazard ratio 2.26) than patients dismissed from the CPU. Patients admitted after a cardiac stress test in the CPU had higher rates of the secondary outcome (adjusted hazard ratio 2.42) than patients dismissed from the CPU. A CPU does not increase long-term adverse outcomes in patients with chest pain at intermediate risk for an acute event. Copyright © 2011 Mosby, Inc. All rights reserved.

  6. A case of unilateral atypical orofacial pain with Eagle's syndrome

    Directory of Open Access Journals (Sweden)

    G V Sowmya

    2016-01-01

    Full Text Available Eagle's syndrome is not an uncommon condition, but less known to physicians, where an elongated styloid process or calcified stylohyoid ligament compresses the adjacent anatomical structures leading to orofacial pain. Diagnosis is made with appropriate radiological examination. Nonsurgical treatment options include reassurance, analgesia, and anti.inflammatory medications; and the surgical option includes a transoral or external approach. Here, we present a case report of a male patient, of age38 years, with a chief complaint of unilateral atypical orofacial pain on the right side of his face radiating to the neck region, for the last two months.

  7. A difficult diagnosis for a patient with chest pain

    Directory of Open Access Journals (Sweden)

    M.A. Iacono

    2013-05-01

    Full Text Available BACKGROUND Brugada syndrome is a condition which can cause syncope or sudden death in young subjects without recognized cardiac structural abnormalities. Diagnosis is based on the thorough evaluation at rest, on exertion and during sleep. CLINICAL CASE We report the ECG of a 70-year-old man admitted with fever and chest pain. ECG on admission was suggestive for acute coronary syndrome. In the differential diagnosis we considered a possible case of Brugada syndrome.

  8. How do we define non-cardiac chest pain?

    Science.gov (United States)

    Kachintorn, Udom

    2005-12-01

    Noncardiac chest pain (NCCP) is a heterogeneous disorder associated with substantial health-care costs and resource utilization. NCCP is defined by recurrent episodes of substernal chest pain in patients lacking a cardiac cause after a comprehensive evaluation. The magnitude of the problem is quite high because of fear of serious or life-threatening heart diseases. Patients with chest pain who present for the first time to ambulatory care or to the emergency room, only 11% to 39% are ultimately diagnosed with coronary artery disease. The likely causes of NCCP are numerous and often overlap. Diagnosing NCCP is difficult because NCCP remains a diagnosis of exclusion that encompasses heterogeneous patient populations. First, cardiac ischemic must be excluded and coronary angiography remains the gold standard. Once cardiac causes have been ruled out, a diagnosis of NCCP is made. Mostly, the source for NCCP originates in essence from the esophagus. Gastroesophageal reflux disease (GERD) is the most common esophageal diseases present in patients with NCCP. An initial empiric trail of high-dose acid suppression is the most cost-effective measure in the management of these patients. When a diagnostic workup is chosen, it centers on upper gastrointestinal endoscopy, 24-hr esophageal pH monitoring and esophageal manometry.

  9. Chest Pain: The Need to Consider Less Frequent Diagnosis

    Directory of Open Access Journals (Sweden)

    Pedro Magalhães

    2016-01-01

    Full Text Available Chest pain is one of the most frequent patient’s complaints. The commonest underlying causes are well known, but, sometimes, in some clinical scenarios, it is necessary to consider other diagnoses. We report a case of a 68-year-old Caucasian male, chronically hypertensive, who complained of recurrent episodes of chest pain and fever with elevated acute phase reactants. The first investigation was negative for some of the most likely diagnosis and he quickly improved with anti-inflammatory drugs. Over a few months, his symptoms continued to recur periodically, his hypertension was aggravated, and he developed headaches and lower limbs claudication. After a temporal artery biopsy that was negative for vasculitis, he underwent a positron emission tomography suggestive of Takayasu Arteritis. Takayasu Arteritis is a rare chronic granulomatous vasculitis of the aorta and its first-order branches affecting mostly females up to 50 years old. Chest pain is experienced by >40% of the patients and results from the inflammation of the aorta, pulmonary artery, or coronaries.

  10. Approach to chest pain and acute myocardial infarction.

    Science.gov (United States)

    Pandie, S; Hellenberg, D; Hellig, F; Ntsekhe, M

    2016-03-01

    Patient history, physical examination, 12-lead electrocardiogram (ECG) and cardiac biomarkers are key components of an effective chest pain assessment. The first priority is excluding serious chest pain syndromes, namely acute coronary syndromes (ACSs), aortic dissection, pulmonary embolism, cardiac tamponade and tension pneumothorax. On history, the mnemonic SOCRATES (Site Onset Character Radiation Association Time Exacerbating/relieving factor and Severity) helps differentiate cardiac from non-cardiac pain. On examination, evaluation of vital signs, evidence of murmurs, rubs, heart failure, tension pneumothoraces and chest infections are important. A 12-lead ECG should be interpreted within 10 minutes of first medical contact, specifically to identify ST elevation myocardial infarction (STEMI). High-sensitivity troponins improve the rapid rule-out of myocardial infarction (MI) and confirmation of non-ST elevation MI (NSTEMI). ACS (STEMI and NSTEMI/unstable anginapectoris (UAP)) result from acute destabilisation of coronary atheroma with resultant complete (STEMI) or subtotal (NSTEMI/UAP) thrombotic coronary occlusion. The management of STEMI patients includes providing urgent reperfusion: primary percutaneous coronary intervention(PPCI) if available, deliverable within 60 - 120 minutes, and fibrinolysis if PPCI is not available. Essential adjunctive therapies include antiplatelet therapy (aspirin, P2Y12 inhibitors), anticoagulation (heparin or low-molecular-weight heparin) and cardiac monitoring.

  11. Cardiac computed tomography in patients with acute chest pain.

    Science.gov (United States)

    Nieman, Koen; Hoffmann, Udo

    2015-04-14

    The efficient and reliable evaluation of patients with acute chest pain is one of the most challenging tasks in the emergency department. Coronary computed tomography (CT) angiography may play a major role, since it permits ruling out coronary artery disease with high accuracy if performed with expertise in properly selected and prepared patients. Several randomized trials have established early cardiac CT as a viable safe and potentially more efficient alternative to functional testing in the evaluation of acute chest pain. Ongoing investigations explore whether advanced anatomic and functional assessments such as high-risk coronary plaque, resting myocardial perfusion, and left ventricular function, or the simulation of the fractional coronary flow reserve will add information to the anatomic assessment for stenosis, which would allow expanding the benefits of cardiac CT from triage to treatment decisions. Especially, the combination of high-sensitive troponins and coronary computed tomography angiography may play a valuable role in future strategies for the management of patients presenting with acute chest pain. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

  12. Chest pain following oesophageal stenting for malignant dysphagia

    Energy Technology Data Exchange (ETDEWEB)

    Golder, Mark; Tekkis, Paris P.; Kennedy, Colette; Lath, Sadaf; Toye, Rosemary; Steger, Adrian C

    2001-03-01

    AIM: The palliative use of self-expanding metallic stents has been widely reported to relieve dysphagia in cases of oesophageal carcinoma. Little has been documented on the severity of chest pain following oesophageal stenting. The aim of this study was to investigate the association of pain with oesophageal stenting for malignant dysphagia. METHODS: Fifty-two patients with inoperable oesophageal carcinoma underwent stent placement between 1995-1999. Daily opioid analgesic requirements (mg of morphine equivalent doses) were monitored for 3 days before and 7 days after stenting. The degree of palliation was expressed as a dysphagia score (0-3). Hospital stay, readmission days, stent complications and patient survival time were also recorded. RESULTS: Twenty-six patients (50%) required opioid analgesia for chest pain (median dose: 80 mg morphine/day) within 48 h of the procedure compared to 11 (21.2%) patients before stenting (P = 0.0041). A significant increase was evident in the analgesic consumption following stent deployment (P < 0.001). The dysphagia score improved by a median value of 1 (CI 0.25)P < 0.001, with a re-intervention rate of 11.5%. The median survival time was 40 days post stenting (range 1-120). CONCLUSION: A significant proportion of patients developed chest pain after oesophageal stenting, requiring high dose opioid analgesia. As the origin of the pain is still unknown, pre-emptive analgesia may a play role in reducing stent-related morbidity and possibly in-hospital stay. Golder, M. et al. (2001)

  13. CPDX (Chest Pain Diagnostic Program) - A Decision Support System for the Management of Acute Chest Pain (User’s Manual)

    Science.gov (United States)

    1988-02-25

    hypertension, hyperlipidemia, and smoking. Diabetes and angina are related risk factors unlikely to be present in the submarine population. A...HISTORY FOR definition: MI ANGINA BRONCHITIS HYPERTENSION DIABETES This refers to a relevant history of chest problems either pain, cough or...also check the extremities and mucus membranes, e.g. nailbeds, nose, lips, conjunctivae. Remember that studies have shown that patients tend to

  14. Diagnostic performance of copeptin in patients with acute nontraumatic chest pain: BWH-TIMI ED chest pain study.

    Science.gov (United States)

    Sukul, Devraj; Bonaca, Marc P; Ruff, Christian T; Kosowsky, Joshua; Conrad, Michael; Murphy, Sabina A; Sabatine, Marc S; Jarolim, Petr; Morrow, David A

    2014-04-01

    Arginine-vasopressin (AVP) is an acute marker of physiologic stress. Copeptin is the C-terminal fragment of vasopressin precursor hormone that is more easily measured than AVP. Studies assessing the utility of copeptin in the diagnosis of myocardial infarction (MI) have demonstrated mixed results. The aim of this study was to test the hypothesis that copeptin improves diagnostic performance when added to troponin for detecting MI in patients presenting to the emergency department with nontraumatic chest pain. We measured copeptin, local cardiac troponin I (local cTnI), and a contemporary sensitive cardiac troponin I (sensitive cTnI) at presentation and serially in patients who presented with acute chest pain. A copeptin cutoff of 14 pmol/L was utilized. MI was diagnosed in 25.7% of patients. Noncoronary acute cardiopulmonary causes of chest pain occurred in 12.8%. Patients with MI had significantly higher copeptin levels than patients with noncardiac chest pain (P < 0.001). The area under the receiver operating characteristic curve (AUC) for copeptin was 0.60 (95% confidence interval: 0.54-0.66), significantly less than the AUC for local cTnI (0.92) or sensitive cTnI (0.96). The combination of copeptin with either the local or sensitive troponin assay (c-statistics 0.92 and 0.95, respectively) did not significantly improve the AUC as compared to either troponin assay alone. This finding persisted in the subgroup of early presenters (≤ 6 hours from symptom onset). Copeptin did not improve the diagnostic performance for detecting MI when used alone or in combination with a contemporary sensitive cTnI assay, though our cohort had relatively few early presenters. © 2014 Wiley Periodicals, Inc.

  15. Evaluation of patients with methamphetamine- and cocaine-related chest pain in a chest pain observation unit.

    Science.gov (United States)

    Diercks, Deborah B; Kirk, J Douglas; Turnipseed, Samuel D; Amsterdam, Ezra A

    2007-12-01

    Risk of acute coronary events in patients with methamphetamine and cocaine intoxication has been described. Little is known about the need for additional evaluation in these patients who do not have evidence of myocardial infarction after the initial emergency department evaluation. We herein describe our experience with these patients in a chest pain unit (CPU) and the rate of cardiac-related chest pain in this group. Retrospective analysis of patients evaluated in our CPU from January 1, 2000 to December 16, 2004 with a history of chest pain. Patients who had a positive urine toxicologic screen for methamphetamine or cocaine were included. No patients had ECG or cardiac injury marker evidence of myocardial infarction or ischemia during the initial emergency department evaluation. A diagnosis of cardiac-related chest pain was based upon positive diagnostic testing (exercise stress testing, nuclear perfusion imaging, stress echocardiography, or coronary artery stenosis >70%). During the study period, 4568 patients were evaluated in the CPU. A total of 1690 (37%) of patients admitted to the CPU underwent urine toxicologic testing. The result of urine toxicologic test was positive for cocaine or methamphetamine in 224 (5%). In the 2871 patients who underwent diagnostic testing for coronary artery disease (CAD), 401 (14%) were found to have positive results. There was no difference in the prevalence of CAD between those with positive result for toxicology screens (26/156, 17%) and those without (375/2715, 13%, RR 1.2, 95% CI 0.8-1.7). These findings suggest a relatively high rate of CAD in patients with methamphetamine and cocaine use evaluated in a CPU.

  16. [Exploration on eighteen incompatible medicaments of chest pain prescriptions based on association rules mining].

    Science.gov (United States)

    Zhang, Yuhua; Hua, Haoming; Fan, Xinsheng; Wang, Chongjun; Duan, Jinao

    2011-12-01

    To investigate the laws of eighteen incompatible medicaments of the chest pain prescriptions based on association rules mining. The database of chest pain prescription was established and then the chest pain prescriptions composed of eighteen incompatible medicaments were screened. The dynasty, couplet medicines, the property and flavor of drugs and preparation form were analyzed with the frequent item sets and corresponding analysis methods. Eight hundred and fifty chest pain prescriptions were collected, and 88 of them contained eighteen incompatible medicaments, taking 10.3% of all; the applications of ancient and modern chest pain prescriptions containing eighteen incompatible medicaments are significant difference (P rules for application of anti-drug compatibility to treat chest pain.

  17. Stress Tests for Chest Pain: When You Need an Imaging Test -- and When You Don't

    Science.gov (United States)

    ... Resources Adult , Geriatric Stress Tests for Chest Pain Stress Tests for Chest Pain When you need an ... pain isn’t from heart disease. A cardiac stress test makes the heart work hard so your ...

  18. Retroperitoneal Paraganglioma Presenting as a Chest Pain: A Case Report

    Directory of Open Access Journals (Sweden)

    Parag Brahmbhatt

    2013-01-01

    Full Text Available Paragangliomas are very rare tumors derived from neuroendocrine cells of autonomic nervous system. Extra-adrenal paragangliomas account for only 10 to 15% of all paragangliomas and may present incidentally as a mass. Typical triad of fluctuating hypertension, headache, and sweating is not always present which makes the diagnosis difficult sometimes. Definitive diagnosis is usually made with histologic findings and surgery is the treatment of choice. We report a case of a 53-year-old male who presented with chest pain and vomiting.

  19. Remote management of low to intermediate risk chest pain: A case series.

    Science.gov (United States)

    Chiu, Alexander; Shumaker, Kathleen; Del Corral, Christopher; George, Blessy; Kasper, Michael; Jois, Preeti; Dipsia, Daniel; Donnelly, Meaghan; Sidow, Lauren; Chau, Caroline; Ash, Adam

    2017-08-01

    We report a case series of three low to intermediate risk chest pain patients who presented to the emergency department and were managed as outpatients via the Cellular Outpatient Twelve-Lead Telemetry with Emergency Response (COTTER™). This technology allows for certain chest pain patients to be managed remotely via telemedicine while receiving care comparable to that which would be available in a hospital or chest pain observation unit. Copyright © 2017 Elsevier Inc. All rights reserved.

  20. Chest Pain as a presenting complaint in patients with acute myocardial infarction (AMI).

    Science.gov (United States)

    Malik, Muhammad Ajmal; Alam Khan, Shahzad; Safdar, Sohail; Taseer, Ijaz-Ul-Haque

    2013-04-01

    To study various characteristics of chest pain in acute myocardial infarction patients. A total of 331 patients of AMI admitted at Cardiology unit Nishtar Hospital Multan and Chaudhry Pervez Elahi Institute of Cardiology Multan, irrespective of the age and gender, were included in this study. The study duration was one year starting from June 2011 to June 2012. Non-probability purposive sampling technique was used in this descriptive study. Informed consent to participate in this study was taken. Data were entered and analyzed using SPSS-11. A total number of 331 patients with AMI were included in the study. Mean age was 54.99±11.25 years with minimum age 20 years and maximum age 90 years. It included 264(79.8%) male and 67(20.2%) female patients with male to female ratio of 3.9:1. Out of these 331 patients 308 (93.1%) patients reported chest pain as the presenting complaint. Remaining 23(6.9%) presented with clinical features other than chest pain. There were 127(38.4%) patients with pre-cordial chest pain, 115(34.7%) had retrosternal chest pain, 58(17.5%) were having epigastric pain. Severe chest pain was seen in 281(84.9%) patients while 26(7.9%) had only mild chest discomfort. Radiation of the pain to shoulder, neck and jaw was seen in 75 (22.7%) patients. In 42(12.7%) patients, pain radiated to both sides of chest. Another 55(16.6%) patients had pain radiation to chest, shoulder, upper arm and ulnar side of left forearm. Chest pain radiation to interscapular region along with both sides of chest was present in 10(3.0%) patients. In 11(3.3%) patients' pain radiated only to left side of chest. Pain persisting for >20 minutes was reported by 298 (90%) patients while only 10(3.1%) had pain persisting for chest pain of cardiac as well as non cardiac causes. However, vigilant evaluation of characteristics of chest pain in history taking may help to overcome this dilemma. Severe and prolonged precordial chest pain in a male patient between the age of 41-70 years

  1. Chest pain prevalence, causes, and disposition in the emergency department of a regional hospital in Pretoria.

    Science.gov (United States)

    Geyser, Mimi; Smith, Selma

    2016-06-10

    Chest pain is a common clinical syndrome. However, there is a paucity of African studies describing the causes, prevalence, aetiology, and disposition of patients with chest pain presenting in the emergency department (ED). The aim of this retrospective descriptive study was to determine the prevalence, causes, demographics, and disposition of all adult patients with the main complaint of chest pain presenting at the ED of a regional hospital in South Africa. Records of all patients 18 years and older presenting with the complaint of chest pain from 1 December 2011 through 10 April 2012 were assessed. A data collection sheet capturing patient demographics and disposition from the ED was used. The diagnosis was subdivided into groups: cardiovascular, respiratory, gastrointestinal, musculoskeletal, psychiatric/psychogenic, other, and unknown. Of the 312 patients presenting with chest pain, 210 patient files were retrieved. The prevalence of non-traumatic chest pain was 1.66%. Respiratory disease was the most common cause (36.19%), with pneumonia the most common diagnosis (24.40%). Logistic regression showed diagnoses of acute cardiovascular disease or respiratory disease, older age, and transport by ambulance as being associated with admission. The main cause of acute chest pain was found to be respiratory disease, followed by musculoskeletal disorders. In the African context, the aetiology of acute chest pain differs from that in first world countries. Health workers should therefore pay special attention to respiratory conditions during diagnosis and management in African patients with acute chest pain.

  2. The use of coronary CT angiography for the evaluation of chest pain.

    Science.gov (United States)

    Schlett, Christopher L; Pursnani, Amit; Marcus, Roy P; Truong, Quynh A; Hoffmann, Udo

    2014-01-01

    Coronary computed tomography angiography (CCTA) may improve the diagnosis and management of acute and stable chest pain syndromes. The key for caregivers of patients presenting with acute chest pain is the early identification and management of life-threatening conditions, such as acute coronary syndromes, pulmonary embolism, and acute aortic dissection. The main goal in stable chest pain syndromes is to determine the extent and severity of coronary artery disease. This review article will critically evaluate the current literature supporting the evidence for the clinical use of CCTA in acute and stable chest pain syndromes, considering the latest innovations in CCTA technology and their potential impact on patient care.

  3. Evaluation and Management of Patients with Noncardiac Chest Pain

    Directory of Open Access Journals (Sweden)

    C. Shekhar

    2008-01-01

    Full Text Available Up to a third of patients undergoing coronary angiography for angina-like chest pain are found to have normal coronary arteries and a substantial proportion of these individuals continue to consult and even attend emergency departments. Initially, these patients are usually seen by cardiologists but with accumulating evidence that the pain might have a gastrointestinal origin, it may be more appropriate for them to be cared for by the gastroenterologist once a cardiological cause has been excluded. This review covers the assessment and management of this challenging condition, which includes a combination of education, reassurance, and pharmacotherapy. For the more refractory cases, behavioral treatments, such as cognitive behavioral therapy or hypnotherapy, may have to be considered.

  4. Cost effectiveness of chest pain unit care in the NHS

    Directory of Open Access Journals (Sweden)

    Wailoo Allan

    2008-08-01

    Full Text Available Abstract Background Acute chest pain is responsible for approximately 700,000 patient attendances per year at emergency departments in England and Wales. A single centre study of selected patients suggested that chest pain unit (CPU care could be less costly and more effective than routine care for these patients, although a more recent multi-centre study cast doubt on the generalisability of these findings. Methods Our economic evaluation involved modelling data from the ESCAPE multi-centre trial along with data from other sources to estimate the comparative costs and effects of CPU versus routine care. Cost effectiveness ratios (cost per QALY were generated from our model. Results We found that CPU compared to routine care resulted in a non-significant increase in effectiveness of 0.0075 QALYs per patient and a non-significant cost decrease of £32 per patient and thus a negative incremental cost effectiveness ratio. If we are willing to pay £20,000 for an additional QALY then there is a 70% probability that CPU care will be considered cost-effective. Conclusion Our analysis shows that CPU care is likely to be slightly more effective and less expensive than routine care, however, these estimates are surrounded by a substantial amount of uncertainty. We cannot reliably conclude that establishing CPU care will represent a cost-effective use of health service resources given the substantial amount of investment it would require.

  5. Persistent orodental pain, atypical odontalgia, and phantom tooth pain: when are they neuropathic disorders?

    Science.gov (United States)

    Clark, Glenn T

    2006-08-01

    Patients with unrelenting pain in the teeth, gingival, palatal or alveolar tissues often see multiple dentists and have multiple irreversible procedures performed and still have their pain. Up to one-third of patients attending a chronic facial pain clinic have undergone prior irreversible dental procedures for their pain without success. In these cases, if no local source of infectious, inflammatory, or other pathology can be found, then the differential diagnosis must include a focal neuropathic pain disorder. The common diagnoses given include the terms atypical odontalgia, persistent orodental pain, or if teeth have been extracted, phantom tooth pain. One possibility is that these pain complaints are due to a neuropathic alteration of the trigeminal nerve. There are several diagnostic procedures that need to be performed in any patient suspected of having a trigeminal neuropathic disorder including (1) cold testing of involved teeth for pulpal nonvitality; (2) a periapical radiograph examining the teeth for apical change; (3) a panoramic radiograph examining for other maxillofacial disease; (4) a thorough head and neck examination also looking for abnormality; (5) a cranial nerve examination including anesthetic testing which documents any increased or decreased nerve trigeminal nerve sensitivity and rules out other neurologic changes outside the trigeminal nerve; and (6) MRI imaging in some cases. Finally, when a nonobvious atypical toothache first presents, direct microscopic examination of the tooth for incomplete tooth fracture is also suggested. The majority of these patients are women over the age 30 with pain in the posterior teeth/alveolar arch. Multiple causes exist for sustained neuropathic pain including direct nerve injury (e.g., associated with fracture or surgical treatment), nerve injection injury, nerve compression injury (e.g., implant, osseous growth, neoplastic invasion) and infection-inflammation damage to the nerve itself. Sustained nerve

  6. Editor's Choice-The organization of chest pain units: Position statement of the Acute Cardiovascular Care Association.

    Science.gov (United States)

    Claeys, Marc J; Ahrens, Ingo; Sinnaeve, Peter; Diletti, Roberto; Rossini, Roberta; Goldstein, Patrick; Czerwińska, Kasia; Bueno, Héctor; Lettino, Maddalena; Münzel, Thomas; Zeymer, Uwe

    2017-04-01

    Chest pain units are defined as organizational short stay units with specific management protocols designed to facilitate and optimize the diagnosis of patients presenting with chest pain in the emergency department. The present document is intended to standardize and facilitate the installation of chest pain units nearby to the emergency department or as an integral part of the emergency department. Recommendations on organizational structure, physical and technical requirements and on disease management are presented. More standardized installation and implementation of chest pain units will enhance the quality of chest pain units and improve the quality of care of our chest pain patients.

  7. Association between comorbidities and absence of chest pain in acute coronary syndrome with in-hospital outcome.

    Science.gov (United States)

    Manfrini, Olivia; Ricci, Beatrice; Cenko, Edina; Dorobantu, Maria; Kalpak, Oliver; Kedev, Sasko; Kneževic, Božidarka; Koller, Akos; Milicic, Davor; Vasiljevic, Zorana; Badimon, Lina; Bugiardini, Raffaele

    2016-08-01

    To evaluate the impact of comorbidities on the management and outcomes of acute coronary syndrome (ACS) patients without chest pain/discomfort (i.e. ACS without typical presentation). Of the 11,458 ACS patients, enrolled by the International Survey of Acute Coronary Syndrome in Transitional Countries (ISACS-TC; ClinicalTrials.gov: NCT01218776), 8.7% did not have typical presentation at the initial evaluation, and 40.2% had comorbidities. The odds of atypical presentation increased proportionally with the number of comorbidities (odds ratio [OR]: 1, no-comorbid; OR: 1.64, 1 comorbidity; OR: 2.52, 2 comorbidities; OR: 4.57, ≥3 comorbidities). Stratifying the study population by the presence/absence of comorbidities and typical presentation, we found a decreasing trend for use of medications and percutaneous intervention (OR: 1, typical presentation and no-comorbidities; OR: 0.70, typical presentation and comorbidities; OR: 0.23, atypical presentation and no-comorbidities; OR: 0.18, atypical presentation and comorbidities). On the opposite, compared with patients with typical presentation and no-comorbidities (OR: 1, referent), there was an increasing trend (pcomorbidities, medications and invasive procedures, atypical presentation was not a predictor of in-hospital death. Independent predictors of poor outcome were history of stroke (OR: 2.04), chronic kidney disease (OR: 1.57), diabetes mellitus (OR: 1.49) and underuse of invasive procedures. In the ISACS-TC, atypical ACS presentation was often associated with comorbidities. Atypical presentation and comorbidities influenced underuse of in-hospital treatments. The latter and comorbidities are related with poor in-hospital outcome, but not atypical presentation, per se. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  8. Reconstruction of the decision-making process in assessing musculoskeletal chest pain

    DEFF Research Database (Denmark)

    Stochkendahl, Mette J; Vach, Werner; Hartvigsen, Jan

    2012-01-01

    The purposes of this study were to identify the most important determinants from the patient history and clinical examination in diagnosing musculoskeletal chest pain (MSCP) in patients with acute noncardiac chest pain when supported by a structured protocol and to construct a decision tree...

  9. ANMCO-SIMEU Consensus Document: in-hospital management of patients presenting with chest pain.

    Science.gov (United States)

    Zuin, Guerrino; Parato, Vito Maurizio; Groff, Paolo; Gulizia, Michele Massimo; Di Lenarda, Andrea; Cassin, Matteo; Cibinel, Gian Alfonso; Del Pinto, Maurizio; Di Tano, Giuseppe; Nardi, Federico; Rossini, Roberta; Ruggieri, Maria Pia; Ruggiero, Enrico; Scotto di Uccio, Fortunato; Valente, Serafina

    2017-05-01

    Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. However, the evaluation of acute chest pain remains challenging, despite many new insights over the past two decades. The percentage of patients presenting to the emergency departments because of acute chest pain appears to be increasing. Nowadays, there are two essential chest pain-related issues: (i) the missed diagnoses of acute coronary syndromes with a poor short-term prognosis; and (ii) the increasing percentage of hospitalizations of low-risk cases. It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs. Therefore, the significantly reduced financial resources of healthcare systems induce physicians and administrators to improve the efficiency of care protocols for patients with acute chest pain. Despite the efforts of the Scientific Societies in producing statements on this topic, in Italy there is still a significant difference between emergency physicians and cardiologists in managing patients with chest pain. For this reason, the aim of the present consensus document is double: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the critical pathways (describing key steps) that need to be implemented in order to standardize the management of chest pain patients, making a correct diagnosis and treatment as uniform as possible across the entire country.

  10. [ANMCO/SIMEU Consensus document: In-hospital management of patients presenting with chest pain].

    Science.gov (United States)

    Zuin, Guerrino; Parato, Vito Maurizio; Groff, Paolo; Gulizia, Michele Massimo; Di Lenarda, Andrea; Cassin, Matteo; Cibinel, Gian Alfonso; Del Pinto, Maurizio; Di Tano, Giuseppe; Nardi, Federico; Rossini, Roberta; Ruggieri, Maria Pia; Ruggiero, Enrico; Scotto Di Uccio, Fortunato; Valente, Serafina

    2016-06-01

    Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. However, the evaluation of acute chest pain remains challenging, despite many new insights over the past two decades. The percentage of patients presenting to the emergency departments because of acute chest pain appears to be increasing. Nowadays, there are two essential chest pain-related issues: 1) the missed diagnoses of acute coronary syndromes with a poor short-term prognosis; 2) the increasing percentage of hospitalizations of low-risk cases.It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs. Therefore, the significantly reduced financial resources of healthcare systems induce physicians and administrators to improve the efficiency of care protocols for patients with acute chest pain. Despite the efforts of the Scientific Societies in producing statements on this topic, in Italy there is still a significant difference between emergency physicians and cardiologists in managing patients with chest pain. For this reason, the aim of the present consensus document is double: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the critical pathways (describing key steps) that need to be implemented in order to standardize the management of chest pain patients, making a correct diagnosis and treatment as uniform as possible across the entire country.

  11. Ludwig's angina: an uncommon cause of chest pain.

    Science.gov (United States)

    Ocasio-Tascón, María Elena; Martínez, Miriam; Cedeño, Arturo; Torres-Palacios, Alfonso; Alicea, Edwin; Rodríguez-Cintrón, William

    2005-05-01

    A 71-year-old male with coronary artery disease, hypertension, diabetes mellitus, tobacco and opioid dependence came to the emergency room complaining of one episode of retrosternal chest pain oppressive in nature of one day of evolution. He had acute respiratory distress and required mechanical ventilation. The initial impression was myocardial ischemia, but electrocardiography and cardiac enzymes ruled it out. During the following hours, neck and tongue edema developed. He was started on broad-spectrum antibiotics empirically. Neck computed tomography scan revealed a left parapharyngeal and submandibular abscess. The abscess was drained. The source of infection was found on the second molar of the left lower jaw. The patient improved and was successfully weaned from mechanical ventilation. Despite advances in therapy, Ludwig's angina remains a potentially lethal infection in which early recognition plays a crucial role.

  12. Communication problems for patients hospitalized with chest pain.

    Science.gov (United States)

    Simon, S R; Lee, T H; Goldman, L; McDonough, A L; Pearson, S D

    1998-12-01

    In many settings, primary care physicians have begun to delegate inpatient care to hospitalists, but the impact of this change on patients' hospital experience is unknown. To determine the effect on physician-patient communication of having the regular outpatient physician (continuity physician) continue involvement in hospital care, we surveyed 1,059 consecutive patients hospitalized with chest pain. Patients whose continuity physicians remained involved in their hospital care were less likely to report communication problems regarding tests (20% vs 31%, p =.03), activity after discharge (42% vs 51%, p =.02), and health habits (31% vs 38%, p =. 07). In a setting without a designated hospitalist system, communication problems were less frequent among patients whose continuity physicians were involved in their hospital care. New models of inpatient care delivery can maintain patient satisfaction but to do so must focus attention on improving physician-patient communication.

  13. 25-year-old man with chest pain.

    Science.gov (United States)

    Singh, Dhara; Bhat, Rachana; Kothari, Shyam S

    2018-01-01

    CLINICAL INTRODUCTION: A 25-year-old man presented with complaints of acute-onset chest pain for 2 hours associated with diaphoresis and generalised weakness. He had history of smoking for 10 years. There was no history of hypertension, diabetes, family history of premature coronary artery disease or drug abuse. On evaluation, his heart rate was 76/min, blood pressure 130/90 mm Hg and oxygen saturation 97% on room air. Cardiovascular examination was normal. The ECG is shown in figure 1.heartjnl;104/1/72/F1F1F1Figure 1. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

  14. Cost-effectiveness of chiropractic care versus self-management in patients with musculoskeletal chest pain

    DEFF Research Database (Denmark)

    Stochkendahl, Mette Jensen; Sørensen, Jan; Vach, Werner

    2016-01-01

    AIMS: To assess whether primary sector healthcare in the form of chiropractic care is cost-effective compared with self-management in patients with musculoskeletal chest pain, that is, a subgroup of patients with non-specific chest pain. METHODS AND RESULTS: 115 adults aged 18-75 years with acute......, non-specific chest pain of musculoskeletal origin were recruited from a cardiology department in Denmark. After ruling out acute coronary syndrome and receiving usual care, patients with musculoskeletal chest pain were randomised to 4 weeks of community-based chiropractic care (n=59) or to a single...... in QALYs between the groups were negligible. CONCLUSIONS: Chiropractic care was more cost-effective than self-management. Therefore, chiropractic care can be seen as a good example of a targeted primary care approach for a subgroup of patients with non-specific chest pain. TRIAL REGISTRATION NUMBER: NCT...

  15. Chest Pain and Mental Stress Induced Myocardial Ischemia: Sex Differences.

    Science.gov (United States)

    Pimple, Pratik; Hammadah, Muhammad; Wilmot, Kobina; Ramadan, Ronnie; Mheid, Ibhar Al; Levantsevych, Oleksiy; Sullivan, Samaah; Garcia, Ernest V; Nye, Jonathon; Shah, Amit J; Ward, Laura; Mehta, Puja; Raggi, Paolo; Bremner, J Douglas; Quyyumi, Arshed A; Vaccarino, Viola

    2017-12-07

    Mental stress-induced myocardial ischemia (MSIMI) is a frequent phenomenon in patients with coronary artery disease. Women with coronary artery disease tend to have more MSIMI and more chest pain/anginal symptoms than men, but whether the association between MSIMI and angina burden differs in women and men, is unknown. This was a cross-sectional study with experimental manipulation of 950 individuals with stable coronary artery disease. Chest pain/angina frequency in the previous 4 weeks was assessed with the Seattle Angina Questionnaire's angina-frequency subscale. MSIMI was assessed with myocardial perfusion imaging during mental stress (standardized public speaking task). Presence of MSIMI was based on expert readers and established criteria. A conventional (exercise or pharmacological) stress test was used as a control condition. Overall, 338 individuals (37%) reported angina; 112 (12%) developed MSIMI, and 256 (29%) developed conventional stress ischemia. Women who reported angina had almost double the probability to develop MSIMI (19% vs. 10%), adjusted prevalence rate ratio (PRR)= 1.90, 95% CI: 1.04-3.46), while there was no such difference in men (11% vs. 11%, adjusted PRR= 1.09, 95% CI: 0.66-1.82). No association was found between angina symptoms and conventional stress ischemia for either women or men. Results for ischemia as a continuous variable were similar. In women, but not in men, anginal symptoms may be a marker of vulnerability towards ischemia induced by psychological stress. These results highlight the psychosocial origins of angina in women, and may have important implications for the management and prognosis of women with angina. Copyright © 2017. Published by Elsevier Inc.

  16. Two-step electrocardiogram for chest pain reported on multiphasic screening.

    Science.gov (United States)

    Skoulas, A; Conlon, D

    1975-01-01

    Among 264 consecutive persons (142 men, 122 women) greater than or equal to 35 years of age presenting for multiphasic screening examination, 85 (54 men, 31 women) reported chest pain. In most, the pain was not typical of coronary artery disease. The two-step exercise electrocardiogram (ECG) was positive (greater than or equal to 0.5-mm ischemic ST depression) in 21% of the patients who reported pain and in 19.5% of 66 randomly selected, similarly examined controls without chest pain (36 men, 30 women) (difference not significant). Females with positive ECGs (5-mm or 1-mm depression) predominated over males greater than or equal to 5:1 in the chest pain group and greater than 3:1 in controls. This study indicates that the routine two-step exercise ECG is not helpful in detecting ischemic heart disease in persons reporting chest pain during their multiphasic screening examination.

  17. Diagnostic values of chest pain history, ECG, troponin and clinical gestalt in patients with chest pain and potential acute coronary syndrome assessed in the emergency department.

    Science.gov (United States)

    Mokhtari, Arash; Dryver, Eric; Söderholm, Martin; Ekelund, Ulf

    2015-01-01

    In the assessment of chest pain patients with suspected acute coronary syndrome (ACS) in the emergency department (ED), physicians rely on global diagnostic impressions ('gestalt'). The aim of this study was to determine the diagnostic value of the ED physician's overall assessment of ACS likelihood, and the values of the main diagnostic modalities underlying this assessment, namely the chest pain history, the ECG and the initial troponin result. 1,151 consecutive ED chest pain patients were prospectively included. The ED physician's interpretation of the chest pain history, the ECG, and the global likelihood of ACS were recorded on special forms. The discharge diagnoses were retrieved from the medical records. A chart review was carried out to determine whether patients with a non-ACS diagnosis at the index visit had ACS or suffered cardiac death within 30 days. The gestalt was better than its components both at ruling in ("Obvious ACS", LR 29) and at ruling out ("No Suspicion of ACS", LR 0.01) ACS. In the "Strong suspicion of ACS" group, 60% of the patients did not have ACS. A positive TnT (LR 24.9) and an ischemic ECG (LR 8.3) were strong predictors of ACS and seemed superior to pain history for ruling in ACS. In patients with a normal TnT and non-ischemic ECG, chest pain history typical of AMI was not a significant predictor of AMI (LR 1.9) while pain history typical of unstable angina (UA) was a moderate predictor of UA (LR 4.7). Clinical gestalt was better than its components both at ruling in and at ruling out ACS, but overestimated the likelihood of ACS when cases were assessed as strong suspicion of ACS. Among the components of the gestalt, TnT and ECG were superior to the chest pain history for ruling in ACS, while pain history was superior for ruling out ACS.

  18. Atypical odontalgia misdiagnosed as odontogenic pain: a case report and discussion of treatment.

    Science.gov (United States)

    Lilly, J P; Law, A S

    1997-05-01

    Atypical odontalgia is characterized by prolonged periods of throbbing or burning pain in the teeth or alveolar process, which occurs in the absence of any identifiable odontogenic etiology. The pain may be bilateral and change in location. This article presents two cases of atypical odontalgia that were misdiagnosed and initially treated as pain of odontogenic origin. A therapeutic regimen of tricyclic antidepressants alleviated the pain in one patient and was unsuccessful in the second. These two cases demonstrate the importance of having a thorough knowledge of both odontogenic and nonodontogenic causes of orofacial pain as well as the need for careful diagnosis before undertaking any treatment.

  19. Time trends of chest pain symptoms and health related quality of life in coronary artery disease

    Directory of Open Access Journals (Sweden)

    Henriksson Peter

    2007-03-01

    Full Text Available Abstract Background There is at present a lack of knowledge of time trends in health related quality of life (HRQL in common patients with coronary artery disease (CAD treated in ordinary care. The objective of this study is to assess and compare time trends of health related quality of life (HRQL and chest pain in patients with coronary artery disease. Methods 253 consecutive CAD patients in Stockholm County, Sweden – 197 males/56 females; 60 ± 8 years – were followed during two years. Perceived chest pain symptoms and three global assessments of HRQL were assessed at baseline, after one and after two years. EuroQol-5 dimension (EQ-5D with a predefined focus on function and symptoms; the broader tapping global estimates of HRQL; EuroQol VAS (EQ-VAS and Cardiac Health Profile (CHP were used. Chest pain was ranked according to Canadian Cardiovascular Society (CCS. Change in HRQL was analysed by a repeated measurements ANOVA and chest pain symptoms were analysed by Friedman non-parametric ANOVA. Results Perceived chest pain decreased during the two years (p Conclusion HRQL did not increase despite a reduction in the severity of chest pain during two years. This implies that the major part of HRQL in these consecutive ordinary patients with CAD is unresponsive to change in chest pain symptoms.

  20. Traumatic Atypical Low Back Pain With Radiculopathy Following a Failed Cheerleading Dismount: A Case Study

    National Research Council Canada - National Science Library

    R Schmidt; K Miller

    2017-01-01

    An abstract of the study by Schmidt evaluating the patient was a 12 year old female cheerleading flyer with an 8 week history of atypical low back pain with radiculopathy after a failed cheerleading dismount...

  1. Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care

    OpenAIRE

    Goodacre, S; Nicholl, J; Dixon, S.; Cross, E; Angelini, K.; Arnold, J.; Revill, S.; Locker, T; Capewell, S J; Quinney, D.; Campbell, S.; Morris, F

    2004-01-01

    Objectives To measure the effectiveness and cost effectiveness\\ud of providing care in a chest pain observation unit compared\\ud with routine care for patients with acute, undifferentiated chest\\ud pain.\\ud Design Cluster randomised controlled trial, with 442 days\\ud randomised to the chest pain observation unit or routine care,\\ud and cost effectiveness analysis from a health service costing\\ud perspective.\\ud Setting The emergency department at the Northern General\\ud Hospital, Sheffield, U...

  2. Editor's Choice-Chest pain relief in patients with acute myocardial infarction.

    Science.gov (United States)

    Parodi, Guido

    2016-06-01

    Chest pain is the prevalent symptom at presentation in patients with acute myocardial infarction (AMI). Despite the complete absence of rigorous studies designed to assess the impact of morphine administration in patients with AMI, clinical practice guidelines strongly recommend morphine for analgesia. However, when using morphine to relieve chest pain in AMI patients, physicians must be aware that hypotension, respiratory depression, vomiting, and delayed onset of action of antiplatelet agents are potential unwanted side effects of the drug. The purpose of this report is to review morphine's clinical and side effects and to propose strategies able to reduce chest pain in AMI patients. © The European Society of Cardiology 2015.

  3. Takotsubo cardiomyopathy: an overlooked cause of chest pain

    Directory of Open Access Journals (Sweden)

    Leonardo Hackbart Bermudes

    2014-06-01

    Full Text Available Takotsubo cardiomyopathy (TTC, also known as apical ballooning syndrome, broken heart syndrome, or stress-induced cardiomyopathy, is defined as a transient disturbance of the left ventricle, which is quite often associated with electrocardiographic abnormalities that may mimic acute myocardial infarction. The syndrome is also characterized by a mild alteration of cardiac biomarkers in absence of coronary blood flow obstruction on the coronariography. Clinical presentation is often manifested by angina, dyspnea, syncope, and arrhythmias. Peculiarly, the left ventricle takes the form of “tako-tsubo” (a Japanese word for “octopus trap” on the imaging workup. The authors report the case of a post-menopausal, hypertensive, dyslipidemic and type-II diabetic woman admitted at the emergency service with acute chest pain post physical exertion. Electrocardiogram showed signs of ischemia and myocardial necrosis markers were mildly increased. Echocardiography and ventriculography showed apical and mid-ventricular akinesia, with mild atherosclerotic coronary lesions. Thus diagnostic workup and the outcome followed the diagnostic criteria for TTC. The authors called attention to the potential of overlooking this diagnosis, since this syndrome is still not widely recognized.

  4. Clinical assessment of chest pain and guidelines for imaging

    Energy Technology Data Exchange (ETDEWEB)

    Gruettner, J., E-mail: joachim.gruettner@umm.de [1st Department of Medicine (Cardiology), University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim (Germany); Henzler, T. [Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim (Germany); Sueselbeck, T. [1st Department of Medicine (Cardiology), University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim (Germany); Fink, C. [Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim (Germany); Borggrefe, M.; Walter, T. [1st Department of Medicine (Cardiology), University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim (Germany)

    2012-12-15

    For many emergency facilities, risk assessment of patients with diffuse chest pain still poses a major challenge. In their currently valid recommendations, the international cardiological societies have defined a standardized assessment of the prognostically relevant cardiac risk criteria. Here the classic sequence of basic cardiac diagnostics including case history (cardiac risk factors), physical examination (haemodynamic and respiratory vital parameters), ECG (ST segment analysis) and laboratory risk markers (troponin levels) is paramount. The focus is, on the one hand, on timely indication for percutaneous catheterization, especially in patients at high cardiac risk with or without ST-segment elevation in the ECG, and, on the other hand, on the possibility of safely discharging patients with intermediate or low cardiac risk after non-invasive exclusion of a coronary syndrome. For patients in the intermediate or low risk group, physical or pharmacological stress testing in combination with scintigraphy, echocardiography or magnetic resonance imaging is recommended in addition to basic diagnostics. Moreover, the importance of non-invasive coronary imaging, primarily cardiac CT angiography (CCTA), is increasing. Current data show that in intermediate or low risk patients this method is suitable to reliably rule out coronary heart disease. In addition, attention is paid to the major differential diagnoses of acute coronary syndrome, particularly pulmonary embolism and aortic dissection. Here the diagnostic method of choice is thoracic CT, possibly also in combination with CCTA aiming at a triple rule-out.

  5. Music: an intervention for pain during chest tube removal after open heart surgery.

    Science.gov (United States)

    Broscious, S K

    1999-11-01

    Pain associated with chest tube removal is a major problem for patients who undergo open heart surgery. Because this pain is short-lived, timing the administration of pharmacological agents for pain relief is difficult and is therefore done inconsistently. To examine the effect of music as an intervention for pain relief during chest tube removal after open heart surgery. In an experimental design, 156 subjects (mean age, 66 years; 69% men) were randomly assigned to 1 of 3 groups: control, white noise, or music. All subjects preselected the type of music they preferred hearing. Ten minutes before the chest tube was removed, the patient's heart rate and blood pressure were measured, the patient rated pain intensity by using a numeric rating scale, and the prerecorded audiotape of music was begun. The patients rated their pain again immediately after chest tube removal and 15 minutes later. Physiological variables were assessed every 5 minutes until 15 minutes after the chest tubes were removed. Self-reported pain intensity, physiological responses, and narcotic intake after chest tube removal did not differ significantly among the 3 groups. Although the findings were not statistically significant, most subjects enjoyed listening to the music, and therefore the use of music as an adjuvant to other therapies may be an appropriate nursing intervention.

  6. Cardiac CT for the assessment of chest pain: Imaging techniques and clinical results

    Energy Technology Data Exchange (ETDEWEB)

    Becker, Hans-Christoph, E-mail: christoph.becker@med.uni-muenchen.de [Ludwig-Maximilians-University, Grosshadern Clinic, Department of Clinical Radiology, Marchioninistr. 15, 81377 Munich (Germany); Johnson, Thorsten [Ludwig-Maximilians-University, Grosshadern Clinic, Department of Clinical Radiology, Marchioninistr. 15, 81377 Munich (Germany)

    2012-12-15

    Immediate and efficient risk stratification and management of patients with acute chest pain in the emergency department is challenging. Traditional management of these patients includes serial ECG, laboratory tests and further on radionuclide perfusion imaging or ECG treadmill testing. Due to the advances of multi-detector CT technology, dedicated coronary CT angiography provides the potential to rapidly and reliably diagnose or exclude acute coronary artery disease. Life-threatening causes of chest pain, such as aortic dissection and pulmonary embolism can simultaneously be assessed with a single scan, sometimes referred to as “triple rule out” scan. With appropriate patient selection, cardiac CT can accurately diagnose heart disease or other sources of chest pain, markedly decrease health care costs, and reliably predict clinical outcomes. This article reviews imaging techniques and clinical results for CT been used to evaluate patients with chest pain entering the emergency department.

  7. Role of Quantitative Wall Motion Analysis in Patients with Acute Chest Pain at Emergency Department.

    Science.gov (United States)

    Kim, Kyung-Hee; Na, Sang-Hoon; Park, Jin-Sik

    2017-03-01

    Evaluation of acute chest pain in emergency department (ED), using limited resource and time, is still very difficult despite recent development of many diagnostic tools. In this study, we tried to determine the applicability of new semi-automated cardiac function analysis tool, velocity vector imaging (VVI), in the evaluation of the patients with acute chest pain in ED. We prospectively enrolled 48 patients, who visited ED with acute chest pain, and store images to analyze VVI from July 2005 to July 2007. In 677 of 768 segments (88%), the analysis by VVI was feasible among 48 patients. Peak systolic radial velocity (Vpeak) and strain significantly decreased according to visual regional wall motion abnormality (Vpeak, 3.50 ± 1.34 cm/s for normal vs. 3.46 ± 1.52 cm/s for hypokinesia, 2.51 ± 1.26 for akinesia, p patient with acute chest pain at ED.

  8. Chronic pseudo-angina left precordial chest pain caused by a thoracic meningioma

    OpenAIRE

    Azabou, Eric; Kumako, Vincent; Moussawi, Mahmoud; Berger, Colette; André-Obadia, Nathalie; Kocher, Laurence; Gonnaud, Pierre-Marie

    2013-01-01

    International audience; Left precordial chest pain (LPCP) evokes above all angina. Eliminating a cardiac origin is then always the first priority. When cardiac causes are eliminated, non-cardiac causes are sought in order to avoid leaving patients with undiagnosed or undifferentiated chest pain. There is a myriad of non-cardiac causes ranging from heartburn, panic attacks, pleurisy, pulmonary embolism, pneumothorax, Tietze syndrome, bruises and fractures of the ribs, to spine meningioma, neur...

  9. Coronary CT angiography in acute chest pain [version 1; referees: 3 approved

    Directory of Open Access Journals (Sweden)

    Nikhil Goyal

    2017-07-01

    Full Text Available Coronary computed tomographic angiography has become a reliable diagnostic tool in the evaluation of patients with chest pain. Studies have shown this modality to be accurate and safe when compared with conventional methods of assessing patients with chest pain. We review the recent developments with coronary computed tomographic angiography and devote particular attention toward its application to triage patients in the emergency department.

  10. Ineffective and prolonged apical contraction is associated with chest pain and ischaemia in apical hypertrophic cardiomyopathy.

    Science.gov (United States)

    Stephenson, Edward; Monney, Pierre; Pugliese, Francesca; Malcolmson, James; Petersen, Steffen E; Knight, Charles; Mills, Peter; Wragg, Andrew; O'Mahony, Constantinos; Sekhri, Neha; Mohiddin, Saidi A

    2018-01-15

    To investigate the hypothesis that persistence of apical contraction into diastole is linked to reduced myocardial perfusion and chest pain. Apical hypertrophic cardiomyopathy (HCM) is defined by left ventricular (LV) hypertrophy predominantly of the apex. Hyperdynamic contractility resulting in obliteration of the apical cavity is often present. Apical HCM can lead to drug-refractory chest pain. We retrospectively studied 126 subjects; 76 with apical HCM and 50 controls (31 with asymmetrical septal hypertrophy (ASH) and 19 with non-cardiac chest pain and culprit free angiograms and structurally normal hearts). Perfusion cardiac magnetic resonance imaging (CMR) scans were assessed for myocardial perfusion reserve index (MPRi), late gadolinium enhancement (LGE), LV volumes (muscle and cavity) and regional contractile persistence (apex, mid and basal LV). In apical HCM, apical MPRi was lower than in normal and ASH controls (p<0.05). In apical HCM, duration of contractile persistence was associated with lower MPRi (p<0.01) and chest pain (p<0.05). In multivariate regression, contractile persistence was independently associated with chest pain (p<0.01) and reduced MPRi (p<0.001). In apical HCM, regional contractile persistence is associated with impaired myocardial perfusion and chest pain. As apical myocardium makes limited contributions to stroke volume, apical contractility is also largely ineffective. Interventions to reduce apical contraction and/or muscle mass are potential therapies for improving symptoms without reducing cardiac output. Copyright © 2017 Elsevier B.V. All rights reserved.

  11. Resource reduction in pediatric chest pain: Standardized clinical assessment and management plan.

    Science.gov (United States)

    Saleeb, Susan F; McLaughlin, Sarah R; Graham, Dionne A; Friedman, Kevin G; Fulton, David R

    2018-01-01

    Using a Standardized Clinical Assessment and Management Plan (SCAMP) for pediatric patients presenting to clinic with chest pain, we evaluated the cost impact associated with implementation of the care algorithm. Prior to introduction of the SCAMP, we analyzed charges for 406 patients with chest pain, seen in 2009, and predicted 21% reduction of overall charges had the SCAMP methodology been used. The SCAMP recommended an echocardiogram for history, examination, or ECG findings suggestive of a cardiac etiology for chest pain. Resource utilization was reviewed for 1517 patients (7-21 years) enrolled in the SCAMP from July 2010 to April 2014. Compared to the 2009 historic cohort, patients evaluated by the SCAMP had higher rates of exertional chest pain (45% vs 37%) and positive family history (5% vs 1%). The SCAMP cohort had fewer abnormal physical examination findings (1% vs 6%) and abnormal electrocardiograms (3% vs 5%). Echocardiogram use increased in the SCAMP cohort compared to the 2009 historic cohort (45% vs 41%), whereas all other ancillary testing was reduced: exercise stress testing (4% SCAMP vs 28% historic), Holter (4% vs 7%), event monitors (3% vs 10%), and MRI (1% vs 2%). Total charges were reduced by 22% ($822 625) by use of the Chest Pain SCAMP, despite a higher percentage of patients for whom echocardiogram was recommended compared to the historic cohort. The Chest Pain SCAMP effectively streamlines cardiac testing and reduces resource utilization. Further reductions can be made by algorithm refinement regarding echocardiograms for exertional symptoms. © 2017 Wiley Periodicals, Inc.

  12. Unexplained acute chest pain in young adults: disease patterns and medication use 25 years later.

    Science.gov (United States)

    Roll, Martin; Rosenqvist, Mårten; Sjöborg, Bengt; Wettermark, Björn

    2015-06-01

    Patients with unexplained chest pain are commonly revisiting an emergency department with various symptoms, but comprehensive long-term studies are lacking. A total of 150 young adults (aged 18-40 years) with unexplained chest pain who presented at an emergency unit for 16 weeks in mid-1980s were included in a prospective cohort study. An age- and sex-matched control group was randomly selected from the same area. Data were retrieved from registers that recorded death, income, education, country of birth, diagnoses, hospitalizations, outpatient visits, and medications dispensed. Patients with unexplained acute chest pain had lower levels of education and income and were more often immigrants. Long-term mortality rates did not differ between cases (4%) and controls (5%) during 25 years of follow-up, nor were there differences in diagnosis of ischemic heart disease. Patients with unexplained acute chest pain had more outpatient visits (median, 5 versus 2; p chest pain, palpitations, abdominal discomfort, musculoskeletal symptoms, sleeping disturbance, and stress reactions (p values acute chest pain showed no increased risk of mortality or ischemic heart disease during 25 years of follow-up, but they had higher incidence of a wide range of disorders and used more medications. Early identification and preventive interventions may improve health outcomes in these patients.

  13. Coronary computed tomography angiography for the assessment of chest pain: current status and future directions.

    Science.gov (United States)

    Nasis, Arthur; Meredith, Ian T; Cameron, James D; Seneviratne, Sujith K

    2015-12-01

    Chest pain is one of the most common presenting symptoms leading to presentation to medical clinics and Emergency Departments worldwide. Defining the nature and etiology of chest pain can pose a diagnostic dilemma for clinicians, despite the availability of several diagnostic algorithms and guidelines to assist them in evaluating these patients. Most investigations in patients with acute chest pain are initially performed to either exclude or diagnose and manage potentially life-threatening conditions such as acute coronary syndrome, pulmonary embolism and aortic dissection. In cases of stable chest pain syndromes, the focus shifts to determining the presence, extent and severity of coronary artery disease. In recent years, coronary computed tomography angiography (CCTA) is being increasingly used worldwide in the assessment of both stable and acute chest pain syndromes. This review evaluates the current evidence regarding the clinical utility of CCTA in the stable and acute chest pain settings and outlines the latest advances in CCTA techniques, including functional assessment of coronary stenoses, and their potential clinical application to improve patient care in a cost-effective manner.

  14. Brugada ECG Sign & Chest Pain Mimicking ST Elevation Myocardial Infarction

    Directory of Open Access Journals (Sweden)

    Omar Mousa

    2013-11-01

    Full Text Available Background: Management of patients with the brugada ECG sign who have no previous history of syncope is still negotiable. We present a case of a 57 year-old Caucasian lady who presented to the emergency department with substernal chest pain. Results: Her past medical history showed that she had two previous episodes of lightheadedness, but no syncope. She had a family history of sudden death secondary to unknown cause in her aunt at the age of 61. Physical exam was unremarkable except for diaphoresis. Electrocardiography (ECG showed ST elevation in the right precordial leads (V1-V2 with T inversion, mimicking a STEMI. Emergent cardiac catheterization revealed normal coronary arteries. Echocardiogram was normal. Again, interpretation of ECG revealed a Brugada type 1 pattern, characterized by coved-type, gradually descending ST-T segment, elevated J point of more than 2 mm and T wave inversion. Electrophysiological (EPS testing with a Sodium channel blocker challenge showed a persistent Brugada type 1 pattern with non inducible ventricular tachycardia. This patient had Brugada type 1 ECG pattern with no previous history of syncope (asymptomatic. Thus she was considered at low risk of developing a serious arrhythmogenic event in the future. Conclusion: A history of syncope remains the best available predictor for arrhythmogenic events. EPS testing in such patients, to stratify the risk and predict for any future events, is still controversial. It is still unjustified to place an implantable cardioverter-defibrillator in asymptomatic non-inducible individuals with the Brugada pattern. These patients should follow up closely with a cardiologist and be aware of the risk of possible triggers of ventricular arrhythmias.

  15. Radiological diagnostic in acute chest pain; Radiologische Diagnostik bei akutem Thoraxschmerz

    Energy Technology Data Exchange (ETDEWEB)

    Kawel, Nadine; Bremerich, Jens [Universitaetskliniken Basel (Switzerland). Abt. fuer kardiale und thorakale Radiologie

    2010-09-15

    Acute chest pain is one of the main symptoms leading to a consultation of the emergency department. Main task of the initial diagnostic is the confirmation or exclusion of a potentially life threatening cause. Conventional chest X-ray and computed tomography are the most significant techniques. Due to limited availability and long examination times magnetic resonance tomography rather plays a limited role in routine clinical workup. In the following paper we will systematically review the radiological diagnostic of the acute life threatening causes of chest pain. Imaging modalities, technical aspects and image interpretation will be discussed. (orig.)

  16. Chest Pain and Costochondritis Associated with Vitamin D Deficiency: A Report of Two Cases

    Directory of Open Access Journals (Sweden)

    Robert C. Oh

    2012-01-01

    Full Text Available Vitamin D is integral for bone health, and severe deficiency can cause rickets in children and osteomalacia in adults. Although osteomalacia can cause severe generalized bone pain, there are only a few case reports of chest pain associated with vitamin D deficiency. We describe 2 patients with chest pain that were initially worked up for cardiac etiologies but were eventually diagnosed with costochondritis and vitamin D deficiency. Vitamin D deficiency is known to cause hypertrophic costochondral junctions in children (“rachitic rosaries” and sternal pain with adults diagnosed with osteomalacia. We propose that vitamin D deficiency may be related to the chest pain associated with costochondritis. In patients diagnosed with costochondritis, physicians should consider testing and treating for vitamin D deficiency.

  17. Acute Hypotension and Chest Pain as The Presentation of a Post-Myocardial Infarction Acute Pericarditis (Dressler’s Syndrome

    Directory of Open Access Journals (Sweden)

    Alfredo De Giorgi

    2016-01-01

    Full Text Available We report a case of a 53-year old man admitted because of fever (38.5°C and atypical chest pain. He also complained of epigastric pain spread to left hypochondrium and exacerbated by breathing. In his past medical history, Hodgkin’s lymphoma, gastric MALToma (oncologic follow-up only, hypothyroidism, and hypertension are recorded. Fifteen days prior actual hospital admission, the patient underwent angioplasty with stenting due to a ST elevation myocardial infarction. Moreover, he was enrolled in the experimental clinical double-blind trial GEMINI-ACS [1], designed to compare the safety of rivaroxaban vs aspirin in addition to either clopidogrel or ticagrelor. Thus, his complete therapy included also ticagrelor, bisoprolol, perindopril, levothyroxine, pantoprazole, and atorvastatin. At the time of admission chest X-ray showed bilateral pleural effusion. Blood chemistry panel showed moderate anemia, increase of inflammatory indexes, in particular fibrinogen 1057 mg/dl (normal range 150-400 mg/dl, C-reactive-protein 17.6 mg/dl (normal range <0.5 mg/dl, serum ferritin 650 ng/ml (normal range 11-306 ng/ml, while serum pro-calcitonin was normal. Electrocardiography and cardiac troponin I were not suggestive of further heart ischemic damage. Two days later, the patient showed hypotension, exacerbation of chest pain, as well as a rapid drop hemoglobin values. A thoracicabdominal CT (figure 1 was performed, showing peri-hepatic and pericardial effusions associated with hyper-reflectivity of pericardial leaflets. After a precautionary discontinuation of the experimental drugs, acetylsalicylic acid and clopidogrel were only given, together with antibiotics, diuretics and steroids. Clinical conditions slowly improved, blood pressure levels raised, together with hemoglobin values, and inflammatory parameters decreased. The patient was discharged in good clinical conditions, with the conclusive discharge diagnosis of Dressler syndrome (DS related to

  18. Inflammation and Rupture of a Congenital Pericardial Cyst Manifesting Itself as an Acute Chest Pain Syndrome.

    Science.gov (United States)

    Aertker, Robert A; Cheong, Benjamin Y C; Lufschanowski, Roberto

    2016-12-01

    We present the case of a 63-year-old woman with a remote history of supraventricular tachycardia and hyperlipidemia, who presented with recurrent episodes of acute-onset chest pain. An electrocardiogram showed no evidence of acute coronary syndrome. A chest radiograph revealed a prominent right-sided heart border. A suspected congenital pericardial cyst was identified on a computed tomographic chest scan, and stranding was noted around the cyst. The patient was treated with nonsteroidal anti-inflammatory drugs, and the pain initially abated. Another flare-up was treated similarly. Cardiac magnetic resonance imaging was then performed after symptoms had resolved, and no evidence of the cyst was seen. The suspected cause of the patient's chest pain was acute inflammation of a congenital pericardial cyst with subsequent rupture and resolution of symptoms.

  19. Validation of the North American Chest Pain Rule in Prediction of Very Low-Risk Chest Pain; a Diagnostic Accuracy Study

    Directory of Open Access Journals (Sweden)

    Somayeh Valadkhani

    2017-01-01

    Full Text Available Introduction: Acute coronary syndrome accounts for more than 15% of the chest pains. Recently, Hess et al. developed North American Chest Pain Rule (NACPR to identify very low-risk patients who can be safely discharged from emergency department (ED. The present study aimed to validate this rule in EDs of two academic hospitals.Methods: A prospective diagnostic accuracy study was conducted on consecutive patients 24 years of age and older presenting to the ED with the chief complaint of acute chest pain, during March 2013 to June 2013. Chest pain characteristics, cardiac history, electrocardiogram findings, and cardiac biomarker measurement of patients were collected and screening performance characteristics of NACPR with 95% confidence interval were calculated using SPSS 21.Results: From 400 eligible patients with completed follow up, 69 (17.25 % developed myocardial infarction, 121 (30.25% underwent coronary revascularization, and 4 (2% died because of cardiac or unidentifiable causes. By using NACPR, 34 (8.50% of all the patients could be considered very low- risk and discharged after a brief ED assessment. Among these patients, none developed above-mentioned adverse outcomes within 30 days. Sensitivity, specificity, positive prediction value, and negative prediction value of the rule were 100% (95% CI: 87.35 - 100.00, 45.35 (95% CI: 40.19 - 50.61, 14.52 (95% CI: 10.40 – 19.85, and 100 (95% CI: 97.18 - 100.00, respectively.Conclusions: The present multicenter study showed that NACPR is a good screening tool for early discharge of patients with very low-risk chest pain from ED.

  20. Validation of the Vancouver Chest Pain Rule: a prospective cohort study.

    Science.gov (United States)

    Jalili, Mohammad; Hejripour, Zia; Honarmand, Amir Reza; Pourtabatabaei, Nasim

    2012-07-01

    The objective was to validate the Vancouver Chest Pain Rule in an emergency department (ED) setting to identify very-low-risk patients with acute chest pain. A prospective cohort study was conducted on consecutive patients 25 years of age and older presenting to the ED with a chief complaint of acute chest pain during January 2009 to July 2009. According to the Vancouver Chest Pain Rule, cardiac history, chest pain characteristics, physical and electrocardiogram (ECG) findings, and cardiac biomarker measurement (creatine kinase-myocardial band isoenzyme [CK-MB]) were used to identify patients with very low risk for developing acute coronary syndrome (ACS) in 30 days. The primary outcome was defined as developing ACS (myocardial infarction or non-ST-elevation myocardial infarction [MI]/unstable angina) within 30 days of ED presentation, and all diagnoses were made using predefined explicit criteria. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated. Of 593 patients who were eligible for evaluation, 39 (6.6%) developed MI and 43 (7.3%) developed unstable angina. Among all patients, 292 (49.2%) patients could have been assigned to the very-low-risk group and discharged after a brief ED assessment according to the Vancouver Chest Pain Rule. Among these patients, four (1.4%) developed ACS within 30 days. Sensitivity of the rule was 95.1% (95% confidence interval [CI]=88.0% to 98.7%), specificity was 56.3% (95% CI=52.0% to 60.7%), positive prediction value was 25.9% (95% CI=21.0% to 31.0%), and negative prediction value was 98.6% (95% CI=96.5% to 99.6%). This study showed a lower sensitivity and higher specificity when applying the Vancouver Chest Pain Rule to this population as compared to the original study. © 2012 by the Society for Academic Emergency Medicine.

  1. High sensitivity troponin T provides useful prognostic information in non-acute chest pain.

    Science.gov (United States)

    George, J; Jack, D; Mackle, G; Callaghan, T S; Wei, L; Lang, C C; Dow, E; Struthers, A D

    2012-02-01

    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. 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. Hs-cTnT and B-type Natriuretic Peptide (BNP) were measured and final diagnosis recorded. Twelve-month follow-up for cardiac events and hospital admission data was collected. Sensitivity, specificity, positive predictive value and negative predictive value (NPV), for both prognosis and diagnosis, were produced using various pre-specified cut-off values for hs-cTnT and BNP. A total of 579 patients were included in the final analysis. Of these, 477 had intermediate/high-pretest probability of CAD. A total of 431 (90.4%) of patients had a hs-cTnT ≤14 ng/l. In this study, hs-cTnT of 14 ng/l was the best cut-off for ruling out if a patient would have an admission for cardiac chest pain in the following 12 months (specificity 90%, NPV 91.4%). It performed well as a predictor of a subsequent negative diagnosis of cardiac chest pain with a specificity of 92.4% and NPV of 83.5%. Hs-cTnT, at the same level currently used in clinical practice as a diagnostic cut-off for myocardial infarction and acute coronary syndromes, is also a clinically-meaningful indicator for further 12-month cardiac chest pain hospital admissions in patients with non-acute chest pain referred to chest pain clinics by GPs.

  2. The Evaluation of Patients Presenting with Chest Pain to Pediatric Cardiology Outpatient Clinics

    Directory of Open Access Journals (Sweden)

    Mehmet Kervancıoğlu

    2005-01-01

    Full Text Available Although the possibility of the cardiac origin of chest pains in childhood is low, perception of the chest pain as heart pain by families makes this issue more important. A total of 223 patients (134 male, 99 female with a mean age of 11.3±4.3 years ranging between 4 and 15 years, who were admitted with chest pain to the Pediatric Cardiology Outpatient Clinics of Dicle University Hospital between April 2004 and January 2005, were enrolled into the study. Investigations with electrocardiography, holter monitoring and echocardiography revealed MVP in 12, pulmonary valve stenosis in three, pericardial effusion in two, focal septal hypertrophy in one, mild cardiomyopathic changes in two and operated ASD in two patients. There were Wolf-Parkinson-White in one, premature supraventricular beats in three, sinus tachycardia in two, ventricular tachycardia attack in one, and frequent single ventricular premature beats in one patient. In conclusion, despite scarcity of cardiac origin in chest pain of childhood, differential diagnosis should be made carefully due to possibility of life threatening consequences of cardiac disorders. The chest pains, with acute onset,triggered by exercise, awakening the child from sleep, accompanied with dyspnea, palpitation, dizziness, pre-syncope and syncope should be evaluated in detail for cardiac pathologies.

  3. Estimation of the radiation exposure of a chest pain protocol with ECG-gating in dual-source computed tomography

    Energy Technology Data Exchange (ETDEWEB)

    Ketelsen, Dominik; Luetkhoff, Marie H.; Thomas, Christoph; Werner, Matthias; Tsiflikas, Ilias; Reimann, Anja; Kopp, Andreas F.; Claussen, Claus D.; Heuschmid, Martin [University Hospital Tuebingen, Eberhard-Karls-University, Department of Diagnostic and Interventional Radiology, Tuebingen (Germany); Buchgeister, Markus [University Hospital, Department of Radiotherapy and Radiooncology, Tuebingen (Germany); Burgstahler, Christof [University Hospital Tuebingen, Department of Cardiology, Tuebingen (Germany)

    2009-01-15

    The aim of the study was to evaluate radiation exposure of a chest pain protocol with ECG-gated dual-source computed tomography (DSCT). An Alderson Rando phantom equipped with thermoluminescent dosimeters was used for dose measurements. Exposure was performed on a dual-source computed tomography system with a standard protocol for chest pain evaluation (120 kV, 320 mAs/rot) with different simulated heart rates (HRs). The dose of a standard chest CT examination (120 kV, 160 mAs) was also measured. Effective dose of the chest pain protocol was 19.3/21.9 mSv (male/female, HR 60), 17.9/20.4 mSv (male/female, HR 80) and 14.7/16.7 mSv (male/female, HR 100). Effective dose of a standard chest examination was 6.3 mSv (males) and 7.2 mSv (females). Radiation dose of the chest pain protocol increases significantly with a lower heart rate for both males (p = 0.040) and females (p = 0.044). The average radiation dose of a standard chest CT examination is about 36.5% that of a CT examination performed for chest pain. Using DSCT, the evaluated chest pain protocol revealed a higher radiation exposure compared with standard chest CT. Furthermore, HRs markedly influenced the dose exposure when using the ECG-gated chest pain protocol. (orig.)

  4. Imaging of non-cardiac, non-traumatic causes of acute chest pain

    Energy Technology Data Exchange (ETDEWEB)

    Kienzl, Daniela, E-mail: daniela.kienzl@meduniwien.ac.at [Department of Radiology, Medical University of Vienna (Austria); Prosch, Helmut; Töpker, Michael; Herold, Christian [Department of Radiology, Medical University of Vienna (Austria)

    2012-12-15

    Non-traumatic chest pain is a common symptom in patients who present in the emergency department. From a clinical point of view, it is important to differentiate cardiac chest pain from non-cardiac chest pain (NCCP). Among the plethora of potential causes of NCCP, life-threatening diseases, such as aortic dissection, pulmonary embolism, tension pneumothorax, and esophageal rupture, must be differentiated from non-life threatening causes. The majority of NCCP, however, is reported to be benign in nature. The presentation of pain plays an important role in narrowing the differential diagnosis and initiating further diagnostic management and treatment. As the benign causes tend to recur, and may lead to patient anxiety and great costs, a meticulous evaluation of the patient is necessary to diagnose the underlying disorder or disease.

  5. Imaging of non-cardiac, non-traumatic causes of acute chest pain.

    Science.gov (United States)

    Kienzl, Daniela; Prosch, Helmut; Töpker, Michael; Herold, Christian

    2012-12-01

    Non-traumatic chest pain is a common symptom in patients who present in the emergency department. From a clinical point of view, it is important to differentiate cardiac chest pain from non-cardiac chest pain (NCCP). Among the plethora of potential causes of NCCP, life-threatening diseases, such as aortic dissection, pulmonary embolism, tension pneumothorax, and esophageal rupture, must be differentiated from non-life threatening causes. The majority of NCCP, however, is reported to be benign in nature. The presentation of pain plays an important role in narrowing the differential diagnosis and initiating further diagnostic management and treatment. As the benign causes tend to recur, and may lead to patient anxiety and great costs, a meticulous evaluation of the patient is necessary to diagnose the underlying disorder or disease. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

  6. Clinical presentation and chiropractic treatment of Tietze syndrome: A 34-year-old female with left-sided chest pain

    National Research Council Canada - National Science Library

    Gijsbers, Eefje; Knaap, Simone F.C

    2011-01-01

    ... of chiropractic care in managing this patient with Tietze syndrome. Case report A 34-year-old woman presented with chest pain of 2 months' duration, which started while driving. In the car, the patient experienced a sudden onset of left-sided chest pain, which felt as a knife stabbing along with a crushing sensation, unlike any pain she experienced befor...

  7. Novel Biomarkers: Utility in Patients with Acute Chest Pain and Relationship to Coronary Artery Disease on Coronary CT Angiography

    OpenAIRE

    Babatunde, Adefolakemi; Rizvi, Asim; Truong, Quynh A.

    2014-01-01

    Acute chest pain remains one of the most common patient presentations encountered in the emergency department. With the evolution of biomarkers and improvement in cardiac imaging there has been advancement in risk stratification of patients, but millions of dollars continue to be spent in the assessment of chest pain. Investigators have explored possible comparative alternatives to the traditional work up of chest pain. In this review, we will discuss the current state of biomarker use in the...

  8. The prognostic impact of chest pain in 1306 patients presenting with confirmed acute pulmonary embolism.

    Science.gov (United States)

    Wong, Christopher C Y; Ng, Austin C C; Lau, Jerrett K; Chow, Vincent; Sindone, Andrew P; Kritharides, Leonard

    2016-10-15

    The prognostic influence of chest pain in patients presenting with pulmonary embolism has not been well defined. We investigated whether the presence of chest pain at presentation affected the mortality of patients with acute pulmonary embolism. Retrospective cohort study of consecutive patients admitted to a tertiary hospital with confirmed acute pulmonary embolism from 2000 to 2012, with study outcomes tracked using a state-wide death registry. Of the 1306 patients included in the study, 771 (59%) had chest pain at presentation. These patients were younger with fewer comorbidities, and had lower 6-month mortality compared to patients without chest pain (5% vs 15%, PChest pain was consistently found to be an independent predictor of 6-month mortality in three separate multivariable models (range of hazard ratios 0.52-0.60, all with Pchest pain to a multivariable model that included the simplified pulmonary embolism severity index, haemoglobin, and sodium led to a significant net reclassification improvement of 18% (PChest pain is a novel, favourable prognostic marker in patients with acute pulmonary embolism. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  9. Spontaneous pneumomediastinum (Hamman's syndrome): a rare cause of postpartum chest pain.

    Science.gov (United States)

    Cho, Cho; Parratt, Jennifer Ruth; Smith, Steve; Patel, Ramnik

    2015-08-19

    We present a case of a 28-year-old primiparous woman with facial swelling followed by acute chest pain immediately after delivery. Chest radiograph revealed pneumomediastinum and surgical emphysema. She recovered well within 24 h of observation and conservative management. Postpartum spontaneous pneumomediastinum should be considered in the differential diagnosis of sudden-onset postpartum chest pain immediately or a few hours after delivery. It is a rare benign condition and usually resolves spontaneously without serious consequences. Chest X-ray is the single most important diagnostic test. It is important to rule out other serious and life-threatening conditions. Prolonged pushing, difficult labour and use of inhalational drugs place young primiparous women at higher risk. Recurrence is uncommon in subsequent pregnancy and management is unclear, although expectant management with epidural analgaesia to prevent recurrence in subsequent pregnancy is suggested. 2015 BMJ Publishing Group Ltd.

  10. Role of Multidetector CT in Evaluation of Acute Chest Pain: Non-Cardiac Vascular and Pulmonary Causes

    OpenAIRE

    Rania S Sayed *, Hisham M Mansour **, Mohammad H Khaleel ***, Sherif H Abo Gamra ** and Merhan A Nasr

    2013-01-01

    Background: Triage of patients with acute chest pain is one of the most important issues currently facing physicians in the emergency department. Acute chest pain may be a symptom of a number of serious conditions and is generally considered a medical emergency. The causes of acute chest pain range from non-serious to life threatening. A rapid, accurate and cost-effective approach for the evaluation of emergency department patients with chest pain is needed. Aim of the work: This work aims to...

  11. Morbidity of "DSM-IV" Axis I Disorders in Patients with Noncardiac Chest Pain: Psychiatric Morbidity Linked with Increased Pain and Health Care Utilization

    Science.gov (United States)

    White, Kamila S.; Raffa, Susan D.; Jakle, Katherine R.; Stoddard, Jill A.; Barlow, David H.; Brown, Timothy A.; Covino, Nicholas A.; Ullman, Edward; Gervino, Ernest V.

    2008-01-01

    The present study examined current and lifetime psychiatric morbidity, chest pain, and health care utilization in 229 patients with noncardiac chest pain (NCCP), angina-like pain in the absence of cardiac etiology. Diagnostic interview findings based on the "Diagnostic and Statistical Manual of Mental Disorders" (4th ed.; "DSM-IV"; American…

  12. Cost-effectiveness of chiropractic care versus self-management in patients with musculoskeletal chest pain

    DEFF Research Database (Denmark)

    Stochkendahl, Mette Jensen; Sørensen, Jan; Vach, Werner

    2016-01-01

    in QALYs between the groups were negligible. CONCLUSIONS: Chiropractic care was more cost-effective than self-management. Therefore, chiropractic care can be seen as a good example of a targeted primary care approach for a subgroup of patients with non-specific chest pain. TRIAL REGISTRATION NUMBER: NCT......AIMS: To assess whether primary sector healthcare in the form of chiropractic care is cost-effective compared with self-management in patients with musculoskeletal chest pain, that is, a subgroup of patients with non-specific chest pain. METHODS AND RESULTS: 115 adults aged 18-75 years with acute...... information session aimed at encouraging self-management as complementary to usual care (n=56). Data on resource use were obtained from Danish national registries and valued from a societal perspective. Patient cost and health-related quality-adjusted life years (QALYs; based on EuroQol five...

  13. Chest pain, panic disorder and coronary artery disease: a systematic review.

    Science.gov (United States)

    Soares-Filho, Gastão L F; Arias-Carrión, Oscar; Santulli, Gaetano; Silva, Adriana C; Machado, Sergio; Valenca, Alexandre M; Nardi, Antonio E

    2014-01-01

    Chest pain may be due benign diseases but often suggests an association with coronary artery disease, which justifies a quick search for medical care. However, some people have anxiety disorder with symptoms that resemble clearly an acute coronary syndrome. More specifically, during a panic attack an abrupt feeling of fear accompanied by symptoms such as breathlessness, palpitations and chest pain, makes patients believe they have a heart attack and confuse physicians about the diagnosis. The association between panic disorder and coronary artery disease has been extensively studied in recent years and, although some studies have shown anxiety disorders coexisting or increasing the risk of heart disease, one causal hypothesis is still missing. The aim of this systematic review is to present the various ways in which the scientific community has been investigating the relation between chest pain, panic disorder and coronary artery disease.

  14. The prognostic value of copeptin in patients with acute chest pain.

    Science.gov (United States)

    Marston, Nicholas A; Maisel, Alan S

    2014-10-01

    The prognostic value of copeptin in acute chest pain is an area of rapid growth and research interest. Copeptin has already established a role in early diagnosis and rule out of acute myocardial infarction, but as its use increases much of the attention has been directed at the prognostic value of copeptin. This article reviews the growing body of evidence supporting the use of copeptin to further risk-stratify chest pain patients. The studies included address a variety of populations ranging from all patients presenting with chest pain to those who are at high risk, diagnosed with acute coronary syndrome or found to have left ventricular dysfunction. Many of the studies compare and combine the prognostic value of copeptin with other prognostic markers such as troponin, brain natriuretic peptide and Global Registry of Acute Coronary Events scores. Caveats of copeptin are also discussed such as gender differences, cutoff points and the importance of timing in the copeptin assay.

  15. Connecticut Hospital Readmissions Related to Chest Pain and Heart Failure: Differences by Race, Ethnicity, and Payer.

    Science.gov (United States)

    Aseltine, Robert H; Yan, Jun; Gruss, Claudia B; Wagner, Catherine; Katz, Matthew

    2015-02-01

    Racial and ethnic disparities in hospital readmissions for several major illnesses and conditions are well-documented. However, due to the data typically used to assess readmission disparities little is known regarding the interplay between race/ethnicity and payer in fostering readmissions. This study used a statewide database of acute-care hospital admissions to examine 30-day readmission rates following hospitalization for chest pain and heart failure byrace/ethnicity and insurance status. Connecticut hospital discharge data for patients admitted for Chest Pain-DRG 313 (n = 23,450) and Heart Failure and Shock-DRG 291 and 292 (n = 39,985) from 2008 - 2012 were analyzed using marginal logistic models for clustered data with generalized estimating equations. Results from logistic models indicated that Black patients were significantly more likely to be readmitted within 30 days of discharge following hospitalization for chest pain (OR = 1.19, CI = 1.04, 1.37) than were White patients. Hispanics, but not Blacks, were significantly more likely to be readmitted within 30 days of discharge following hospitalization for heart failure (OR = 1.30, CI = 1.15, 1.47). Rates of 30-day readmission across these conditions were between 50-100% higher among those covered by Medicaid compared to those covered by private payer. Controlling for patient socioeconomic status, patient comorbidities, and payer substantially reduced Black/White differences in the odds of readmission for chest pain but did not reduce Hispanic-White differences for heart failure. Racial and ethnic disparities were seen in hospital readmission rates for Chest Pain (DRG 313) and Heart Failure and Shock (DRG 291 and 292) when a statewide database that captures all acute care hospital admissions was analyzed. When controlling for patient socioeconomic status, comorbidities, and payer status, the difference in the odds of readmission for chest pain, but not heart failure, was reduced.

  16. Role of anxiety and depression in adolescents with chest pain referred to a cardiology clinic.

    Science.gov (United States)

    Khairandish, Zahra; Jamali, Leila; Haghbin, Saeedeh

    2017-01-01

    We carried out this study in order to evaluate the causes of chest pain in teenagers and the role of anxiety and depression in this age group compared with the normal population. In this prospective case-control study, all patients aged 11-18 years with chest pain and no history of trauma and referred to a paediatric cardiology clinic from March, 2009-April, 2010 were selected. A chest pain protocol including a detailed history, full physical examination, required blood tests, electrocardiography, and echocardiography was performed for all. The presence of depression and anxiety and their severity were assessed by Beck questionnaires. The patients were compared with age- and sex-matched, randomly selected healthy controls. In total, 194 patients with a mean age of 14±2 years were selected. The most frequent presentation was idiopathic chest pain (43.3%), followed by the psychological group (29.9%). These groups had no abnormal points in history, physical, and para-clinical tests. Moderate-to-severe depression was found in 45.9% in the patients group, compared with 17.6% of controls, which was statistically significant (p=0.016). Moreover, anxiety was detected in 67.5% of patients versus 15.4% in controls, which is a statistically significant difference (p=0.009). Cardiac chest pain with 9.27% was the most common type of organic causes. Chest pain during teenage is more prevalent, but not risky. Undergoing a detailed history and full physical examination can help diagnose the causes in the majority of cases. Given the prevalence of a psychological group as well as role of anxiety and depression in most patients, referring to a psychiatrist is suggested.

  17. Systolic blood pressure at Emergency Department presentation and 1-year mortality in acute chest pain patients.

    Science.gov (United States)

    Irfan, Affan; Haaf, Philip; Meissner, Julia; Twerenbold, Raphael; Reiter, Miriam; Reichlin, Tobias; Schaub, Nora; Zbinden, Anina; Heinisch, Corinna; Drexler, Beatrice; Winkler, Katrin; Mueller, Christian

    2011-10-01

    High blood pressure at rest has been an established risk factor for cardiovascular disease. However the relationship between Systolic Blood Pressure (SBP) and 1-year-mortality among acute chest pain patients presenting to Emergency Department (ED); and effects of preexisting renal insufficiency, hemodynamic stress - as quantified by Brain Natriuretic Peptide (BNP) and chest pain duration, on this relationship is unknown. Data was used from APACE (Advantageous Predictors of Acute Coronary Syndrome Evaluation), a prospective observational multicenter study of 1240 ED chest pain patients. SBP at presentation was categorized into quartiles: Q1≤127mmHg; Q2 128-142mmHg; Q3 143-160mmHg; Q4≥161mmHg. 60 deaths occurred during 1-year. One-year-mortality-rate showed lower Hazard Ratios for Q2, Q3 and Q4 vs Q1 (HR [95% CI]; 0.39 (0.19-0.78), 0.34 (0.17-0.70), 0.35 (0.17-0.72); pPatients showed progressively better prognosis from Q2 through Q4 vs Q1 only in patients who presented to ED with for more than 12h of chest pain duration. Patients with renal insufficiency had lower SBP at presentation than others (p=0.001). There was no association between the outcome and interaction variable of SBP quartiles and BNP (p=0.27). Acute chest pain patients presenting to ED exhibit an inverse association between SBP at presentation and 1-year-mortality; a relationship which appears stronger in those who present with chest pain of greater than 12h duration. Copyright © 2011 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

  18. Diagnosis and treatment of musculoskeletal chest pain: design of a multi-purpose trial

    Directory of Open Access Journals (Sweden)

    Høilund-Carlsen Poul

    2008-03-01

    Full Text Available Abstract Background Acute chest pain is a major health problem all over the western world. Active approaches are directed towards diagnosis and treatment of potentially life threatening conditions, especially acute coronary syndrome/ischemic heart disease. However, according to the literature, chest pain may also be due to a variety of extra-cardiac disorders including dysfunction of muscles and joints of the chest wall or the cervical and thoracic part of the spine. The diagnostic approaches and treatment options for this group of patients are scarce and formal clinical studies addressing the effect of various treatments are lacking. Methods/Design We present an ongoing trial on the potential usefulness of chiropractic diagnosis and treatment in patients dismissed from an acute chest pain clinic without a diagnosis of acute coronary syndrome. The aims are to determine the proportion of patients in whom chest pain may be of musculoskeletal rather than cardiac origin and to investigate the decision process of a chiropractor in diagnosing these patients; further, to examine whether chiropractic treatment can reduce pain and improve physical function when compared to advice directed towards promoting self-management, and, finally, to estimate the cost-effectiveness of these procedures. This study will include 300 patients discharged from a university hospital acute chest pain clinic without a diagnosis of acute coronary syndrome or any other obvious cardiac or non-cardiac disease. After completion of the clinic's standard cardiovascular diagnostic procedures, trial patients will be examined according to a standardized protocol including a a self-report questionnaire; b a semi-structured interview; c a general health examination; and d a specific manual examination of the muscles and joints of the neck, thoracic spine, and thorax in order to determine whether the pain is likely to be of musculoskeletal origin. To describe the patients status with

  19. Diagnosis and treatment of musculoskeletal chest pain: design of a multi-purpose trial.

    Science.gov (United States)

    Stochkendahl, Mette J; Christensen, Henrik W; Vach, Werner; Høilund-Carlsen, Poul Flemming; Haghfelt, Torben; Hartvigsen, Jan

    2008-03-31

    Acute chest pain is a major health problem all over the western world. Active approaches are directed towards diagnosis and treatment of potentially life threatening conditions, especially acute coronary syndrome/ischemic heart disease. However, according to the literature, chest pain may also be due to a variety of extra-cardiac disorders including dysfunction of muscles and joints of the chest wall or the cervical and thoracic part of the spine. The diagnostic approaches and treatment options for this group of patients are scarce and formal clinical studies addressing the effect of various treatments are lacking. We present an ongoing trial on the potential usefulness of chiropractic diagnosis and treatment in patients dismissed from an acute chest pain clinic without a diagnosis of acute coronary syndrome. The aims are to determine the proportion of patients in whom chest pain may be of musculoskeletal rather than cardiac origin and to investigate the decision process of a chiropractor in diagnosing these patients; further, to examine whether chiropractic treatment can reduce pain and improve physical function when compared to advice directed towards promoting self-management, and, finally, to estimate the cost-effectiveness of these procedures. This study will include 300 patients discharged from a university hospital acute chest pain clinic without a diagnosis of acute coronary syndrome or any other obvious cardiac or non-cardiac disease. After completion of the clinic's standard cardiovascular diagnostic procedures, trial patients will be examined according to a standardized protocol including a) a self-report questionnaire; b) a semi-structured interview; c) a general health examination; and d) a specific manual examination of the muscles and joints of the neck, thoracic spine, and thorax in order to determine whether the pain is likely to be of musculoskeletal origin. To describe the patients status with regards to ischemic heart disease, and to compare and

  20. Patient satisfaction with chest pain unit care: findings from the Effectiveness and Safety of Chest Pain Assessment to Prevent Emergency Admissions (ESCAPE) cluster randomised trial.

    Science.gov (United States)

    Cross, Elizabeth; Goodacre, Steve

    2010-10-01

    Chest pain attendances at the emergency department (ED) in the UK are continuing to rise. Chest pain units (CPU) provide nurse-led, protocol-driven care for patients attending the ED with acute chest pain. The ESCAPE trial evaluated the effectiveness, cost-effectiveness and acceptability of CPU care in the NHS. This paper reports the quantitative evaluation of acceptability: patient satisfaction with CPU and routine care. The ESCAPE study was a cluster-randomised controlled trial of 14 hospitals in which seven hospitals were allocated to establish CPU care and seven to continue providing routine care. As part of the study, postal questionnaires were sent to a subgroup of patients attending the ED with chest pain before and after intervention at all 14 hospitals. There was a 42.8% response rate (2389/5584) for unsolicited self-administered questionnaires. There was no significant change in any dimension of patient satisfaction, although there was some weak evidence that the introduction of CPU care was associated with reduced satisfaction with explanations about medical procedures and treatments (effect of CPU -0.16 points on a 5-point Likert scale, 95% CI -0.35 to 0.02; p=0.089) and attention given to what the patient had to say (-0.17 points, 95% CI -0.35 to 0.02; p=0.077). CPU care had no effect on overall satisfaction with care (-0.08 points, 95% CI -0.26 to 0.10; p=0.393). No evidence was found that improvements in patient satisfaction associated with CPU care in previous single-centre trials were reproduced in this multicentre study. ISRCTN55318418 International Standard Randomised Controlled Trial Number Register.

  1. Care of the Patient with Chest Pain in the Observation Unit.

    Science.gov (United States)

    Borawski, Joseph B; Graff, Louis G; Limkakeng, Alexander T

    2017-08-01

    Care of the patient presenting to an emergency department (ED) with chest pain remains a common yet challenging aspect of emergency medicine. Acute coronary syndrome presents in nonspecific fashion. The development and evolution of the ED-based observation unit has helped to safely assess and diagnose those most at risk for an adverse cardiac event. Furthermore, there are several provocative testing modalities to help assess for coronary artery disease. This article serves to describe and discuss the modern ED-based observation unit approach to patients with chest pain and/or angina equivalents presenting to an ED. Copyright © 2017 Elsevier Inc. All rights reserved.

  2. Comparison of Fentanyl and Morphine in the Prehospital Treatment of Ischemic Type Chest Pain.

    Science.gov (United States)

    Weldon, Erin R; Ariano, Robert E; Grierson, Robert A

    2016-01-01

    In the treatment of acute coronary syndromes, reduction of sympathetic stress and catecholamine release is an important therapeutic goal. One method used to achieve this goal is pain reduction through the systemic administration of analgesia. Historically, morphine has been the analgesic of choice in ischemic cardiac pain. This randomized double-blind controlled trial seeks to prove the utility of fentanyl as an alternate first-line analgesic for ischemic-type chest pain in the prehospital setting. Successive patients who were treated for suspected ischemic chest pain in the emergency medical services system were considered eligible. Once chest pain was confirmed, patients received oxygen, aspirin, and nitroglycerin therapy. If the ischemic-type chest pain continued the patient was randomized in a double-blinded fashion to treatment with either morphine or fentanyl. Pain scale scores, necessity for additional dosing, and rate of adverse events between the groups were assessed every 5 minutes and were compared using t-testing, Fisher's Exact test, or Analysis of Variance (ANOVA) where appropriate. The primary outcome of the study was incidence of hypotension and the secondary outcome was pain reduction as measured by the visual analog score and numeric rating score. A total of 207 patients were randomized with 187 patients included in the final analysis. Of the 187 patients, 99 were in the morphine group and 88 in the fentanyl group. No statistically significant difference between the two groups with respect to hypotension was found (morphine 5.1% vs. fentanyl 0%, p = 0.06). Baseline characteristics, necessity for additional dosing, and other adverse events between the two groups were not statistically different. There were no significant differences between the changes in visual analog scores and numeric rating scale scores for pain between the two groups (p = 0.16 and p = 0.15, respectively). This study supports that fentanyl and morphine are comparable in

  3. Treatment of non-cardiac chest pain: a controlled trial of hypnotherapy.

    Science.gov (United States)

    Jones, H; Cooper, P; Miller, V; Brooks, N; Whorwell, P J

    2006-10-01

    Non-cardiac chest pain (NCCP) is an extremely debilitating condition of uncertain origin which is difficult to treat and consequently has a high psychological morbidity. Hypnotherapy has been shown to be effective in related conditions such as irritable bowel syndrome where its beneficial effects are long lasting. This study aimed to assess the efficacy of hypnotherapy in a selected group of patients with angina-like chest pain in whom coronary angiography was normal and oesophageal reflux was not contributory. Twenty eight patients fulfilling the entry criteria were randomised to receive, after a four week baseline period, either 12 sessions of hypnotherapy or supportive therapy plus placebo medication over a 17 week period. The primary outcome measure was global assessment of chest pain improvement. Secondary variables were a change in scores for quality of life, pain severity, pain frequency, anxiety, and depression, as well as any alteration in the use of medication. Twelve of 15 (80%) hypnotherapy patients compared with three of 13 (23%) controls experienced a global improvement in pain (p = 0.008) which was associated with a significantly greater reduction in pain intensity (p = 0.046) although not frequency. Hypnotherapy also resulted in a significantly greater improvement in overall well being in addition to a reduction in medication usage. There were no differences favouring hypnotherapy with respect to anxiety or depression scores. Hypnotherapy appears to have use in this highly selected group of NCCP patients and warrants further assessment in the broader context of this disorder.

  4. Diagnostic value of exercise-induced changes in circulating high sensitive troponin T in stable chest pain patients

    DEFF Research Database (Denmark)

    Mouridsen, Mette Rauhe; Nielsen, Olav Wendelboe; Pedersen, Ole Dyg

    2013-01-01

    We investigated the diagnostic value of exercise-induced increase in cardiac Troponin T (cTnT) in stable chest pain subjects.......We investigated the diagnostic value of exercise-induced increase in cardiac Troponin T (cTnT) in stable chest pain subjects....

  5. Fast assessment and management of chest pain without ST-elevation in the pre-hospital gateway : rationale and design

    NARCIS (Netherlands)

    Ishak, Maycel; Ali, Danish; Fokkert, Marion J; Slingerland, Robbert J; Dikkeschei, Bert; Tolsma, Rudolf T; Lichtveld, Rob A; Bruins, Wendy; Boomars, René; Bruheim, Kim; van Eenennaam, Fred; Timmers, Leo; Voskuil, Michiel; Doevendans, Pieter A; Mosterd, Arend; Hoes, Arno W; ten Berg, Jurriën M; van 't Hof, Arnoud W J

    BACKGROUND: For chest pain patients without ST-segment elevation in the pre-hospital setting, current clinical guidelines merely offer in-hospital risk stratification and management, as opposed to chest pain patients with ST-segment elevation for whom there is a straightforward pre-hospital strategy

  6. Targeting A-type K(+) channels in primary sensory neurons for bone cancer pain in a rat model.

    Science.gov (United States)

    Duan, Kai-Zheng; Xu, Qian; Zhang, Xiao-Meng; Zhao, Zhi-Qi; Mei, Yan-Ai; Zhang, Yu-Qiu

    2012-03-01

    Cancer pain is one of the most severe types of chronic pain, and the most common cancer pain is bone cancer pain. The treatment of bone cancer pain remains a clinical challenge. Here, we report firstly that A-type K(+) channels in dorsal root ganglion (DRG) are involved in the neuropathy of rat bone cancer pain and are a new target for diclofenac, a nonsteroidal anti-inflammatory drug that can be used for therapy for this distinct pain. There are dynamically functional changes of the A-type K(+) channels in DRG neurons during bone cancer pain. The A-type K(+) currents that mainly express in isolectin B4-positive small DRG neurons are increased on post-tumor day 14 (PTD 14), then faded but still remained at a higher level on PTD 21. Correspondingly, the expression levels of A-type K(+) channel Kv1.4, Kv3.4, and Kv4.3 showed time-dependent changes during bone cancer pain. Diclofenac enhances A-type K(+) currents in the DRG neurons and attenuates bone cancer pain in a dose-dependent manner. The analgesic effect of diclofenac can be reversed or prevented by A-type K(+) channel blocker 4-AP or pandinotoxin-Kα, also by siRNA targeted against rat Kv1.4 or Kv4.3. Repeated diclofenac administration decreased soft tissue swelling adjacent to the tumor and attenuated bone destruction. These results indicate that peripheral A-type K(+) channels were involved in the neuropathy of rat bone cancer pain. Targeting A-type K(+) channels in primary sensory neurons may provide a novel mechanism-based therapeutic strategy for bone cancer pain. Copyright © 2011 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

  7. Accuracy of gestalt perception of acute chest pain in predicting coronary artery disease.

    Science.gov (United States)

    das Virgens, Cláudio Marcelo Bittencourt; Lemos, Laudenor; Noya-Rabelo, Márcia; Carvalhal, Manuela Campelo; Cerqueira Junior, Antônio Maurício Dos Santos; Lopes, Fernanda Oliveira de Andrade; de Sá, Nicole Cruz; Suerdieck, Jéssica Gonzalez; de Souza, Thiago Menezes Barbosa; Correia, Vitor Calixto de Almeida; Sodré, Gabriella Sant'Ana; da Silva, André Barcelos; Alexandre, Felipe Kalil Beirão; Ferreira, Felipe Rodrigues Marques; Correia, Luís Cláudio Lemos

    2017-03-26

    To test accuracy and reproducibility of gestalt to predict obstructive coronary artery disease (CAD) in patients with acute chest pain. We studied individuals who were consecutively admitted to our Chest Pain Unit. At admission, investigators performed a standardized interview and recorded 14 chest pain features. Based on these features, a cardiologist who was blind to other clinical characteristics made unstructured judgment of CAD probability, both numerically and categorically. As the reference standard for testing the accuracy of gestalt, angiography was required to rule-in CAD, while either angiography or non-invasive test could be used to rule-out. In order to assess reproducibility, a second cardiologist did the same procedure. In a sample of 330 patients, the prevalence of obstructive CAD was 48%. Gestalt's numerical probability was associated with CAD, but the area under the curve of 0.61 (95%CI: 0.55-0.67) indicated low level of accuracy. Accordingly, categorical definition of typical chest pain had a sensitivity of 48% (95%CI: 40%-55%) and specificity of 66% (95%CI: 59%-73%), yielding a negligible positive likelihood ratio of 1.4 (95%CI: 0.65-2.0) and negative likelihood ratio of 0.79 (95%CI: 0.62-1.02). Agreement between the two cardiologists was poor in the numerical classification (95% limits of agreement = -71% to 51%) and categorical definition of typical pain (Kappa = 0.29; 95%CI: 0.21-0.37). Clinical judgment based on a combination of chest pain features is neither accurate nor reproducible in predicting obstructive CAD in the acute setting.

  8. Chest Pain and Sudden-Onset Paraplegia at the Emergency Department: An Uncommon Presentation.

    Science.gov (United States)

    Chiu, Feng Han; Tsai, Shih Hung; Ho, Cheng Hsuan

    2017-06-29

    BACKGROUND Coarctation of the aorta is characterized by narrowing of the descending aorta. The narrowing typically is at the isthmus, the segment just distal to the left subclavian artery. Adults with undiagnosed aortic coarctation are asymptomatic or may present with nonspecific hypertension. We present a case that highlights the uncommon complication of aortic coarctation with spinal compression syndrome. CASE REPORT A 45-year-old male presented to the emergency department (ED) with acute-onset chest pain; he experienced urinary incontinence and bilateral lower limb weakness during his ED visit. Chest CT showed coarctation of the aorta and MRI of the spine showed an epidural nodular lesion. He received emergency aortic stent placement surgery, followed by successful hematoma removal and was discharged with residual lower-extremity paraplegia. CONCLUSIONS Chest pain with lower limb paraplegia presentation should consider aortic coarctation complicated with spinal hemorrhage as a possible cause.

  9. Soluble Urokinase Plasminogen Activator Receptor for Risk Prediction in Patients Admitted with Acute Chest Pain

    DEFF Research Database (Denmark)

    Lyngbæk, Stig; Andersson, Charlotte; Marott, Jacob L

    2013-01-01

    Plasma concentrations of soluble urokinase plasminogen activator receptor (suPAR) predict mortality in several clinical settings, but the long-term prognostic importance of suPAR in chest pain patients admitted on suspicion of non-ST-segment elevation acute coronary syndrome (NSTEACS) is uncertain....

  10. A prospective validation of the HEART score for chest pain patients at the emergency department

    NARCIS (Netherlands)

    Backus, B. E.; Six, A. J.; Kelder, J. C.; Bosschaert, M. A. R.; Mast, E. G.; Mosterd, A.; Veldkamp, R. F.; Wardeh, A. J.; Tio, R.; Braam, R.; Monnink, S. H. J.; van Tooren, R.; Mast, T. P.; van den Akker, F.; Cramer, M. J. M.; Poldervaart, J. M.; Hoes, A. W.; Doevendans, P. A.

    2013-01-01

    Background: The focus of the diagnostic process in chest pain patients at the emergency department is to identify both low and high risk patients for an acute coronary syndrome (ACS). The HEART score was designed to facilitate this process. This study is a prospective validation of the HEART score.

  11. Elevated troponin levels and typical chest pain: Is always acute coronary syndrome?

    Directory of Open Access Journals (Sweden)

    Altug Osken

    2016-01-01

    Full Text Available Aortic dissection is a fatal disease that must be considered in the differential diagnosis of chest pain. If the diagnosis cannot be made in early period, mortality is very high. Here, we present a case of aortic dissection, clinically mimicking acute coronary syndrome.

  12. An Evaluation of the Ability of Navy Hospital Corpsmen to Collect Chest Pain Data from Patients

    Science.gov (United States)

    1984-01-11

    compare left to right aides; rhonchi - continuous musical sounds: rales - discrete, non-continuous sounds; decreased - on© side markedly...Procedure Ail corpsmen received 2 hours Of didactic instruction in the use of the chest pain datasheet. This included instruction in the

  13. Atherosclerotic plaque burden in cocaine users with acute chest pain : Analysis by coronary computed tomography angiography

    NARCIS (Netherlands)

    Ebersberger, Ullrich; Sudarski, Sonja; Schoepf, U. Joseph; Bamberg, Fabian; Tricarico, Francesco; Apfaltrer, Paul; Blanke, Philipp; Schindler, Andreas; Makowski, Marcus R.; Headden, Gary F.; Leber, Alexander W.; Hoffmann, Ellen; Vliegenthart, Rozemarijn

    Chest pain associated with cocaine use represents an increasing problem in the emergency department (ED). Cocaine use has been linked to the acute coronary syndrome (ACS) and acute myocardial infarction (AMI). We used coronary computed tomography angiography (cCTA) to evaluate the prevalence,

  14. Diagnosis and treatment of musculoskeletal chest pain: design of a multi-purpose trial

    DEFF Research Database (Denmark)

    Stochkendahl, Mette J; Christensen, Henrik W; Vach, Werner

    2008-01-01

    will be elucidated and reconstructed using the CART method. Out of the 300 patients 120 intended patients with suspected musculoskeletal chest pain will be randomized into one of two groups: a) a course of chiropractic treatment (therapy group) of up to ten treatment sessions focusing on high velocity, low amplitude...

  15. Implementing change: evaluating the Accelerated Chest pain Risk Evaluation (ACRE) project.

    Science.gov (United States)

    Parsonage, William A; Milburn, Tanya; Ashover, Sarah; Skoien, Wade; Greenslade, Jaimi H; McCormack, Louise; Cullen, Louise

    2017-08-04

    To evaluate hospital length of stay (LOS) and admission rates before and after implementation of an evidence-based, accelerated diagnostic protocol (ADP) for patients presenting to emergency departments (EDs) with chest pain. Quasi-experimental design, with interrupted time series analysis for the period October 2013 - November 2015. Setting, participants: Adults presenting with chest pain to EDs of 16 public hospitals in Queensland. Implementation of the ADP by structured clinical re-design. Primary outcome: hospital LOS. ED LOS, hospital admission rate, proportion of patients identified as being at low risk of an acute coronary syndrome (ACS). Outcomes were recorded for 30 769 patients presenting before and 23 699 presenting after implementation of the ADP. Following implementation, 21.3% of patients were identified by the ADP as being at low risk for an ACS. Following implementation of the ADP, mean hospital LOS fell from 57.7 to 47.3 hours (rate ratio [RR], 0.82; 95% CI, 0.74-0.91) and mean ED LOS for all patients presenting with chest pain fell from 292 to 256 minutes (RR, 0.80; 95% CI, 0.72-0.89). The hospital admission rate fell from 68.3% (95% CI, 59.3-78.5%) to 54.9% (95% CI, 44.7-67.6%; P patients with chest pain was feasible across a range of hospital types, and achieved a substantial release of health service capacity through reductions in hospital admissions and ED LOS.

  16. Best Clinical Practice: Current Controversies in Evaluation of Low-Risk Chest Pain-Part 1.

    Science.gov (United States)

    Long, Brit; Koyfman, Alex

    2016-12-01

    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. 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). Chest pain accounts for 10 million ED visits in the United States annually. Many patients are at low risk for a major cardiac adverse event (MACE). With negative troponin and nonischemic electrocardiogram (ECG), the risk of MACE and myocardial infarction (MI) is evaluation in low- to intermediate-risk patients within 72 h. These modalities add little to further risk stratification. These evaluations do not appropriately risk stratify patients who are already at low risk, nor do they diagnose acute MI. CCTA is an anatomic evaluation of the coronary vasculature with literature support to decrease ED length of stay, though it is associated with downstream testing. Literature is controversial concerning further risk stratification in already low-risk patients. With nonischemic ECG and negative cardiac biomarker, the risk of ACS approaches chest pain patients is controversial. These tests may allow prognostication but do not predict ACS risk beyond ECG and troponin. CCTA may be useful for intermediate-risk patients, though further studies are required. Copyright © 2016 Elsevier Inc. All rights reserved.

  17. The value of clinical and laboratory diagnostics for chest pain patients at the emergency department

    NARCIS (Netherlands)

    Jellema, Laurens-Jan C.; Backus, Barbra E.; Six, A. Jacob; Braam, Richard; Groenemeijer, Bjorn; van der Zaag-Loonen, Hester J.; Tio, Rene; van Suijlen, Jeroen D. E.

    Background: The focus during the diagnostic process for patients with acute chest pain is to discriminate patients who can be safely discharged from those who are at risk for an acute coronary syndrome (ACS). In this study the diagnostic value of the clinical examination is compared with laboratory

  18. Acute chest pain in contingency operations at a Role 1 facility.

    Science.gov (United States)

    Barker, Steven; White, S; Bailey, K; Rees, P

    2015-09-01

    Acute chest pain is a common medical presenting complaint which can be difficult to diagnose and treat outside of a fully equipped emergency department. In future contingency operations the number of personnel deployed is likely be smaller, with the medical cover appropriate for the population at risk, such that the deployed medical facilities will be smaller than the Role 3 unit with which we have become familiar over the last 10 years of operations in Afghanistan. Physician involvement in these smaller medical facilities is crucial to maintain clinical effect when dealing with patients presenting with disease and non-battle injury, which can often make up the majority of deployed healthcare work. Patients presenting with chest pain require rapid assessment and stabilisation prior to medical evacuation to a suitable definitive care unit. This article focuses on emergency acute chest pain presentations, non-cardiac causes of chest pain, risk reduction and how contingency will affect patient care. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

  19. Coronary Computed Tomography Angiography in the Assessment of Acute Chest Pain in the Emergency Room

    Energy Technology Data Exchange (ETDEWEB)

    Prazeres, Carlos Eduardo Elias dos; Cury, Roberto Caldeira; Carneiro, Adriano Camargo de Castro [Hospital do Coração - HCor, Associação do Sanatório Sírio, São Paulo, SP (Brazil); Rochitte, Carlos Eduardo, E-mail: rochitte@cardiol.br [Hospital do Coração - HCor, Associação do Sanatório Sírio, São Paulo, SP (Brazil); Instituto do Coração - InCor - HCFMUSP, São Paulo, SP (Brazil)

    2013-12-15

    The coronary computed tomography angiography has recently emerged as an accurate diagnostic tool in the evaluation of coronary artery disease, providing diagnostic and prognostic data that correlate directly with the data provided by invasive coronary angiography. The association of recent technological developments has allowed improved temporal resolution and better spatial coverage of the cardiac volume with significant reduction in radiation dose, and with the crucial need for more effective protocols of risk stratification of patients with chest pain in the emergency room, recent evaluation of the computed tomography coronary angiography has been performed in the setting of acute chest pain, as about two thirds of invasive coronary angiographies show no significantly obstructive coronary artery disease. In daily practice, without the use of more efficient technologies, such as coronary angiography by computed tomography, safe and efficient stratification of patients with acute chest pain remains a challenge to the medical team in the emergency room. Recently, several studies, including three randomized trials, showed favorable results with the use of this technology in the emergency department for patients with low to intermediate likelihood of coronary artery disease. In this review, we show data resulting from coronary angiography by computed tomography in risk stratification of patients with chest pain in the emergency room, its diagnostic value, prognosis and cost-effectiveness and a critical analysis of recently published multicenter studies.

  20. Coronary computed tomography angiography in the assessment of acute chest pain in the emergency room.

    Science.gov (United States)

    Prazeres, Carlos Eduardo Elias dos; Cury, Roberto Caldeira; Carneiro, Adriano Camargo de Castro; Rochitte, Carlos Eduardo

    2013-12-01

    The coronary computed tomography angiography has recently emerged as an accurate diagnostic tool in the evaluation of coronary artery disease, providing diagnostic and prognostic data that correlate directly with the data provided by invasive coronary angiography. The association of recent technological developments has allowed improved temporal resolution and better spatial coverage of the cardiac volume with significant reduction in radiation dose, and with the crucial need for more effective protocols of risk stratification of patients with chest pain in the emergency room, recent evaluation of the computed tomography coronary angiography has been performed in the setting of acute chest pain, as about two thirds of invasive coronary angiographies show no significantly obstructive coronary artery disease. In daily practice, without the use of more efficient technologies, such as coronary angiography by computed tomography, safe and efficient stratification of patients with acute chest pain remains a challenge to the medical team in the emergency room. Recently, several studies, including three randomized trials, showed favorable results with the use of this technology in the emergency department for patients with low to intermediate likelihood of coronary artery disease. In this review, we show data resulting from coronary angiography by computed tomography in risk stratification of patients with chest pain in the emergency room, its diagnostic value, prognosis and cost-effectiveness and a critical analysis of recently published multicenter studies.

  1. Non-cardiac Chest Pain: A Review for the Consultation-Liaison Psychiatrist.

    Science.gov (United States)

    Campbell, Kirsti A; Madva, Elizabeth N; Villegas, Ana C; Beale, Eleanor E; Beach, Scott R; Wasfy, Jason H; Albanese, Ariana M; Huffman, Jeff C

    Patients presenting with chest pain to general practice or emergency providers represent a unique challenge, as the differential is broad and varies widely in acuity. Importantly, most cases of chest pain in both acute and general practice settings are ultimately found to be non-cardiac in origin, and a substantial proportion of patients experiencing non-cardiac chest pain (NCCP) suffer significant disability. In light of emerging evidence that mental health providers can serve a key role in the care of patients with NCCP, knowledge of the differential diagnosis, psychiatric co-morbidities, and therapeutic techniques for NCCP would be of great use to both consultation-liaison (C-L) psychiatrists and other mental health providers. We reviewed prior published work on (1) the appropriate medical workup of the acute presentation of chest pain, (2) the relevant medical and psychiatric differential diagnosis for chest pain determined to be non-cardiac in origin, (3) the management of related conditions in psychosomatic medicine, and (4) management strategies for patients with NCCP. We identified key differential diagnostic and therapeutic considerations for psychosomatic medicine providers in 3 different clinical contexts: acute care in the emergency department, inpatient C-L psychiatry, and outpatient C-L psychiatry. We also identified several gaps in the literature surrounding the short-term and long-term management of NCCP in patients with psychiatric etiologies or co-morbid psychiatric conditions. Though some approaches to the care of patients with NCCP have been developed, more work is needed to determine the most effective management techniques for this unique and high-morbidity population. Copyright © 2017 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

  2. Chest pain presenting to the Emergency Department--to stratify risk with GRACE or TIMI?

    Science.gov (United States)

    Lyon, Richard; Morris, Andrew Conway; Caesar, David; Gray, Sarah; Gray, Alasdair

    2007-07-01

    There is a need to stratify risk rapidly in patients presenting to the Emergency Department (ED) with undifferentiated chest pain. The Global Registry of Acute Coronary Events (GRACE) and the Thrombolysis in Myocardial Infarction (TIMI) scoring systems predict outcome of adverse coronary events in patients admitted to specialist cardiac units. This study evaluates the relationship between GRACE score and outcome in patients presenting to the ED with undifferentiated chest pain and establishes whether GRACE is preferential to TIMI in stratifying risk in patients in the ED setting. Descriptive study of a consecutive sample of 1000 ED patients with undifferentiated chest pain presenting to Edinburgh Royal Infirmary, Scotland. GRACE and TIMI scores were calculated for each patient and outcomes noted at 30 days. Outcomes included ST and non-ST myocardial infarction, cardiac arrest, revascularisation, unstable angina with myocardial damage and all cause mortality at 30 days. Score and outcome were compared using receiver operator characteristic curves (AUC-ROC). The GRACE score stratifies risk accurately in patients presenting to the ED with undifferentiated chest pain (AUC-ROC 0.80 (95% CI 0.75-0.85), see Table 1). The TIMI score was found to be similarly accurate in stratifying risk in the study cohort with an AUC-ROC of 0.79 (95% CI 0.74-0.85). It was only possible to calculate a complete GRACE score in 76% (n=760) cases as not all the data variables were measured routinely in the ED. GRACE and TIMI are both effective in accurately stratifying risk in patients presenting to the ED with undifferentiated chest pain. The GRACE score is more complex than the TIMI score and in the ED setting TIMI may be the preferred scoring method.

  3. Prospective evaluation of outcomes among geriatric chest pain patients in an ED observation unit.

    Science.gov (United States)

    Madsen, Troy E; Fuller, Matthew; Hartsell, Sydney; Hamilton, David; Bledsoe, Joseph

    2016-02-01

    Because of concerns of high admission rates and adverse events in geriatric patients, hospitals may exclude this group from emergency department observation unit (EDOU) chest pain protocols. We sought to evaluate characteristics and outcomes of geriatric chest pain patients treated in an EDOU. We performed a prospective, observational study of chest pain patients admitted to our EDOU over a 36-month period. We recorded baseline demographics and risk factors as well as outcomes related to the EDOU stay. We performed 30-day follow-up using telephone contact and review of the electronic medical record. Over the 36-month study period, 1276 chest pain patients agreed to participate in the study. Two hundred seventy-six patients (21.6%) were 65 years and older. Geriatric patients in the EDOU were more likely to report a history of coronary artery disease than nongeriatric patients (27.1% vs 11.6%, Pgeriatric patients. The proportion of geriatric patients who experienced myocardial infarction, stent, or coronary artery bypass graft during the EDOU stay or follow-up period was 4.7% vs 2.7% for nongeriatric patients (P=.09). Inpatient admission rates were significantly higher for geriatric patients (15.6% vs 9.7%, P=.006). Similarly, geriatric patients had higher rates of cardiac catheterization than did nongeriatric patients (13.4% vs 7.9%, P=.005). Geriatric patients with chest pain may represent a higher-risk group for evaluation in the EDOU. In our experience, however, these patients were safely evaluated in the EDOU setting and their inpatient admission rate fell within generally accepted guidelines. Copyright © 2015 Elsevier Inc. All rights reserved.

  4. [Characteristics of pulmonary function in children with atypical asthma with chest tightness as chief complaint before and after bronchial provocation test].

    Science.gov (United States)

    Wei, Wen; Lv, Min; Zhang, Jian; Hua, Shan; Shang, Qi-Yun

    2015-07-01

    To investigate the characteristics of pulmonary function in children with atypical asthma with chest tightness as the chief complaint before and after a bronchial provocation test. This study included 34 children with atypical asthmas who underwent bronchial provocation test between January 2010 and December 2013. Thirty-four children with typical asthmas were selected as the control group. The pulmonary function of the atypical asthma group was examined before and after the bronchial provocation test and compared with that of the control group in the acute episode and remission stages. The forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), FEV1/FVC, peak expiratory flow, forced expiratory flow 25%, 50%, 75% (FEF25, FEF50, FEF75), and maximum mid-expiratory flow (MMEF75/25) in the atypical asthma group before the bronchial provocation test were (105±12)%, (104±12)%, (100±7)%, (88±13)%, (90±14)%, (81±17)%, (73±25)%, and (80±17)%, respectively; these functional indices were significantly higher than in the control group in the acute episode stage (P0.05). In addition, no significant difference in pulmonary indices was observed between the atypical asthma group after the bronchial provocation test and the control group in the acute episode stage (P>0.05), but functional indices above were significantly lower in the atypical asthma group after the bronchial provocation test than in the control group in the remission stage and the atypical asthma group before the bronchial provocation test (PBronchial provocation test is useful in the diagnosis of atypical asthma in children.

  5. Transtelephonic electrocardiography for managing out-of-hospital chest pain emergencies.

    Science.gov (United States)

    Barón-Esquivias, Gonzalo; Santana-Cabeza, Juan Jesús; Haro, Roberto; Núñez, Antonio; Pérez, Enrique; Martínez, Ángel; Martínez-Rubio, Antoni

    2011-01-01

    Some healthcare facilities lack professionals qualified to interpret electrocardiograms. We aimed to assess the usefulness of transtelephonic electrocardiography in combination with patients' clinical histories in the diagnosis and management of patients with acute chest pain in out-of-hospital healthcare facilities with personnel without expertise in cardiology or electrocardiography. Data from 506 consecutive patients (53.9 ± 16.2 years old) referred from 55 healthcare facilities without professionals specialized in cardiology or electrocardiography form the basis of analysis. Patients were classified into 2 groups according to the results of transtelephonic electrocardiography: (A) patients without electrocardiographic abnormalities (n = 445) and (B) patients who presented abnormalities suggesting a cardiac origin (n = 61) of the chest pain. The presence of risk factors was evaluated by multivariate analysis. The following risk factors were independent predictors of electrocardiographic abnormalities: male gender (P = .006), diabetes mellitus (P = .0001), and dyslipidemia (P = .001). The multivariate analysis yielded a high degree of specificity (99.6%). Follow-up visits confirmed the noncardiac origin of pain in 432 patients (97%) in group A and the cardiac origin of pain in 59 patients (97%) in group B. Transtelephonic electrocardiography combined with awareness of the risk factors of patients presenting with chest pain is useful for the diagnostic management of these patients in health care facilities without the means to interpret electrocardiograms. Copyright © 2011. Published by Elsevier Inc.

  6. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction.

    Science.gov (United States)

    Rubini Gimenez, Maria; Reiter, Miriam; Twerenbold, Raphael; Reichlin, Tobias; Wildi, Karin; Haaf, Philip; Wicki, Katharina; Zellweger, Christa; Hoeller, Rebeca; Moehring, Berit; Sou, Seoung Mann; Mueller, Mira; Denhaerynck, Kris; Meller, Bernadette; Stallone, Fabio; Henseler, Sarah; Bassetti, Stefano; Geigy, Nicolas; Osswald, Stefan; Mueller, Christian

    2014-02-01

    Whether sex-specific chest pain characteristics (CPCs) would allow physicians in the emergency department to differentiate women with acute myocardial infarction (AMI) from women with other causes of acute chest pain more accurately remains unknown. OBJECTIVE To improve the management of suspected AMI in women by exploring sex-specific CPCs. From April 21, 2006, through August 12, 2012, we enrolled 2475 consecutive patients (796 women and 1679 men) presenting with acute chest pain to 9 emergency departments in a prospective multicenter study. The final diagnosis of AMI was adjudicated by 2 independent cardiologists. Treatment of AMI in the emergency department. Sex-specific diagnostic performance of 34 predefined and uniformly recorded CPCs in the early diagnosis of AMI. Acute myocardial infarction was the adjudicated final diagnosis in 143 women (18.0%) and 369 men (22.0%). Although most CPCs were reported with similar frequency in women and men, several CPCs were reported more frequently in women (P pain duration (2-30 and >30 minutes) and dynamics (decreasing pain intensity). However, because their likelihood ratios were close to 1, the 3 CPCs did not seem clinically helpful. Similar results were obtained when examining combinations of CPCs (all interactions, P ≥ .05). Differences in the sex-specific diagnostic performance of CPCs are small and do not seem to support the use of women-specific CPCs in the early diagnosis of AMI. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00470587.

  7. The effect of streptokinase on chest pain in acute myocardial infarction

    DEFF Research Database (Denmark)

    Christensen, J H; Sørensen, H T; Rasmussen, S E

    1991-01-01

    Treatment with intravenous streptokinase is known to restore blood flow to the ischaemic myocardium in patients with acute myocardial infarction. However, little is known about its effect on chest pain. In a retrospective cohort study, 76 patients treated with streptokinase were compared to 76......, the median duration (3.5 h) of pain was reduced significantly in patients treated with streptokinase compared to patients not treated (24 h). We conclude that intravenous streptokinase given in the acute phase of myocardial infarction is effective in reducing the duration of cardiac chest pain....... patients not treated with streptokinase. All patients had acute myocardial infarction and less than 6 h of cardiac symptoms. Patients treated with streptokinase had a significantly lower need for nicomorphine (median 20 mg) than patients not treated with streptokinase (median 41 mg). Correspondingly...

  8. Another cause of chest pain: Staphylococcus aureus sternal osteomyelitis in an otherwise healthy adult

    Directory of Open Access Journals (Sweden)

    Vacek TP

    2014-09-01

    Full Text Available Thomas P Vacek, Shahnaz Rehman, Shipeng Yu, Ankush Moza, Ragheb Assaly Department of Internal Medicine, The University of Toledo Medical Center, Toledo OH, USAAbstract: Chest pain requires a detailed differential diagnosis with good history-taking skills to differentiate between cardiogenic and noncardiogenic causes. Moreover, when other symptoms such as fever and elevated white blood cell count are involved, it may be necessary to consider causes that include infectious sources. A 53-year-old female with no significant past medical history returned to the hospital with recurrent complaints of chest pain that was constant, substernal, reproducible, and exacerbated with inspiration and expiration. The chest pain was thought to be noncardiogenic, as electrocardiography did not demonstrate changes, and cardiac enzymes were found to be negative for signs of ischemia. The patient's blood cultures were analyzed from a previous admission and were shown to be positive for Staphylococcus aureus. The patient was started empirically on vancomycin, which was later switched to ceftriaxone as the bacteria were more sensitive to this antibiotic. A transthoracic echocardiogram did not demonstrate any vegetation or signs of endocarditis. There was a small right pleural effusion discovered on X-ray. Therefore, computed tomography as well as magnetic resonance imaging of the chest were performed, and showed osteomyelitis of the chest. The patient was continued on intravenous ceftriaxone for a total of 6 weeks. Tests for HIV, hepatitis A, B, and C were all found to be negative. The patient had no history of childhood illness, recurrent infections, or previous trauma to the chest, and had had no recent respiratory infections, pneumonia, or any underlying lung condition. Hence, her condition was thought to be a case of primary sternal osteomyelitis without known cause.Keywords: substernal, pleuritic, myocardial infarction, differential

  9. Chest pain in a 56 year old female with neglected primary hyperparathyroidism, Case Report

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    Gholamreza Mortazavimoghaddam

    2013-02-01

    Full Text Available Primary hyperparathyroidism is a benign disease and is most often diagnosed during routine calcium measurement. It would be astonishing if a patient is symptomatic, but the diagnosis is neglected. A 56-year-old woman was admitted with complaint of localized pain in the chest wall following a regular bending and straightening. CXR showed a mass like lesion of the chest wall on the left and also bulged margin of the rib on the right side of the rib cage. Chest CT images revealed a dumbbell-shaped lesion of the rib on the right and an intramedulary mass on the rib on the left rib cage (brown tumor. Isotope bone scan showed an increased uptake in the skull, pelvis, spine, and ribs suggestive of osteomalacia. The main laboratory findings were: Ca=13.6 mg/dl, phosphorus=2.6mg/dl and PTH=633.6pg/ml. Sestamibi parathyroid scan revealed thyroid adenoma in the right lower lobe. Pathological lab tests confirmed parathyroid adenoma. Therefore, the patient was operated on. Four weeks after surgery, PTH level was 20pg/ml. Although most cases of hyperparathyroidism are patients with asymptomatic hypercalcaemia, it is important to have a good insight into diagnosing patients with localized and unexplained bone pain particularly because the pain may be felt in uncommon sites like the chest cavity.

  10. Initial experience with a chest pain protocol using 320-slice volume MDCT

    Energy Technology Data Exchange (ETDEWEB)

    Hein, Patrick A.; Romano, Valentina C.; Lembcke, Alexander; May, Juliane; Rogalla, Patrik [Charite - Universitaetsmedizin, Institut fuer Radiologie, Charite Campus Mitte, Berlin (Germany)

    2009-05-15

    We sought to determine the feasibility and image quality of 320-slice volume computed tomography (CT) angiography for the evaluation of patients with acute chest pain. Thirty consecutive patients (11 female, 19 male, mean age 63.2 {+-} 14.2 years) with noncritical, acute chest pain underwent 320-slice CT using a protocol consisting of a nonspiral, nongated CT of the entire chest, followed by a nonspiral, electrocardiography-gated CT study of the heart. Data were acquired following a biphasic intravenous injection of 90 ml iodinated contrast agent. Vessel attenuation values of different thoracic vascular territories were recorded, and image quality scored on a five-point scale by two readers. Mean attenuation was 467 {+-} 69 HU in the ascending aorta, 334 {+-} 52 HU in the aortic arch, 455 {+-} 71 HU in the descending aorta, 492 {+-} 94 HU in the pulmonary trunk, and 416 {+-} 63 HU and 436 {+-} 62 HU in the right and left coronary artery, respectively. Radiation exposure estimates ranged between 7 and 14 mSv. The CT protocol investigated enabled imaging of the thoracic aorta, coronary and pulmonary arteries with an excellent diagnostic quality for chest pain triage in all patients. This result was achieved with less contrast material and reduced radiation exposure compared with previously investigated imaging protocols. (orig.)

  11. A 26-year-old man with dyspnea and chest pain

    Directory of Open Access Journals (Sweden)

    Saurabh Mittal

    2017-01-01

    Full Text Available A 26-year-old smoker male presented with a history of sudden onset dyspnea and right-sided chest pain. Chest radiograph revealed large right-sided pneumothorax which was managed with tube thoracostomy. High-resolution computed tomography thorax revealed multiple lung cysts, and for a definite diagnosis, a video-assisted thoracoscopic surgery-guided lung biopsy was performed followed by pleurodesis. This clinicopathologic conference discusses the clinical and radiological differential diagnoses, utility of lung biopsy, and management options for patients with such a clinical presentation.

  12. A 26-year-old man with dyspnea and chest pain.

    Science.gov (United States)

    Mittal, Saurabh; Jain, Akanksha; Arava, Sudheer; Hadda, Vijay; Mohan, Anant; Guleria, Randeep; Madan, Karan

    2017-01-01

    A 26-year-old smoker male presented with a history of sudden onset dyspnea and right-sided chest pain. Chest radiograph revealed large right-sided pneumothorax which was managed with tube thoracostomy. High-resolution computed tomography thorax revealed multiple lung cysts, and for a definite diagnosis, a video-assisted thoracoscopic surgery-guided lung biopsy was performed followed by pleurodesis. This clinicopathologic conference discusses the clinical and radiological differential diagnoses, utility of lung biopsy, and management options for patients with such a clinical presentation.

  13. Pontine Infarct Presenting with Atypical Dental Pain: A Case Report

    OpenAIRE

    Goel, Rajat; Kumar, Sanjeev; Panwar, Ajay; Singh, Abhishek B

    2015-01-01

    Orofacial pain’ most commonly occurs due to dental causes like caries, gingivitis or periodontitis. Other common causes of ‘orofacial pain’ are sinusitis, temporomandibular joint(TMJ) dysfunction, otitis externa, tension headache and migraine. In some patients, the etiology of ‘orofacial pain’ remains undetected despite optimal evaluation. A few patients in the practice of clinical dentistry presents with dental pain without any identifiable dental etiology. Such patients are classified under...

  14. Design and implementation of a stand-alone chest pain evaluation center within an academic emergency department.

    Science.gov (United States)

    Winchester, David E; Stomp, Dhane; Shifrin, Roger Y; Jois, Preeti

    2012-09-01

    Chest pain is a common presenting symptom for emergency department (ED) patients; however, a thorough cardiac evaluation can be difficult to complete within the ED setting. Implementation of a stand-alone unit for the evaluation of chest pain may improve care for patients with chest pain. We designed a protocol for identifying patients without an acute coronary syndrome and with low-to-intermediate likelihood of obstructive coronary artery disease (CAD). These patients were monitored in a stand-alone chest pain evaluation center (CPEC) staffed with a small group of providers and tested for CAD, if necessary. In the first 6 weeks of operation, 181 patients were evaluated in the CPEC. The prevalence of CAD risk factors was low. Of the 181 patients, 159 (88%) were discharged home and 22 (12%) required admission to the hospital for further care. We compared the number of chest pain evaluations and admissions for first 6 weeks of operation to the same 6-week period from the 2 previous years. Whereas ED chest pain evaluations increased 66% over the 2-year time frame, the proportion admitted to the hospital decreased from 53% to 42% (P evaluation of chest pain in patients without acute coronary syndrome and with low-to-intermediate likelihood of obstructive CAD can result in the significant majority of patients being discharged from the ED. Creation of a stand-alone CPEC in an academic hospital was associated with a significant reduction in hospital admissions.

  15. Prevalence and Overlap of Noncardiac Conditions in the Evaluation of Low-risk Acute Chest Pain Patients.

    Science.gov (United States)

    Al-Ani, Mohammad; Winchester, David E

    2015-09-01

    When patients present to the emergency department with a complaint concerning for heart disease, this often becomes the primary focus of their evaluation. While patients with noncardiac causes of chest pain outnumber those with cardiac causes, noncardiac etiologies are frequently overlooked. We investigated symptoms and noncardiac conditions in a cohort of patients with chest pain at low risk of cardiac disease. We analyzed data from a prospective registry of patients who were evaluated in our chest pain evaluation center. Registry participants completed standardized and validated instruments for depression (by Patient Health Questionnaire PHQ-9), anxiety (by Generalized Anxiety Disorder GAD-7), and Gastroesophageal Reflux Disorder (GERD; by GERD Symptom Frequency Questionnaire). Chest pain characteristics were recorded; severity was reported on a 10-point scale. A total of 195 patients were included in the investigation. Using the instruments noted above, the prevalence of depression was 34%, anxiety was 30%, and GERD was 44%, each of at least moderate severity. 32.5% of patients had 2 or more conditions. The median for the severity of angina was 7/10 and the number of episodes over the preceding week was 2, respectively. Severity of angina was associated with PHQ-9 (r = 0.238; P acute chest pain patients, depression, anxiety, and GERD were common, substantial overlap was observed. The severity of these noncardiac causes of chest pain causes correlated with the self-reported severity and frequency of angina, but weakly. These conditions should be part of a comprehensive plan of care for chest pain management.

  16. Medic - Chest Pain: A Decision Support Program for the Management of Acute Chest Pain (User’s Manual)

    Science.gov (United States)

    1989-10-05

    their complaint. f) Patients with disorders that present with epigastric pain such as gastritis , peptic ulcer, pancreatitis, and cholelithiasis may...of bacterial pneumonia. 3. TREUMENT OF PNEICNIA The treatment of pneumonia consists of bed rest, hydration, adequate nutrition , an antipyretic, an

  17. Conditioned pain modulation and situational pain catastrophizing as preoperative predictors of pain following chest wall surgery: a prospective observational cohort study.

    Science.gov (United States)

    Grosen, Kasper; Vase, Lene; Pilegaard, Hans K; Pfeiffer-Jensen, Mogens; Drewes, Asbjørn M

    2014-01-01

    Variability in patients' postoperative pain experience and response to treatment challenges effective pain management. Variability in pain reflects individual differences in inhibitory pain modulation and psychological sensitivity, which in turn may be clinically relevant for the disposition to acquire pain. The aim of this study was to investigate the effects of conditioned pain modulation and situational pain catastrophizing on postoperative pain and pain persistency. Preoperatively, 42 healthy males undergoing funnel chest surgery completed the Spielberger's State-Trait Anxiety Inventory and Beck's Depression Inventory before undergoing a sequential conditioned pain modulation paradigm. Subsequently, the Pain Catastrophizing Scale was introduced and patients were instructed to reference the conditioning pain while answering. Ratings of movement-evoked pain and consumption of morphine equivalents were obtained during postoperative days 2-5. Pain was reevaluated at six months postoperatively. Patients reporting persistent pain at six months follow-up (n = 15) were not significantly different from pain-free patients (n = 16) concerning preoperative conditioned pain modulation response (Z = 1.0, P = 0.3) or level of catastrophizing (Z = 0.4, P = 1.0). In the acute postoperative phase, situational pain catastrophizing predicted movement-evoked pain, independently of anxiety and depression (β = 1.0, P = 0.007) whereas conditioned pain modulation predicted morphine consumption (β = -0.005, P = 0.001). Preoperative conditioned pain modulation and situational pain catastrophizing were not associated with the development of persistent postoperative pain following funnel chest repair. Secondary outcome analyses indicated that conditioned pain modulation predicted morphine consumption and situational pain catastrophizing predicted movement-evoked pain intensity in the acute postoperative phase. These findings may have important

  18. Conditioned pain modulation and situational pain catastrophizing as preoperative predictors of pain following chest wall surgery: a prospective observational cohort study.

    Directory of Open Access Journals (Sweden)

    Kasper Grosen

    Full Text Available Variability in patients' postoperative pain experience and response to treatment challenges effective pain management. Variability in pain reflects individual differences in inhibitory pain modulation and psychological sensitivity, which in turn may be clinically relevant for the disposition to acquire pain. The aim of this study was to investigate the effects of conditioned pain modulation and situational pain catastrophizing on postoperative pain and pain persistency.Preoperatively, 42 healthy males undergoing funnel chest surgery completed the Spielberger's State-Trait Anxiety Inventory and Beck's Depression Inventory before undergoing a sequential conditioned pain modulation paradigm. Subsequently, the Pain Catastrophizing Scale was introduced and patients were instructed to reference the conditioning pain while answering. Ratings of movement-evoked pain and consumption of morphine equivalents were obtained during postoperative days 2-5. Pain was reevaluated at six months postoperatively.Patients reporting persistent pain at six months follow-up (n = 15 were not significantly different from pain-free patients (n = 16 concerning preoperative conditioned pain modulation response (Z = 1.0, P = 0.3 or level of catastrophizing (Z = 0.4, P = 1.0. In the acute postoperative phase, situational pain catastrophizing predicted movement-evoked pain, independently of anxiety and depression (β = 1.0, P = 0.007 whereas conditioned pain modulation predicted morphine consumption (β = -0.005, P = 0.001.Preoperative conditioned pain modulation and situational pain catastrophizing were not associated with the development of persistent postoperative pain following funnel chest repair. Secondary outcome analyses indicated that conditioned pain modulation predicted morphine consumption and situational pain catastrophizing predicted movement-evoked pain intensity in the acute postoperative phase. These findings may have

  19. The new Vancouver Chest Pain Rule using troponin as the only biomarker: an external validation study.

    Science.gov (United States)

    Cullen, Louise; Greenslade, Jaimi H; Than, Martin; Brown, Anthony F T; Hammett, Christopher J; Lamanna, Arvin; Flaws, Dylan F; Chu, Kevin; Fowles, Lindsay F; Parsonage, William A

    2014-02-01

    To externally evaluate the accuracy of the new Vancouver Chest Pain Rule and to assess the diagnostic accuracy using either sensitive or highly sensitive troponin assays. Prospectively collected data from 2 emergency departments (EDs) in Australia and New Zealand were analysed. Based on the new Vancouver Chest Pain Rule, low-risk patients were identified using electrocardiogram results, cardiac history, nitrate use, age, pain characteristics and troponin results at 2 hours after presentation. The primary outcome was 30-day diagnosis of acute coronary syndrome (ACS), including acute myocardial infarction, and unstable angina. Sensitivity, specificity, positive predictive values and negative predictive values were calculated to assess the accuracy of the new Vancouver Chest Pain Rule using either sensitive or highly sensitive troponin assay results. Of the 1635 patients, 20.4% had an ACS diagnosis at 30 days. Using the highly sensitive troponin assay, 212 (13.0%) patients were eligible for early discharge with 3 patients (1.4%) diagnosed with ACS. Sensitivity was 99.1% (95% CI 97.4-99.7), specificity was 16.1 (95% CI 14.2-18.2), positive predictive values was 23.3 (95% CI 21.1-25.5) and negative predictive values was 98.6 (95% CI 95.9-99.5). The diagnostic accuracy of the rule was similar using the sensitive troponin assay. The new Vancouver Chest Pain Rule should be used for the identification of low risk patients presenting to EDs with symptoms of possible ACS, and will reduce the proportion of patients requiring lengthy assessment; however we recommend further outpatient investigation for coronary artery disease in patients identified as low risk. © 2013.

  20. Treatment of non‐cardiac chest pain: a controlled trial of hypnotherapy

    Science.gov (United States)

    Jones, H; Cooper, P; Miller, V; Brooks, N; Whorwell, P J

    2006-01-01

    Background Non‐cardiac chest pain (NCCP) is an extremely debilitating condition of uncertain origin which is difficult to treat and consequently has a high psychological morbidity. Hypnotherapy has been shown to be effective in related conditions such as irritable bowel syndrome where its beneficial effects are long lasting. Aims This study aimed to assess the efficacy of hypnotherapy in a selected group of patients with angina‐like chest pain in whom coronary angiography was normal and oesophageal reflux was not contributory. Patients and methods Twenty eight patients fulfilling the entry criteria were randomised to receive, after a four week baseline period, either 12 sessions of hypnotherapy or supportive therapy plus placebo medication over a 17 week period. The primary outcome measure was global assessment of chest pain improvement. Secondary variables were a change in scores for quality of life, pain severity, pain frequency, anxiety, and depression, as well as any alteration in the use of medication. Results Twelve of 15 (80%) hypnotherapy patients compared with three of 13 (23%) controls experienced a global improvement in pain (p = 0.008) which was associated with a significantly greater reduction in pain intensity (p = 0.046) although not frequency. Hypnotherapy also resulted in a significantly greater improvement in overall well being in addition to a reduction in medication usage. There were no differences favouring hypnotherapy with respect to anxiety or depression scores. Conclusion Hypnotherapy appears to have use in this highly selected group of NCCP patients and warrants further assessment in the broader context of this disorder. PMID:16627548

  1. Prevalence and implications of severe anxiety in a prospective cohort of acute chest pain patients.

    Science.gov (United States)

    Schwarz, Julio; Prashad, Adesh; Winchester, David E

    2015-03-01

    Anxiety is a common condition which can manifest with symptoms of chest discomfort. Chest discomfort is one of the most common reasons to seek emergency medical care. We hypothesize that anxiety is highly prevalent, poorly diagnosed, and poorly treated in an acute care environment. We analyzed data from a prospective registry of chest pain patients with low to intermediate likelihood of acute coronary syndrome and coronary artery disease. Scores from the General Anxiety Disorder-7 questionnaire determined the prevalence of anxiety. Differences in presentation, evaluation, and 30-day outcomes were compared for subjects with and without severe anxiety. Of the 151 included subjects, severe anxiety was observed in 15%, moderate 14%, mild 30%, and 41% had no anxiety symptoms. Subjects with severe anxiety had similar baseline characteristics, cardiac risk factors, and symptoms to those without severe anxiety, except for the current use of tobacco (50.0% vs. 18.6%; P = 0.001). Anxiety was self-reported by 54.5% of subjects with severe anxiety and 27.3% were on antianxiety medications. Hospital admission (P = 0.888) and repeated emergency department visits within 30 days (P = 0.554) were not different between the 2 groups. Anxiety is common among patients seeking emergency evaluation of chest pain. Half of patients with severe anxiety were diagnosed and roughly one quarter were medically treated. Cardiac risk factors and symptoms are not different for patients with severe anxiety; these patients warrant a similar evaluation for heart disease as those patients without anxiety.

  2. Significance of an isolated new right bundle branch block in a patient with chest pain.

    Science.gov (United States)

    Gilliot, Geraldine; Monney, Pierre; Muller, Olivier; Hugli, Olivier

    2015-06-08

    Chest pain is a common presenting symptom in emergency departments, and a typical manifestation of acute myocardial infarction (AMI). Recognition of ECG changes in AMI is essential for timely diagnosis and treatment. Right bundle branch block (RBBB) may be an isolated sign of AMI, and was previously considered as a criterion for fibrinolytic therapy. Since the most recent European Society of Cardiology and American Heart Association guidelines in 2013, RBBB alone is no longer considered a diagnostic criterion of AMI, even if it occurs in the context of acute chest pain, as RBBB does not usually interfere with the interpretation of ST-segment alteration. Our case illustrates an acute septal myocardial infarction with an isolated RBBB, and thus the importance of recognising this pattern in order to permit timely diagnosis and treatment. 2015 BMJ Publishing Group Ltd.

  3. The role of urgent transthoracic echocardiography in the evaluation of patients presenting with acute chest pain.

    Science.gov (United States)

    Shah, Benoy Nalin; Ahmadvazir, Shahram; Pabla, Jatinder Singh; Zacharias, Kostas; Senior, Roxy

    2012-10-01

    Chest pain is one of the most frequent reasons for presentation to the Emergency Department. The possible causes of chest pain are numerous and diverse, but importantly, several conditions, such as acute coronary syndrome, pulmonary embolism and aortic dissection, require urgent management and, in some cases, may be life-threatening. In such situations, a prompt and accurate diagnosis is vital. Two-dimensional echocardiography is a safe, painless and rapid test that can be performed in the Emergency Department and ensure a correct diagnosis as well as identify other complications and help institute appropriate management strategies swiftly. We review the current indications for urgent echocardiography in this article, with reference to international management guidelines where available, when managing patients with suspected acute coronary syndrome, acute pulmonary embolism, acute aortic dissection, acute pericarditis and trauma. We also discuss the differences between comprehensive and FOcussed Cardiac UltraSound (FOCUS) echocardiography studies, along with the associated quality control and medicolegal implications.

  4. Coronary computed tomography angiography for the evaluation of patients with acute chest pain.

    Science.gov (United States)

    Rajani, R; Brum, R L; Preston, R; Carr-White, G; Berman, D S

    2011-12-01

    Acute chest pain is a common presenting complaint of patients attending emergency room departments. Despite this, it can often be challenging to completely exclude a diagnosis of acute coronary syndrome following an initial standard clinical and biochemical evaluation. As a result of this, patients are often admitted to hospital until the treating clinician is satisfied that this diagnosis can be excluded. This process imparts a significant health economic burden by not only increasing hospital bed occupancy rates but also by the unnecessary layering of diagnostic investigations. With the rapid advances in coronary computed tomography angiography (CTA), there has been considerable interest in whether coronary CTA may be a viable alternative to this current standard care. We review the current literature and supporting evidence for utilising coronary CTA in the evaluation of patients presenting with acute chest pain in terms of its diagnostic accuracy, safety, cost-effectiveness and prognostic implications. © 2011 Blackwell Publishing Ltd.

  5. Atypical hip pain: coexistence of femoroacetabular impingement (FAI) and osteoid osteoma.

    Science.gov (United States)

    Banga, Kamaljeet; Racano, Antonella; Ayeni, Olufemi R; Deheshi, Benjamin

    2015-05-01

    The objective of this article was to emphasize the importance of including less common causes of hip pain in a differential diagnosis, particularly when clinical and radiographic variables are atypical. This article presents the case of a 52-year-old patient with a history of progressive hip pain resulting from the coexistence of both a femoroacetabular impingement (FAI) and an intraarticular osteoid osteoma. The intraarticular osteoid osteoma was initially overlooked due to its unremarkable features on radiographic and resonance imaging. Consequently, the patient was surgically treated for FAI with only partial relief. An osteolytic nidus characteristic of osteoid osteoma was discovered only 1.5 years following surgery. The patient was subsequently treated for osteoid osteoma with anti-inflammatories, after which his pain began to resolve. The patient was completely pain free after 7 months. Level of evidence V.

  6. Mediastinal liposarcoma in a 30-year-old woman with dyspnea and chest pain

    Directory of Open Access Journals (Sweden)

    Ana Fernández-Tena, PhD

    2017-01-01

    Full Text Available Mediastinal liposarcoma (ML is a rare mesenchymal tumor, accounting for less than 1% of mediastinal tumors. They have a slow growth, so they may not give symptoms for a long time, until the tumor produces compression of close structures. The treatment of choice is surgery, which can be combined with chemo-radiotherapy. We present a case in which the diagnosis of a ML was made in a 30-year-old woman with dyspnea and chest pain.

  7. Chest Pain of Suspected Cardiac Origin: Current Evidence-based Recommendations for Prehospital Care

    Directory of Open Access Journals (Sweden)

    P. Brian Savino

    2015-12-01

    Full Text Available Introduction: In the United States, emergency medical services (EMS protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of chest pain of suspected cardiac origin and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California. Methods: We performed a literature review of the current evidence in the prehospital treatment of chest pain and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the chest pain protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were use of supplemental oxygen, aspirin, nitrates, opiates, 12-lead electrocardiogram (ECG, ST segment elevation myocardial infarction (STEMI regionalization systems, prehospital fibrinolysis and β-blockers. Results: The protocols varied widely in terms of medication and dosing choices, as well as listed contraindications to treatments. Every agency uses oxygen with 54% recommending titrated dosing. All agencies use aspirin (64% recommending 325mg, 24% recommending 162mg and 15% recommending either, as well as nitroglycerin and opiates (58% choosing morphine. Prehospital 12- Lead ECGs are used in 97% of agencies, and all but one agency has some form of regionalized care for their STEMI patients. No agency is currently employing prehospital fibrinolysis or β-blocker use. Conclusion: Protocols for chest pain of suspected cardiac origin vary widely across California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.

  8. Acute coronary syndrome among patients with chest pain: Prevalence, incidence and risk factors.

    Science.gov (United States)

    Baccouche, Houda; Belguith, Asma Sriha; Boubaker, Hamdi; Grissa, Mohamed Habib; Bouida, Wahid; Beltaief, Kaouthar; Sekma, Adel; Fredj, Nizar; Bzeouich, Nasri; Zina, Zied; Boukef, Riadh; Soltani, Mohamed; Nouira, Semir

    2016-07-01

    Urbanization and adoption of new diet and lifestyles had increased the cardiovascular risk factor (CVRF) rate and therefore, acute coronary syndrome (ACS) in developing countries such as Tunisia. We aimed at determining ACS prevalence among a sample of Tunisian patients with chest pain, at establishing the standardized incidence rate (SIR) of ACS, and at quantifying the relationship between ASC and CVRF in this population. We studied 3158 patients admitted to a chest pain unit for non-traumatic chest pain collected in Emergency Data from January 2012 to December 2014. For all patients, the data were collected using a standardized form. We performed univariate rather than multivariate logistic regression analyses to identify age and gender-related CVRF in ACS. Linear interpolation was used for curve estimation. 707 (22.3%) chest pain patients were classified as ACS. The age-SIR per 10(-5)personyear (PY) was 85.7; it was 112.6 in men and 45.3 in women. Eighty one percent of patient with ACS cumulated 2 CVRF and more. The highest odds ratio were 2.00 (95% CI 1.64-2.44) for diabetes and 1.81 (95% CI 1.50-2.18) for active smoking. ACS in elderly patients was significantly associated with active smoking (OR: 2.36), diabetes (OR: 1.72) and personal ACS history (OR: 1.71). We found a significant and very high linear relation between the number of CVRF and ACS odds ratio (R(2)=0.958). Our results showed that the incidence of ACS in a Tunisian population is not very different from what is observed in developed countries; with a close relation with CVRF especially diabetes and smoking. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

  9. Chest Pain as a presenting complaint in patients with acute myocardial infarction (AMI)

    OpenAIRE

    Malik, Muhammad Ajmal; Alam Khan, Shahzad; Safdar, Sohail; Taseer, Ijaz-Ul-Haque

    2013-01-01

    Objective: To study various characteristics of chest pain in acute myocardial infarction patients. Methodology: A total of 331 patients of AMI admitted at Cardiology unit Nishtar Hospital Multan and Chaudhry Pervez Elahi Institute of Cardiology Multan, irrespective of the age and gender, were included in this study. The study duration was one year starting from June 2011 to June 2012. Non-probability purposive sampling technique was used in this descriptive study. Informed consent to particip...

  10. Diagnostic yield of routine noninvasive cardiovascular testing in low-risk acute chest pain patients.

    Science.gov (United States)

    Winchester, David E; Brandt, John; Schmidt, Carla; Allen, Brandon; Payton, Thomas; Amsterdam, Ezra A

    2015-07-15

    Contemporary professional society recommendations for patients presenting to the emergency department with acute chest pain and low clinical risk encourage noninvasive testing for coronary artery disease (CAD) before, or shortly after, discharge from the emergency department. Recent reports indicate that a strategy of universal testing has a low diagnostic yield and may not be necessary. We examined data from a prospective cohort of patients who underwent evaluation of acute chest pain in our chest pain evaluation center (CPEC). Patients presenting with normal initial electrocardiogram and cardiac injury markers were eligible for observation and noninvasive testing for CAD in our CPEC. All patients were asked to participate in the prospective registry. The 213 subjects who consented were young, obese, and predominantly women (mean age 43.8 ± 12.5, mean body mass index of 30.8 ± 7, 64.8% women). Prevalence of diabetes was 10.3% (hypertension 37.1%, hyperlipidemia 17.8%, and current tobacco use 23.5%) Exercise treadmill testing was the primary method of evaluation (n = 104, 49%) followed by computed tomography coronary angiography (n = 58, 27%) and myocardial perfusion imaging (n = 20, 9%). Of 203 patients who underwent testing, 11 had abnormal test results, 4 of whom had obstructive CAD based on invasive coronary angiography. The positive predictive value for obstructive CAD after an abnormal test was 45.5%, and the overall diagnostic yield for obstructive CAD was 2.5%. In conclusion, in patients with acute chest pain evaluated in a CPEC, the yield of routine use of noninvasive testing for CAD was minimal and the positive predictive value of an abnormal test was low. Published by Elsevier Inc.

  11. Biomarkers after risk stratification in acute chest pain (from the BRIC Study).

    Science.gov (United States)

    Mathewkutty, Shiny; Sethi, Sanjum S; Aneja, Ashish; Shah, Kshitij; Iyengar, Rupa L; Hermann, Luke; Khakimov, Sayyar; Razzouk, Louai; Esquitin, Ricardo; Vedanthan, Rajesh; Benjamin, Terrie-Ann; Grace, Marie; Nisenbaum, Rosane; Ramanathan, Krishnan; Ramanathan, Lakshmi; Chesebro, James; Farkouh, Michael E

    2013-02-15

    Current models incompletely risk-stratify patients with acute chest pain. In this study, N-terminal pro-B-type natriuretic peptide and cystatin C were incorporated into a contemporary chest pain triage algorithm in a clinically stratified population to improve acute coronary syndrome discrimination. Adult patients with chest pain presenting without myocardial infarction (n = 382) were prospectively enrolled from 2008 to 2009. After clinical risk stratification, N-terminal pro-B-type natriuretic peptide and cystatin C were measured and standard care was performed. The primary end point was the result of a clinical stress test. The secondary end point was any major adverse cardiac event at 6 months. Associations were determined through multivariate stratified analyses. In the low-risk group, 76 of 78 patients with normal levels of the 2 biomarkers had normal stress test results (negative predictive value 97%). Normal biomarkers predicted normal stress test results with an odds ratio of 10.56 (p = 0.006). In contrast, 26 of 33 intermediate-risk patients with normal levels of the 2 biomarkers had normal stress test results (negative predictive value 79%). Biomarkers and stress test results were not associated in the intermediate-risk group (odds ratio 2.48, p = 0.09). There were 42 major adverse cardiac events in the overall cohort. No major adverse cardiac events occurred at 6 months in the low-risk subgroup that underwent stress testing. In conclusion, N-terminal pro-B-type natriuretic peptide and cystatin C levels predict the results of stress tests in low-risk patients with chest pain but should not be substituted for stress testing in intermediate-risk patients. There is potential for their use in the early discharge of low-risk patients after clinical risk stratification. Copyright © 2013 Elsevier Inc. All rights reserved.

  12. Cardiac computed tomography for the evaluation of the acute chest pain syndrome: state of the art.

    Science.gov (United States)

    Schlett, Christopher L; Hoffmann, Udo; Geisler, Tobias; Nikolaou, Konstantin; Bamberg, Fabian

    2015-03-01

    Coronary computed tomography angiography (CCTA) is recommended for the triage of acute chest pain in patients with a low-to-intermediate likelihood for acute coronary syndrome. Absence of coronary artery disease (CAD) confirmed by CCTA allows rapid emergency department discharge. This article shows that CCTA-based triage is as safe as traditional triage, reduces the hospital length of stay, and may provide cost-effective or even cost-saving care. Copyright © 2015 Elsevier Inc. All rights reserved.

  13. Bedside echo for chest pain: an algorithm for education and assessment

    Directory of Open Access Journals (Sweden)

    Amini R

    2016-05-01

    Full Text Available Richard Amini, Lori A Stolz, Jeffrey Z Kartchner, Matthew Thompson, Nicholas Stea, Nicolaus Hawbaker, Raj Joshi, Srikar Adhikari Department of Emergency Medicine, University of Arizona Medical Center, Tucson, AZ, USA Background: Goal-directed ultrasound protocols have been developed to facilitate efficiency, throughput, and patient care. Hands-on instruction and training workshops have been shown to positively impact ultrasound training.  Objectives: We describe a novel undifferentiated chest pain goal-directed ultrasound algorithm-focused education workshop for the purpose of enhancing emergency medicine resident training in ultrasound milestones competencies.  Methods: This was a cross-sectional study performed at an academic medical center. A novel goal-directed ultrasound algorithm was developed and implemented as a model for teaching and learning the sonographic approach to a patient with undifferentiated chest pain. This algorithm was incorporated into all components of the 1-day workshop: asynchronous learning, didactic lecture, case-based learning, and hands-on stations. Performance comparisons were made between postgraduate year (PGY levels.  Results: A total of 38 of the 40 (95% residents who attended the event participated in the chest pain objective standardized clinical exam, and 26 of the 40 (65% completed the entire questionnaire. The average number of ultrasounds performed by resident class year at the time of our study was as follows: 19 (standard deviation [SD]=19 PGY-1, 238 (SD=37 PGY-2, and 289 (SD=73 PGY-3. Performance on the knowledge-based questions improved between PGY-1 and PGY-3. The application of the novel algorithm was noted to be more prevalent among the PGY-1 class.  Conclusion: The 1-day algorithm-based ultrasound educational workshop was an engaging learning technique at our institution. Keywords: point-of care ultrasound, algorithm education, education, chest pain, bedside ultrasound, POCUS

  14. Myocardial bridging causing ischemia and recurrent chest pain: a case report

    Directory of Open Access Journals (Sweden)

    Abdou Mohamed

    2011-07-01

    Full Text Available Abstract Background Myocardial bridging is present when a segment of a major epicardial coronary artery runs intramurally through the myocardium. It usually has a benign prognosis, but in some cases myocardial ischemia, infarction and sudden cardiac death have been reported. We are here reporting a case of myocardial bridging which was complicated with recurrent chest pain and transient ST-segment elevation during exercise treadmill test. Case presentation A 40 year-old-man presented with recurrent retrosternal chest pain of 2 months duration. He had history of smoking and was obese, otherwise no physical abnormalities were detected by examination. Electrocardiogram and blood tests were normal apart from impaired glucose tolerance with elevated triglycerides and decreased level of high density lipoprotein cholesterol. While doing exercise treadmill test, the patient developed chest pain and significant ST-segment elevation in almost all precordial leads that persisted for about 15 minutes through recovery. We decided to admit the patient to the coronary care unit for further management and to perform coronary angiogram. Myocardial bridging was observed in the mid segment of the left anterior descending coronary artery. Medical treatment was decided. At one year follow up, our patient was healthy and had no cardiac complaints. In conclusion, myocardial bridging may predispose to coronary vasospasm that may leads to ischemic complications.

  15. Application of the TIMI risk score in ED patients with cocaine-associated chest pain.

    Science.gov (United States)

    Chase, Maureen; Brown, Aaron M; Robey, Jennifer L; Zogby, Kara E; Shofer, Frances S; Chmielewski, Lauren; Hollander, Judd E

    2007-11-01

    The TIMI risk score has been validated as a risk stratification tool in emergency department (ED) patients with potential acute coronary syndrome. The goal of this study was to assess its ability to predict adverse cardiovascular outcomes in cocaine-associated chest pain. This was a prospective cohort study of ED patients with chest pain with cocaine use. Data included demographics, medical history, and TIMI risk score. The main outcomes were acute myocardial infarction, revascularization, or death within 30 days of ED presentation. There were 261 patient visits. Patients were 43.2+8 years old, 73% male, 92% black, and 75% smokers. There were 33 patients with the composite outcome. The incidence of 30-day outcomes according to TIMI score is as follows: TIMI 0, 3.7% (95% CI, 0.1-8.3); TIMI 1, 13.2% (5.7-20.7); TIMI 2, 17.1% (4.3-29.8); TIMI 3, 21.4% (4.4-38.4); TIMI 4, 20.0% (0.1-43.6); TIMI 5/6, 50.0% (0.1-100). The TIMI risk score has no clinically useful predictive value in patients with cocaine-associated chest pain.

  16. Dual-source computed tomography in patients with acute chest pain: feasibility and image quality

    Energy Technology Data Exchange (ETDEWEB)

    Schertler, Thomas; Scheffel, Hans; Frauenfelder, Thomas; Desbiolles, Lotus; Leschka, Sebastian; Stolzmann, Paul; Marincek, Borut; Alkadhi, Hatem [University Hospital Zurich, Department of Medical Radiology, Institute of Diagnostic Radiology, Zurich (Switzerland); Seifert, Burkhardt [University of Zurich, Department of Biostatistics, Zurich (Switzerland); Flohr, Thomas G. [Computed Tomography CTE PA, Siemens Medical Solutions, Forchheim (Germany)

    2007-12-15

    The aim of this study was to determine the feasibility and image quality of dual-source computed tomography angiography (DSCTA) in patients with acute chest pain for the assessment of the lung, thoracic aorta, and for pulmonary and coronary arteries. Sixty consecutive patients (32 female, 28 male, mean age 58.1{+-}16.3 years) with acute chest pain underwent contrast-enhanced electrocardiography-gated DSCTA without prior beta-blocker administration. Vessel attenuation of different thoracic vascular territories was measured, and image quality was semi-quantitatively analyzed by two independent readers. Image quality of the thoracic aorta was diagnostic in all 60 patients, image quality of pulmonary arteries was diagnostic in 59, and image quality of coronary arteries was diagnostic in 58 patients. Pairwise intraindividual comparisons of attenuation values were small and ranged between 1{+-}6 HU comparing right and left coronary artery and 56{+-}9 HU comparing the pulmonary trunk and left ventricle. Mean attenuation was 291{+-}65 HU in the ascending aorta, 334{+-}93 HU in the pulmonary trunk, and 285{+-}66 HU and 268{+-}67 HU in the right and left coronary artery, respectively. DSCTA is feasible and provides diagnostic image quality of the thoracic aorta, pulmonary and coronary arteries in patients with acute chest pain. (orig.)

  17. Dolor en el pecho: Estrategia diagnóstica Chest pain: Diagnostic strategy

    Directory of Open Access Journals (Sweden)

    Jorge M. Otero Morales

    2006-02-01

    Full Text Available En este artículo se expone la estrategia diagnóstica a seguir ante un paciente con dolor en el pecho. Se hace énfasis en el diagnóstico semiográfico, anatómico y etiológico de este síntoma. En particular se expone la semiografía distintiva de los diferentes prototipos anátomo-clínicos de dolor en el pecho y el enfoque diagnóstico para resolver casos con dolor en el pecho de origen indeterminado. Por último, se hacen consideraciones éticas relacionadas con el manejo diagnóstico de este síntoma.The diagnostic strategy to be followed with a patient suffering from chest pain is exposed in this article. Emphasis is made on the semiographic, anatomical and etiological diagnosis of this symptom. In particular, the distinctive semiography of the different anatomicoclinical prototypes of chest pain and the diagnostic approach to resolve cases with chest pain of unknown origin are exposed. Finally, ethical considerations related to the diagnostic management of this symptom are made.

  18. Predictors of 30 ـ day Incidence of Coronary Artery Disease in Patients with Chest Pain

    Directory of Open Access Journals (Sweden)

    J Hassanzadeh

    2006-07-01

    Full Text Available Introduction & Objective: The previous investigations show that cardiovascular diseases, which are spreading all over our country, account for most health and social problems. The objective of this study was to determine the relation between demographic factors, medical history as well as para clinical factors and Coronary Artery Disease (CAD within a period of 30 days for patients with chest pain. Materials & Methods: This was a prospective cohort study. Patients referred to the emergency department of Tehran heart centre with a chief complaint of chest pain without ST ـ segment elevation were followed for 30 days. The outcome variable was coronary artery disease. The Poisson Regression Model was applied in order to identify significant predictors of outcome. Applying this model, we could calculate Adjusted Risk Ratio and 95% confidence interval. The data were analyzed by standard statistical tests using SAS and Stata software. Results: 609 eligible patients were enrolled. Of these 51% were male and 49% female. Based on the final model of Poisson Regression, variables like sex, blood pressure history, heart disease history, changes in electrocardiogram, WBC and CRP had meaningful relationship with CAD. Conclusion: We concluded that prognosis in patients with chest pain needed considering clinical factors (acquired through interview, electrocardiogram and lab findings. Also we were conducted not to rely on traditional risk factors such as history of diabetes, hypercholesterolemia, smoking and family history of heart disease for prediction of the disease.

  19. Mid-regional pro-adrenomedullin in the early evaluation of acute chest pain patients.

    Science.gov (United States)

    Haaf, Philip; Twerenbold, Raphael; Reichlin, Tobias; Faoro, Jonathan; Reiter, Miriam; Meune, Christophe; Steuer, Stephan; Bassetti, Stefano; Ziller, Ronny; Balmelli, Cathrin; Campodarve, Isabel; Zellweger, Christa; Kilchenmann, Ashley; Irfan, Affan; Papassotiriou, Jana; Drexler, Beatrice; Mueller, Christian

    2013-09-30

    The purpose of this study was to investigate the utility of mid-regional pro-adrenomedullin (MR-proADM) in the early diagnosis and risk stratification of patients with acute chest pain in comparison with established and novel biomarkers and risk scores. In this prospective, observational, international, multi-center trial (APACE), MR-proADM was determined in 1179 unselected patients with acute chest pain. Patients were followed for 24 months. MR-proADM concentrations at presentation were higher in patients with AMI (median: 0.78 nmol/l, IQR 0.60-1.13) than in patients with other diagnoses (0.64 nmol/l, IQR 0.49-0.86 nmol/l; p0.90 nmol/l). Adding MR-proADM to the TIMI-score (AUC 0.87) predicted 1-year mortality more accurately than the TIMI-score alone (AUC 0.82; ppatients with AMI (p=0.015) and in those without AMI (p=0.003). MR-proADM at presentation was tantamount to GRACE score and BNP as to its prognostic accuracy for mortality. The AUC for the prediction of cardiovascular events amounted to 0.63. While MR-proADM does not have clinical utility in the early diagnosis of AMI or predicting cardiovascular events in patients with acute chest pain, it may provide prognostic value for all-cause mortality. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

  20. Acute chest pain after bench press exercise in a healthy young adult

    Directory of Open Access Journals (Sweden)

    Smereck JA

    2016-09-01

    Full Text Available Janet A Smereck,1 Argyro Papafilippaki,2 Sawali Sudarshan3 1Department of Emergency Medicine, MedStar Georgetown University Hospital, Washington, DC, 2Pennsylvania Hospital, Philadelphia, PA,3Emergency Department, Washington Adventist Hospital, Takoma Park, MD, USA Abstract: Bench press exercise, which involves repetitive lifting of weights to full arm extension while lying supine on a narrow bench, has been associated with complications ranging in acuity from simple pectoral muscle strain, to aortic and coronary artery dissection. A 39-year-old man, physically fit and previously asymptomatic, presented with acute chest pain following bench press exercise. Diagnostic evaluation led to the discovery of critical multivessel coronary occlusive disease, and subsequently, highly elevated levels of lipoprotein (a. Judicious use of ancillary testing may identify the presence of “high-risk” conditions in a seemingly “low-risk” patient. Emergency department evaluation of the young adult with acute chest pain must take into consideration an extended spectrum of potential etiologies, so as to best guide appropriate management. Keywords: chest pain, coronary artery disease, lipoprotein (a

  1. Diagnostic yield of coronary angiography in patients with acute chest pain: role of noninvasive test.

    Science.gov (United States)

    Hwang, In-Chang; Kim, Yong-Jin; Kim, Kyung-Hee; Shin, Dong-Ho; Lee, Seung-Pyo; Kim, Hyung-Kwan; Sohn, Dae-Won

    2014-01-01

    This study investigated the diagnostic yield of invasive coronary angiography (CAG) and the impact of noninvasive test (NIV) in patients presented to emergency department (ED) with acute chest pain. Patients 50 years or older who visited ED with acute chest pain and underwent CAG were identified retrospectively. Those with ischemic electrocardiogram, elevated cardiac enzyme, known coronary artery disease (CAD), history of cardiac surgery, renal failure, or allergy to radiocontrast were excluded. Diagnostic yields of CAG to detect significant CAD or differentiate the need for revascularization were analyzed according to whether NIV was performed and its result. Among the total 375 consecutive patients, significant CAD was observed in 244 (65.1%). Diagnostic yields of CAG were higher in patients who underwent NIV before CAG, but the discriminative effect was modest (59.7% vs 70.7% [P = .026] for detection of CAD; 45.0% vs 50.5% [P = .285] for revascularization). Positive results of NIV were significantly associated with the presence of CAD and the need for revascularization, when compared with patients without NIV or patients with negative results (P acute chest pain. Performing of NIV provided only modest improvement in diagnostic yield of CAG. The unexpectedly low diagnostic yield might be attributable to the underuse of NIV and misinterpretation of physicians. We suggest the use of NIV as a gatekeeper to discriminate patients who require CAG and/or revascularization, and for this, better risk stratification and appropriate application of NIV are required. © 2013.

  2. [Chronic chest pain after rib fracture: It can cause a disability?

    Science.gov (United States)

    Rabiou, S; Ouadnouni, Y; Lakranbi, M; Traibi, A; Antoini, F; Smahi, M

    2017-10-13

    The rib fractures and instability of the chest wall are the main lesions of closed chest trauma. These lesions can be a source of chronic, often disabling with daily discomfort resulting limitation of some activities. The objective of this study was to assess the prevalence of this phenomenon in order to improve the quality of early care. Through an observational retrospective cohort study on a number of 41 patients supported and monitored for traumatic rib fractures at the Military Hospital of Meknes during the period from October 2010 to March 2016. The circumstances of the accident were dominated by accidents of public roads (86%) and concerned the young adult male. Radiographs have enumerated 165 fracture lines with an average of 4 rib fractures per patient. These were unilateral fractures in 88% of cases, and concerned the means arc in 46% of cases. The rib fracture was undisplaced fracture in 39% of patients, whereas in 2 patients, a flail chest was present. Post-traumatic hemothorax (63% of cases) were the thoracic lesions most commonly associated with rib fractures. The initial management consisted in the use of analgesics systemically in all patients. The retrospective evaluation of pain by the verbal scale was possible in 30 patients. The persistent pain was noted in 60% of cases. This pain was triggered by a simple effort to moderate in 55% of cases, and hard effort in 28% of cases. In 17% of patients, even at rest, the pain occurred intermittently. The impact in terms of disability was mild to moderate in 28% of cases and important in 17%. The neuropathic pain was found in 3 patients. Therapeutically, the first and second levels of analgesics were sufficient to relieve pain. The neuroleptics were required for 2 patients. Our study confirms the persistence of chronic painful, sometimes lasting several years after the initial chest trauma. This pain is responsible of disability triggered most often after exercise. Copyright © 2017 Elsevier Masson

  3. Clinicians ignore best practice guidelines: prospective audit of cardiac injury marker ordering in patients with chest pain

    National Research Council Canada - National Science Library

    Bellbhudder, U; Stanfliet, J C

    2014-01-01

    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...

  4. Triple-rule-out CT angiography for evaluation of acute chest pain and possible acute coronary syndrome

    National Research Council Canada - National Science Library

    Halpern, Ethan J

    2009-01-01

    Triple-rule-out (TRO) computed tomographic (CT) angiography can provide a cost-effective evaluation of the coronary arteries, aorta, pulmonary arteries, and adjacent intrathoracic structures for the patient with acute chest pain...

  5. Physical therapy intervention in patients with non-cardiac chest pain following a recent cardiac event: A randomized controlled trial

    OpenAIRE

    Berg, Astrid T; Stafne, Signe N; Aud Hiller; Slørdahl, Stig A.; Inger-Lise Aamot

    2015-01-01

    Objectives: To assess the effect of two different physical therapy interventions in patients with stable coronary heart disease and non-cardiac chest pain. Methods: A randomized controlled trial was carried out at a university hospital in Norway. A total of 30 patients with known and stable coronary heart disease and self-reported persistent chest pain reproduced by palpation of intercostal trigger points were participating in the study. The intervention was deep friction massage and heat pac...

  6. High-sensitivity troponin assays in the evaluation of patients with acute chest pain in the emergency department

    OpenAIRE

    Christ, Michael; Bertsch, Thomas; Popp, Steffen; Bahrmann, Philipp; Heppner, Hans-Jürgen; Müller, Christian

    2017-01-01

    Evaluating patients with acute chest pain presenting to the emergency department remains an ongoing challenge. The spectrum of etiologies in acute chest pain ranges from minor disease entities to life-threatening diseases, such as pulmonary embolism, acute aortic dissection or acute myocardial infarction (MI). The diagnosis of acute MI is usually made integrating the triad of patient history and clinical presentation, readings of 12-lead ECG and measurement of cardiac troponins (cTn). Introdu...

  7. Clinical Evaluation Versus Undetectable High-Sensitivity Troponin for Assessment of Patients With Acute Chest Pain.

    Science.gov (United States)

    Sanchis, Juan; García-Blas, Sergio; Carratalá, Arturo; Valero, Ernesto; Mollar, Anna; Miñana, Gema; Ruiz, Vicente; Balaguer, Jose Vicente; Roqué, Mercé; Bosch, Xavier; Núñez, Julio

    2016-12-01

    Decision-making in acute chest pain remains challenging despite normal (below ninety-ninth percentile) high-sensitivity troponin (hs-cTn). Some studies suggest that undetectable hs-cTn, far below the ninety-ninth percentile, might rule out acute coronary syndrome. We investigated clinical data in comparison to undetectable hs-cTnT. The study comprised 682 patients (November 2010 to September 2011) presenting at the emergency department with chest pain and normal hs-cTnT (pain) and 2 points (recurrent pain and prior ischemic heart disease). The negative predictive values of the clinical score and undetectable hs-cTnT (patients suffered long-term MACE. The C-statistics of the clinical score for long-term (0.75) and 30-day (0.88) MACE were higher than with the TIMI(Thrombolysis In Myocardial Infarction) risk (0.68, 0.77) or GRACE(Global Registry of Acute Coronary Events) (0.50, 0.47) scores. Likewise, the negative predictive values of score = 0 (97.5%, 100%) and ≤1 point (95.9%, 100%) were higher than using undetectable hs-cTnT (91.9%, 98.1%). Both clinical scores of 0 and ≤1 better classified patients at risk of MACE (p = 0.0001, log-rank test) than hs-cTnT patients presenting at the emergency department with chest pain and normal hs-cTnT. Copyright © 2016 Elsevier Inc. All rights reserved.

  8. Evaluation of acute chest pain in the emergency department: "triple rule-out" computed tomography angiography.

    Science.gov (United States)

    Yoon, Yeonyee E; Wann, Samuel

    2011-01-01

    Triage of patients with acute, potentially life-threatening chest pain is one of the most important issues currently facing physicians in the emergency department. Appropriate evaluation of these patients begins with a skilled assessment of the individual patient's presenting symptoms and a careful review of his or her history and physical examination, often followed by serial recording of electrocardiograms and measurement of serum biochemical markers such as troponin and d-dimer. Stress testing, often accompanied by rest and stress myocardial perfusion imaging or echocardiography, and other diagnostic testing such as radionuclide lung scanning and invasive angiography may be required. A rapid, accurate, and cost-effective approach for the evaluation of emergency department patients with chest pain is needed. Development of newer generations of multidetector computed tomographic (MDCT) scanners, which are capable not only of performing high-quality noninvasive coronary angiography, but also concurrent aortic and pulmonary angiography, has led to increased use of MDCT for the so-called "triple rule out." MDCT is used for the detection of 3 of the most common life-threatening causes of chest pain-coronary artery disease, acute aortic syndrome, and pulmonary emboli. While triple rule-out protocol can be very useful and potentially cost effective when used appropriately, concern has risen regarding the overuse of this technology, which could expose patients to unnecessary radiation and iodinated contrast. The triple rule-out protocol is most appropriate for patients who present with acute chest pain, but are judged to have low to intermediate increased risk for acute coronary syndrome, and whose chest pain symptoms might also be attributed to acute pathologic conditions of the aorta or pulmonary arteries. MDCT should not be used as a routine screening procedure. Continued technical improvements in acquisition speed and spatial resolution of computed tomography images

  9. Evaluation of Patients with Acute Chest Pain Using SPECT Myocardial Perfusion Imaging: Prognostic Implications of Mildly Abnormal Scans.

    Science.gov (United States)

    Goldkorn, Ronen; Naimushin, Alexey; Beigel, Roy; Naimushin, Ekaterina; Narodetski, Michael; Matetzky, Shlomi

    2017-06-01

    While patients presenting to emergency departments (ER) with chest pain are increasingly managed in chest pain units (CPU) that utilize accelerated diagnostic protocols for risk stratification, such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), data are lacking regarding the prognostic implications of mildly abnormal scans in this population. To evaluate the prognostic implications of mildly abnormal SPECT MPI results in patients with acute chest pain. Of the 3753 chest pain patients admitted to the CPU at the Leviev Heart Center, Sheba Medical Center 1593 were further evaluated by SPECT MPI. Scans were scored by extent and severity of stress-induced perfusion defects, with 1221 patients classified as normal, 82 with myocardial infarction without ischemia, 236 with mild ischemia, and 54 with more than mild ischemia. Mild ischemia patients were further classified to those who did and did not undergo coronary angiography within 7 days. Mild ischemia patients who underwent coronary angiography were more likely to be male (92% vs. 81%, P = 0.01) and to have left anterior descending ischemia (67% vs. 42%, P = 0.004). After 50 months, these patients returned less often to the ER with chest pain (53% vs. 87%, P acute coronary syndrome and death (8% vs. 16%, P patients with chronic stable angina, patients presenting with acute chest pain exhibiting mildly abnormal SPECT MPI findings should perhaps undergo a more aggressive diagnostic and therapeutic approach.

  10. Evaluating Burning Mouth Syndrome as a Comorbidity of Atypical Odontalgia: The Impact on Pain Experiences.

    Science.gov (United States)

    Tu, Trang T H; Miura, Anna; Shinohara, Yukiko; Mikuzuki, Lou; Kawasaki, Kaoru; Sugawara, Shiori; Suga, Takayuki; Watanabe, Takeshi; Watanabe, Motoko; Umezaki, Yojiro; Yoshikawa, Tatsuya; Motomura, Haruhiko; Takenoshita, Miho; Toyofuku, Akira

    2017-10-03

    This study aimed (1) to investigate the differences in clinical characteristics of patients between 2 groups, those who have atypical odontalgia (AO) only and those who have AO with burning mouth syndrome (BMS), and (2) to assess the influence of psychiatric comorbidity factors on patients' experiences. Medical records and psychiatric referral forms of patients visiting the Psychosomatic Dentistry Clinic of Tokyo Medical and Dental University between 2013 and 2016 were reviewed. The final sample included 2 groups of 355 patients: those who have AO only (n = 272) and those who have AO with BMS (AO-BMS; n = 83). Clinicodemographic variables (gender, age, comorbid psychiatric disorders, and history of headache or sleep disturbances) and pain variables (duration of illness, pain intensity, and severity of accompanying depression) were collected. Initial pain assessment was done using the Short-Form McGill Pain Questionnaire, and depressive state was determined using the Zung Self-Rating Depression Scale. The average age, female ratio, and sleep disturbance prevalence in the AO-only group were significantly lower than those in AO-BMS group. AO-BMS patients rated overall pain score and present pain intensity significantly higher than did the AO-only patients (P = 0.033 and P = 0.034, respectively), emphasizing sharp (P = 0.049), hot-burning (P = 0.000), and splitting (P = 0.003) characteristics of pain. Patients having comorbid psychiatric disorders had a higher proportion of sleep disturbance in both groups and a higher proportion of depressive state in the AO-only group. AO-BMS patients have different epidemiological characteristics, sleep quality, and pain experiences compared to AO-only patients. The presence of psychiatric comorbidities in both groups may exacerbate sleep quality. We suggest that BMS as a comorbid oral disorder in AO patients contributes to a more intensively painful experience. © 2017 The Authors. Pain Practice published by Wiley Periodicals, Inc

  11. The association between ethnicity and delay in seeking medical care for chest pain: a systematic review.

    Science.gov (United States)

    Wechkunanukul, Kannikar; Grantham, Hugh; Damarell, Raechel; Clark, Robyn A

    2016-07-01

    Acute coronary syndrome (ACS) is a leading cause of mortality and morbidity worldwide, and chest pain is one of the most common symptoms of ACSs. A rapid response to chest pain by patients and appropriate management by health professionals are vital to improve survival rates.People from different ethnic groups are likely to have different perceptions of chest pain, its severity and the need for urgent treatment. These differences in perception may contribute to differences in response to chests pain and precipitate unique coping strategies. Delay in seeking medical care for chest pain in the general population has been well documented; however, limited studies have focused on delay times within ethnic groups. There is little research to date as to whether ethnicity is associated with the time taken to seek medical care for chest pain. Consequently, addressing this gap in knowledge will play a crucial role in improving the health outcomes of culturally and linguistically diverse (CALD) patients suffering from chest pain and for developing appropriate clinical practice and public awareness for these populations. The current review aimed to determine if there is an association between ethnicity and delay in seeking medical care for chest pain among CALD populations. Patients from different ethnic minority groups presenting to emergency departments (EDs) with chest pain. The current review will examine studies that evaluate the association between ethnicity and delay in seeking medical care for chest pain among CALD populations. The current review will consider quantitative studies including randomized controlled trials (RCTs), non-RCTs, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies. The current review will consider studies that measure delay time as the main outcome. The time will be measured as the interval between the time of symptom onset and time to reach an

  12. Utilizing DMAIC six sigma and evidence-based medicine to streamline diagnosis in chest pain.

    Science.gov (United States)

    Kumar, Sameer; Thomas, Kory M

    2010-01-01

    The purpose of this study was to quantify the difference between the current process flow model for a typical patient workup for chest pain and development of a new process flow model that incorporates DMAIC (define, measure, analyze, improve, control) Six Sigma and evidence-based medicine in a best practices model for diagnosis and treatment. The first stage, DMAIC Six Sigma, is used to highlight areas of variability and unnecessary tests in the current process flow for a patient presenting to the emergency department or physician's clinic with chest pain (also known as angina). The next stage, patient process flow, utilizes DMAIC results in the development of a simulated model that represents real-world variability in the diagnosis and treatment of a patient presenting with angina. The third and final stage is used to analyze the evidence-based output and quantify the factors that drive physician diagnosis accuracy and treatment, as well as review the potential for a broad national evidence-based database. Because of the collective expertise captured within the computer-oriented evidence-based model, the study has introduced an innovative approach to health care delivery by bringing expert-level care to any physician triaging a patient for chest pain anywhere in the world. Similar models can be created for other ailments as well, such as headache, gastrointestinal upset, and back pain. This updated way of looking at diagnosing patients stemming from an evidence-based best practice decision support model may improve workflow processes and cost savings across the health care continuum.

  13. Panic Disorder in Patients Presenting to the Emergency Department With Chest Pain: Prevalence and Presenting Symptoms.

    Science.gov (United States)

    Greenslade, Jaimi H; Hawkins, Tracey; Parsonage, William; Cullen, Louise

    2017-12-01

    Patients with panic disorder experience symptoms such as palpitations, chest pain, dizziness, and breathlessness. Consequently, they may attend the Emergency Department (ED) to be assessed for possible emergency medical conditions. Recognition of panic disorder within the ED is low. We sought to establish the prevalence of panic disorder in patients presenting for ED investigation of potential acute coronary syndrome. We also sought to characterise the cohort of patients with panic disorder in terms of presenting symptoms, risk factors, medical history and major adverse cardiac events (MACE). This was an observational study of 338 adult patients presenting to the Emergency Department of a tertiary hospital in Australia. Research nurses collected clinical data using a customised case report form. The outcome was panic disorder, assessed using the Mini International Neuropsychiatric Interview. The average age of participants was 50.2 years and 37.9% were female. Thirty-day MACE occurred in 7.7% of the cohort. The clinical diagnosis of panic disorder was made in 5.6% (95% CI: 3.4-8.6%) of patients. Compared to patients without panic disorder, patients with panic disorder were slightly more likely to report that their pain felt heavy (48.9% and 73.7% respectively, p=0.04). All other reported symptoms were similar in the two groups. The prevalence of panic disorder was low in patients presenting to an Australian ED with chest pain. Clinical signs or symptoms that are routinely collected as part of the chest pain workup cannot be used to distinguish patients with and without panic disorder. Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.

  14. Treatment of acute, severe epigastric/chest pain in a patient with stomach cancer following gastrectomy: A case report.

    Science.gov (United States)

    Zaporowska-Stachowiak, Iwona; Gorzelińska, Lidia; Sopata, Maciej; Łuczak, Jacek

    2015-03-01

    The treatment of acute chest pain can be a challenge in palliative care. Firstly, because acute chest pain is a symptom of a paucity of diseases, which makes diagnosis difficult and time consuming, while there is also a time constraint, due to the extreme suffering of the patient. Secondly, the condition of a patient with advanced cancer disease and co-morbidities does not always allow for required diagnostic procedures. The present report describes a case of acute, severe epigastric/chest pain in a patient with dynamic disease progression, who was receiving palliative care. This study also demonstrates that the pathophysiology of pain in a terminal patient may determine the treatment strategy. The patient in the present case was a 41-year-old male, who had previously undergone gastrectomy for stomach cancer, followed by postoperative chemotherapy. The patient was treated with palliative chemotherapy for metastases to the lungs, liver and lymph nodes, which led to the development of iatrogenic peripheral neuropathy. The patient was subsequently admitted to the Palliative Medicine In-patient Unit of the University Hospital of Lord's Transfiguration (Poznan, Poland) with the complaint of acute epigastric and chest pain. An electrocardiogram, echocardiogram, chest and abdomen computerized tomography scan, esophagoduodenoscopy and laboratory analyses were performed to determine the source of the pain. The patient was treated with morphine sulfate, metoclopramide, midazolam, diazepam, acetaminophen, ketamine, hyoscine butylbromide, propofol, dexamethasone and amoxycillin, and received parenteral nutrition. As the source of pain remained unclear, a second esophagoduodenoscopy was performed to determine a diagnosis, resulting in pain relief. Thus, in the present case, esophagoduodenoscopy was diagnostic and therapeutic. Furthermore, although the treatment of acute chest pain may be a challenge in palliative care, the present study indicates that pain treatment should be

  15. Chest pain characteristics and gender in the early diagnosis of acute myocardial infarction.

    Science.gov (United States)

    Arora, Garima; Bittner, Vera

    2015-02-01

    Acute myocardial infarction is one of the leading causes of cardiovascular disease mortality in both men and women. Chest pain, which is often described as chest pressure, tightness, or a squeezing sensation, is the most frequent symptom in patients presenting with acute myocardial infarction. Although the diagnosis of acute myocardial infarction is often based on typical changes on a surface electrocardiogram and on changes in cardiac biomarkers, there is a need to better recognize and understand the impact of sex on symptoms among patients presenting with acute coronary syndrome or acute myocardial infarction. We briefly review the pathophysiology of ischemic symptoms, discuss potential mechanisms for variation in ischemic symptoms by sex, and summarize recent publications that have addressed sex differences in ischemic symptoms.

  16. Chronic orofacial pain; atypical facial pain? [Chronische orofaciale pijn: atypische gezichtspijn?

    NARCIS (Netherlands)

    Tjakkes, G.H.; van Wijhe, M.

    2006-01-01

    Difficult to diagnose pain in the orofacial area may be a challenge to the dental practitioner.There still is uncertainty about the taxonomy of chronic orofacial pain, and even more so about its etiology. Treatment of chronic orofacial pain may aim at goals which are set in advance, but also at the

  17. Long-term prognosis of patients with anginalike chest pain and normal coronary angiographic findings.

    Science.gov (United States)

    Lichtlen, P R; Bargheer, K; Wenzlaff, P

    1995-04-01

    This study analyzes the long-term course of patients with typical angina pectoris or anginalike chest pain and normal coronary angiographic findings. In previous studies of such patients the rate of occurrence of typical coronary events during follow-up has differed widely, depending on the duration of the study and the number of patients. One hundred seventy-six patients (mean age 48.3 years) who underwent coronary and left ventricular angiography for typical angina or anginalike chest pain were followed up for 5.8 to 15.8 years (median 12.4). By definition, all patients had normal findings on coronary and left ventricular angiograms; exercise test results were positive in 31. Fourteen patients (8%) had a coronary event (0.65%/year) after an average of 9.3 years (median 9.2). Two of the 14 died of a coronary event (0.09%/year), 1 of cardiogenic shock during acute myocardial infarction, 1 suddenly; 4 had a nonfatal myocardial infarction at an average of 8.1 years (median 9.1); 8 had severe angina pectoris after an average of 10.3 years (median 11.1), confirmed by a second angiogram, now with positive findings. Two patients died of a noncoronary cardiac event (chronic cor pulmonale due to obstructive lung disease, acute pulmonary embolism), eight of a noncardiac cause, mainly cancer. None of the 31 patients with a positive exercise test result had a coronary event. Patients with a coronary event had significantly more risk factors (hypercholesterolemia, hypertension, cigarette smoking, diabetes type II) than did those without an event (average 2.4/patient vs. 1.3/patient, p < 0.01). Chest pain persisted in 133 (81%) of the 164 survivors and disappeared in 31 (19%). Patients with typical angina or anginalike chest pain and normal coronary angiograms have a good long-term prognosis despite persistence of pain for many years; coronary morbidity and mortality are similar to those of the overall population. An increased risk for the development of coronary events is

  18. Chest Pain

    Science.gov (United States)

    ... shortness of breath. A collapsed lung occurs when air leaks into the space between the lung and the ribs. Pulmonary hypertension. This condition occurs when you have high blood pressure in the arteries carrying blood to the lungs, ...

  19. An Unusual Presentation of Adult Tethered Cord Syndrome Associated with Severe Chest and Upper Back Pain

    Directory of Open Access Journals (Sweden)

    Shotaro Kanda

    2015-01-01

    Full Text Available Adult tethered cord syndrome (ATCS is a rare entity that usually presents with multiple neurological symptoms, including lower extremity pain, backache, lower extremity muscle weakness, and bowel/bladder disturbances. Prompt surgical treatment is often necessary to avoid permanent sequelae. We report a 63-year-old man with sudden-onset severe right chest and upper back pain, followed by urinary retention. His initial workup included computed tomography of the abdomen and pelvis, which showed a presacral mass. His symptom-driven neurological workup focused on the cervical and thoracic spine, the results of which were normal. Pelvic radiographs and magnetic resonance imaging of the lumbosacral spine showed spina bifida occulta, meningocele, and presacral masses consistent with a teratomatous tumor. His symptoms, except for urinary retention, improved dramatically with surgical treatment. The excised specimen contained a teratomatous lesion plus an organized hematoma. Hematoma formation was suspected as the trigger of his sudden-onset right chest and upper back pain.

  20. Cost effectiveness of diagnostic strategies for patients with acute, undifferentiated chest pain.

    Science.gov (United States)

    Goodacre, S; Calvert, N

    2003-09-01

    Patients presenting to hospital with acute, undifferentiated chest pain have a low, but important, risk of significant myocardial ischaemia. Potential diagnostic strategies for patients with acute, undifferentiated chest pain vary from low cost, poor effectiveness (discharging all home) to high cost, high effectiveness (admission and intensive investigation). This paper aimed to estimate the relative cost effectiveness of these strategies. Decision analysis modelling was used to measure the incremental cost per quality adjusted year of life (QALY) gained for five potential strategies to diagnose acute undifferentiated chest pain, compared with the next most effective strategy, or a baseline strategy of discharging all patients home without further testing. Cardiac enzyme testing alone costs pound 17 432/QALY compared with discharge without testing. Adding two to six hours of observation and repeat enzyme testing costs an additional pound 18 567/QALY. Adding exercise testing to this strategy costs pound 28 553/QALY. A strategy of overnight admission, enzyme, and exercise testing has an incremental cost of pound 120 369/QALY, while a strategy consisting of overnight admission without exercise testing is subject to extended dominance. Sensitivity analysis revealed that the results are sensitive to variations in the direct costs of running each strategy and to variation in assumptions regarding the effect of diagnostic testing upon quality of life of those with non-cardiac disease. Observation based strategies incur similar costs per QALY to presently funded interventions for coronary heart disease, while strategies requiring hospital admission may be prohibitively poor value for money. Validation of the true costs and effects of observation based strategies is essential before widespread implementation.

  1. Chest pain and high-sensitivity troponin: What is the evidence?

    Directory of Open Access Journals (Sweden)

    Daniel Ashmore

    2015-03-01

    Full Text Available The number of attendances and admissions of patients with chest pain to hospitals in England and Wales is increasing. Initial assessment may be unrewarding. Consequently, cardiac troponin has become the mainstay of investigation for non-ST-segment-elevation myocardial infarction and unstable angina, although only a small proportion of patients are eventually diagnosed as such. Current National Institute for Healthcare and Clinical Excellence guidance recommends measuring cardiac troponin levels on presentation and 10–12 h after onset of symptoms. A more effective diagnostic tool is needed. The aims are twofold: to increase accuracy of acute coronary syndrome diagnosis thus implementing the most appropriate management at an earlier stage while reducing costs and to provide a more rapid diagnosis to ease the anxieties of patients. Three key issues have been highlighted. The first is that many current studies do not have a ‘normal/reference’ population, making comparison between two studies difficult to interpret. Second, whether newer ‘high-sensitivity’ cardiac troponin tests can be used to rule out a myocardial infarction in a patient with chest pain is discussed. Third, whether a ‘high-sensitivity’ cardiac troponin has great enough specificity to differentiate between the number of other causes of raised troponin in a single test or whether serial testing is needed is assessed. A strategy for such serial testing is discussed. Finally, use of ‘high-sensitivity’ cardiac troponin in risk stratification of other disease processes is highlighted, which is likely to become common practice, changing the way we manage patients with, and without, chest pain.

  2. Investigation of paramedics' compliance with clinical practice guidelines for the management of chest pain.

    LENUS (Irish Health Repository)

    Figgis, Ken

    2012-01-31

    BACKGROUND: Acute coronary syndromes remain a leading cause of preventable early deaths. However, previous studies have indicated that paramedics\\' compliance with chest pain protocols is suboptimal and that many patients do not receive the benefits of appropriate prehospital treatment. AIMS: To evaluate paramedics\\' level of compliance with national clinical practice guidelines and to investigate why, in certain circumstances, they may deviate from the clinical guidelines. SETTING: The Health Service Executive Mid-Western Regional Ambulance Service which serves a mixed urban and rural population across three counties in the west of Ireland. METHOD: A retrospective review of completed ambulance Patient Care Report Forms was conducted for all adult patients with non-traumatic chest pain treated between 1 December 2007 and 31 March 2008. During the same study period, paramedics were asked to complete a prospective questionnaire survey investigating the rationale behind their treatment decisions, their estimation of patient risk and their attitudes towards the clinical practice guidelines and training. RESULTS: 382 completed Patient Care Report Forms were identified for patients with chest pain, of whom 84.8% received ECG monitoring, 75.9% were given oxygen, 44.8% were treated with sublingual glyceryl trinitrate (GTN) and 50.8% were treated with aspirin. Only 20.4% of patients had a prehospital 12-lead ECG recorded. 58 completed questionnaires were returned (response rate 15%); 64% of respondents said they had received insufficient training to identify ECG abnormalities. CONCLUSIONS: Prehospital treatment with oxygen, aspirin, sublingual GTN and ECG monitoring remains underused by paramedics, even though only a small number of patients had documented contraindications to their use. The small number of patients who received a prehospital 12-lead ECG is a cause of particular concern and suggests that incomplete patient assessment may contribute to undertreatment

  3. Investigation of paramedics' compliance with clinical practice guidelines for the management of chest pain.

    Science.gov (United States)

    Figgis, Ken; Slevin, Oliver; Cunningham, J Brian

    2010-02-01

    Acute coronary syndromes remain a leading cause of preventable early deaths. However, previous studies have indicated that paramedics' compliance with chest pain protocols is suboptimal and that many patients do not receive the benefits of appropriate prehospital treatment. To evaluate paramedics' level of compliance with national clinical practice guidelines and to investigate why, in certain circumstances, they may deviate from the clinical guidelines. The Health Service Executive Mid-Western Regional Ambulance Service which serves a mixed urban and rural population across three counties in the west of Ireland. A retrospective review of completed ambulance Patient Care Report Forms was conducted for all adult patients with non-traumatic chest pain treated between 1 December 2007 and 31 March 2008. During the same study period, paramedics were asked to complete a prospective questionnaire survey investigating the rationale behind their treatment decisions, their estimation of patient risk and their attitudes towards the clinical practice guidelines and training. 382 completed Patient Care Report Forms were identified for patients with chest pain, of whom 84.8% received ECG monitoring, 75.9% were given oxygen, 44.8% were treated with sublingual glyceryl trinitrate (GTN) and 50.8% were treated with aspirin. Only 20.4% of patients had a prehospital 12-lead ECG recorded. 58 completed questionnaires were returned (response rate 15%); 64% of respondents said they had received insufficient training to identify ECG abnormalities. Prehospital treatment with oxygen, aspirin, sublingual GTN and ECG monitoring remains underused by paramedics, even though only a small number of patients had documented contraindications to their use. The small number of patients who received a prehospital 12-lead ECG is a cause of particular concern and suggests that incomplete patient assessment may contribute to undertreatment. Further provision of training and equipment is necessary to

  4. Low Homoarginine Levels in the Prognosis of Patients With Acute Chest Pain.

    Science.gov (United States)

    Atzler, Dorothee; Baum, Christina; Ojeda, Francisco; Keller, Till; Cordts, Kathrin; Schnabel, Renate B; Choe, Chi-un; Lackner, Karl J; Münzel, Thomas; Böger, Rainer H; Blankenberg, Stefan; Schwedhelm, Edzard; Zeller, Tanja

    2016-04-13

    The endogenous amino acid homoarginine predicts mortality in cerebro- and cardiovascular disease. The objective was to explore whether homoarginine is associated with atrial fibrillation (AF) and outcome in patients with acute chest pain. One thousand six hundred forty-nine patients with acute chest pain were consecutively enrolled in this study, of whom 589 were diagnosed acute coronary syndrome (ACS). On admission, plasma concentrations of homoarginine as well as brain natriuretic peptide (BNP), and high-sensitivity assayed troponin I (hsTnI) were determined along with electrocardiography (ECG) variables. During a median follow-up of 183 days, 60 major adverse cardiovascular events (MACEs; 3.8%), including all-cause death, myocardial infarction, or stroke, were registered in the overall study population and 43 MACEs (7.5%) in the ACS subgroup. Adjusted multivariable Cox regression analyses revealed that an increase of 1 SD of plasma log-transformed homoarginine (0.37) was associated with a hazard reduction of 26% (hazard ratio [HR], 0.74; 95% CI, 0.57-0.96) for incident MACE and likewise of 35% (HR, 0.65; 95% CI, 0.49-0.88) in ACS patients. In Kaplan-Meier survival curves, homoarginine was predictive for patients with high-sensitivity assayed troponin I (hsTnI) above 27 ng/L (Pacute chest pain, in particular, in those with elevated hsTnI. Impaired homoarginine was associated with prevalent AF. Further studies are needed to investigate the link to AF and evaluate homoarginine as a therapeutic option for these patients. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

  5. Increased pain sensitivity to intraoral capsaicin in patients with atypical odontalgia.

    Science.gov (United States)

    Baad-Hansen, Lene; List, Thomas; Jensen, Troels Staehelin; Svensson, Peter

    2006-01-01

    To use 2 well-characterized stimuli, the intraoral capsaicin model and the "nociceptive-specific" electrode, to compare superficial nociceptive function between patients with atypical odontalgia (AO) and matched healthy controls. Furthermore, the authors aimed to describe the sensitivity, specificity, and positive predictive values (PPV) of the techniques if group differences could be established. Thirty-eight patients with AO and 27 matched healthy controls participated in this study. Thirty microliters of 5% capsaicin was applied to the gingiva on the left and right sides of all participants as a pain-provocation test. The participants scored the capsaicin-evoked pain continuously on a 0-to-10 visual analog scale (VAS). Furthermore, individual electrical sensory and pain thresholds to stimulation with a "nociceptive-specific" electrode on the facial skin above the infraorbital or mental nerve were determined. AO patients had higher VAS pain scores for capsaicin application than healthy controls (ANOVA: F > 4.88; P .262). No main effects of group or stimulation side on the electrical sensory and pain thresholds were detected (ANOVA: F .579). Sensitivity was 0.51; specificity, 0.81; and PPV, 0.77 when a VAS value of > or = 8 for capsaicin-evoked pain was used. AO patients show increased sensitivity to intraoral capsaicin but normal sensitivity to "nociceptive-specific" electrical stimulation of the face in an area proximal to the painful site. The use of the intraoral pain-provocation test with capsaicin as a possible adjunct to the diagnostic workup is hampered by the only moderately good sensitivity and specificity.

  6. [What is the utility of proton pump inhibitor testing in non-cardiac chest pain?].

    Science.gov (United States)

    Huamán, José Wálter; Aliaga, Verónica; Domenech, Gemma; Videla, Sebastián; Saperas, Esteban

    2014-10-01

    Noncardiac chest pain (NCCP) often represents a diagnostic and therapeutic challenge. Given that gastroesophageal reflux disease (GERD) is the most common cause of NCCP, initial treatment with proton-pump inhibitors (PPI) has been proposed for all patients (PPI testing), reserving esophageal function testing solely for non-responders. The aim of the present study was to provide evidence on the clinical utility of PPI testing with high-dose pantoprazole in patients with NCCP. We carried out a study of diagnostic performance with a cohort design in patients with NCCP, who had been assessed by the Cardiology Service. All patients underwent upper endoscopy, esophageal manometry, and 24h esophageal pH monitoring before PPI testing with pantoprazole 40 mg every 12h for 1 month. Before and after treatment, we assessed the severity (intensity and frequency) of chest pain, quality of life, and anxiety and depression by means of specific questionnaires. The diagnosis of GERD was based on a pathological finding of esophageal pH monitoring. A positive response to PPI testing was defined as an improvement in chest pain >50% compared with the baseline score after 1 month of PPI therapy. We included 30 consecutive patients (17 men/13 women) with a mean age of 49 years. Of these 30 patients, 20 with NCCP had GERD (67%, 95%CI: 47%-83%). A positive response to PPI therapy was observed in 13 of the 30 (43%) patients with NCCP: 11 of the 20 (55%) patients in the GERD-positive group and 2 of the 10 (20%) in the GERD-negative group. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of PPI testing was 55%, 80%, 85%, 47% and 63%, respectively. A significant reduction in chest pain after pantoprazole therapy (P=.003) and a slight non significant improvement in anxiety and depression was achieved in the GERD-positive group as compared to the GERD-negative group. In NCCP, PPI testing with pantoprazole has a low sensitivity for the diagnosis of

  7. [Patient satisfaction in acute coronary syndrome. Improvement through the establishment of a chest pain unit].

    Science.gov (United States)

    Tzikas, S; Keller, T; Post, F; Blankenberg, S; Genth-Zotz, S; Münzel, T

    2010-09-01

    Chest pain units (CPUs) were established primarily in the United States with the aim of reducing hospital admissions and costs, whilst improving quality of life and patient care. Clinical trials have shown that these units are safe and practical; however, there was a need to investigate to what extent patients are satisfied with the care in CPUs. The aim of this study is to evaluate the experiences of patients receiving CPU care and routine emergency department (ED) treatment for acute chest pain. Patients presenting with acute chest pain at the ED between May 2004 and June 2005 and at the CPU between July 2005 and May 2006 were evaluated in this retrospective analysis. Standardized data collection using all available clinical data as well as telephone follow-up was carried out. Evaluation was carried out on a school-mark basis and a quality assessment was performed. Of the total population, 479 patients (323 male, 156 female) were treated in the ED, whereas 1176 (743 male, 433 female) in the CPU. In the ED, 26 patients (5.4%) were diagnosed as ST segment elevation myocardial infarction (STEMI), 39 (8.1%) as non-ST segment elevation myocardial infarction (NSTEMI) and 16 (3.3%) as unstable angina pectoris (UAP). In 398 patients (83.1%) acute coronary syndrome (ACS) could be ruled out. In the CPU, the incidence of STEMI was 74 (6.3%), of NSTEMI 141 (12%) and of UAP 153 (13%). ACS was excluded in 808 patients (68.7%). Data on satisfaction with in-hospital treatment was available in 78.5% of cases. In the CPU, 92.2% of the patients judged their treatment as excellent/good, 5.9% as appropriate and 1.9% as poor. The distribution of satisfaction in the ED was significantly lower with 78.6% excellent/good, 18.5% appropriate and 2.9% poor. The establishment of a CPU at the University Medical Center of Mainz demonstrated a higher level of patient satisfaction compared to the treatment of patients with acute chest pain in the general ED.

  8. Atypical supernumerary phantom limb and phantom limb pain in two patients with pontine hemorrhage.

    Science.gov (United States)

    Yoo, Seung Don; Kim, Dong Hwan; Jeong, Yong Seol; Chon, Jinmann; Bark, Jihea

    2011-06-01

    Phantom limbs are usually observed after amputation of extremities. In patients after a stroke, a similar but rarely occurring phenomenon consisting of the patient experiencing the presence of an additional limb has been described. This phenomenon, generally called supernumerary phantom limb (SPL), may be caused by lesions in the right or left cerebral hemisphere, but has been predominantly reported in patients who have had a right hemispheric stroke. We report two cases of atypical SPL and phantom limb pain (PLP) after pontine hemorrhage. The patients were treated conservatively and their symptoms lasted more than 1 month. This is the first report of SPLs after left pontine hemorrhage, and phantom perception and pain lasted longer than those in previously observed cases. Our results indicate that SPL may be more common than reported; therefore, thorough examinations are essential for the care of stroke patients.

  9. Safety, feasibility, and results of exercise testing for stratifying patients with chest pain in the emergency room.

    Science.gov (United States)

    Macaciel, Renato Machado; Mesquita, Evandro Tinoco; Vivacqua, Ricardo; Serra, Salvador; Campos, Augusta; Miranda, Marcelo; Gamarski, Roberto; Dohman, Hans; Bassan, Roberto

    2003-08-01

    To assess safety, feasibility, and the results of early exercise testing in patients with chest pain admitted to the emergency room of the chest pain unit, in whom acute myocardial infarction and high-risk unstable angina had been ruled out. A study including 1060 consecutive patients with chest pain admitted to the emergency room of the chest pain unit was carried out. Of them, 677 (64%) patients were eligible for exercise testing, but only 268 (40%) underwent the test. The mean age of the patients studied was 51.7 12.1 years, and 188 (70%) were males. Twenty-eight (10%) patients had a previous history of coronary artery disease, 244 (91%) had a normal or unspecific electrocardiogram, and 150 (56%) underwent exercise testing within a 12-hour interval. The results of the exercise test in the latter group were as follows: 34 (13%) were positive, 191 (71%) were negative, and 43 (16%) were inconclusive. In the group of patients with a positive exercise test, 21 (62%) underwent coronary angiography, 11 underwent angioplasty, and 2 underwent myocardial revascularization. In a univariate analysis, type A/B chest pain (definitely/probably anginal) (ptest (ptest proved to be feasible, safe, and well tolerated.

  10. High-sensitivity troponin assays in the evaluation of patients with acute chest pain in the emergency department.

    Science.gov (United States)

    Christ, Michael; Bertsch, Thomas; Popp, Steffen; Bahrmann, Philipp; Heppner, Hans-Jürgen; Müller, Christian

    2011-09-06

    Evaluating patients with acute chest pain presenting to the emergency department remains an ongoing challenge. The spectrum of etiologies in acute chest pain ranges from minor disease entities to life-threatening diseases, such as pulmonary embolism, acute aortic dissection or acute myocardial infarction (MI). The diagnosis of acute MI is usually made integrating the triad of patient history and clinical presentation, readings of 12-lead ECG and measurement of cardiac troponins (cTn). Introduction of high-sensitivity cTn assays substantially increases sensitivity to identify patients with acute MI even at the time of presentation to the emergency department at the cost of specificity. However, the proportion of patients presenting with cTn positive, non-vascular cardiac chest pain triples with the implementation of new sensitive cTn assays increasing the difficulty for the emergency physician to identify those patients who are at need for invasive diagnostics. The main objectives of this mini-review are 1) to discuss elements of disposition decision made by the emergency physician for the evaluation of chest pain patients, 2) to summarize recent advances in assay technology and relate these findings into the clinical context, and 3) to discuss possible consequences for the clinical work and suggest an algorithm for the clinical evaluation of chest pain patients in the emergency department.

  11. Diagnostic performance of initial salivary alpha-amylase activity for acute myocardial infarction in patients with acute chest pain.

    Science.gov (United States)

    Shen, Ying-Sheng; Chen, Wei-Lung; Chang, Hsin-Yu; Kuo, Hung-Yi; Chang, Yue-Cune; Chu, Hsin

    2012-10-01

    To rule out acute myocardial infarction (AMI) in chest pain patients constitutes a diagnostic challenge to emergency department (ED) physicians. To evaluate the diagnostic value of measuring salivary alpha-amylase (sAA) activity for detecting AMI in patients presenting to the ED with acute chest pain. sAA activity was measured in a prospective cohort of 473 consecutive adult patients within 4 h of onset of chest pain. Comparisons were made between patients with a final diagnosis of AMI and those with non-AMI. Univariate analysis and multiple logistic regression model were used to identify independent clinical predictors of AMI. Initial sAA activity in the AMI group (n = 85; 266 ± 127.6 U/mL) was significantly higher than in the non-AMI group (n = 388; 130 ± 92.8 U/mL, p acute chest pain was 0.826 (95% confidence interval [CI] 0.782-0.869), with diagnostic odds ratio 10.87 (95% CI 6.16-19.18). With a best cutoff value of 197.7 U/mL, the sAA activity revealed moderate sensitivity and specificity as an independent predictor of AMI (78.8% and 74.5%). High initial sAA activity is an independent predictor of AMI in patients presenting to the ED with chest pain. Copyright © 2012 Elsevier Inc. All rights reserved.

  12. Complex regional pain syndrome with associated chest wall dystonia: a case report

    Directory of Open Access Journals (Sweden)

    Schwartzman Robert J

    2011-09-01

    Full Text Available Abstract Patients with complex regional pain syndrome (CRPS often suffer from an array of associated movement disorders, including dystonia of an affected limb. We present a case of a patient with long standing CRPS after a brachial plexus injury, who after displaying several features of the movement disorder previously, developed painful dystonia of chest wall musculature. Detailed neurologic examination found palpable sustained contractions of the pectoral and intercostal muscles in addition to surface allodynia. Needle electromyography of the intercostal and paraspinal muscles supported the diagnosis of dystonia. In addition, pulmonary function testing showed both restrictive and obstructive features in the absence of a clear cardiopulmonary etiology. Treatment was initiated with intrathecal baclofen and the patient had symptomatic relief and improvement of dystonia. This case illustrates a novel form of the movement disorder associated with CRPS with response to intrathecal baclofen treatment.

  13. The independent association of anxiety with non-cardiac chest pain

    DEFF Research Database (Denmark)

    Smeijers, Loes; van de Pas, Harm; Nyklicek, Ivan

    2013-01-01

    the association between anxiety and NCCP is independent of personality factors. Participants with NCCP (N = 46; mean age 44.9 ± 14.7; 67% women) were evaluated for anxiety (Spielberger State-Trait Anxiety Inventory[STAI]), clinical measures and personality factors (negative affectivity and social inhibition......Non-cardiac chest pain (NCCP) is common in clinical cardiology. Anxiety is an important factor in NCCP because of its role in the neurobehavioural processes of pain regulation. It is not well established that which specific anxiety symptoms are disproportionately elevated in NCCP and whether...... measured by the Type D inventory). Item analysis was conducted for each of the anxiety symptoms. A healthy reference group was used for comparison purposes (N = 1233; mean age 55.2 ± 14.3; 50% women). Results showed that NCCP was associated with elevated anxiety levels (STAI ≥ 45) compared to the reference...

  14. Chest tube-delivered bupivacaine improves pain and decreases opioid use after thoracoscopy.

    Science.gov (United States)

    Demmy, Todd L; Nwogu, Chukwumere; Solan, Patrick; Yendamuri, Saikrishna; Wilding, Gregory; DeLeon, Oscar

    2009-04-01

    This study compared a simplified method of intrapleural bupivacaine administration with traditional analgesic therapy to decrease postoperative pain and opioid usage in patients after thoracoscopy. Thirty patients who had non-rib-spreading thoracoscopic operations under general anesthesia were prospectively randomized to no local anesthetic infusion (control), intermittent bolus (30 mL every 6 hours), or continuous infusion (5 mL/h). Bupivacaine (0.25%) was delivered through the pleural infusion channel of a specially designed single silicone 28F chest tube. Total intravenous fentanyl patient-controlled analgesia (boluses with basal rate) infused in the first 24 hours postoperatively was the designated primary study end point. Escalations of analgesic therapy, including ketorolac administration, were standardized across all groups. Nurses assessed pain control at onset and every 6 hours by visual analog pain scales (VAPS, 100 mm). VAPS were repeated 10 minutes later to assess any opioid or bupivacaine bolus effects. No study-related adverse events occurred. Compared with controls, pooled VAPS scores and 24-hour fentanyl consumption were significantly lower for the intermittent and continuous administration groups (1753 vs 1180 vs 1177 microg/24 h, respective median; p = 0.04) Early (6-hour) VAPS analgesic responses were more certain for intermittent (10 of 10) and continuous (10 of 10) patients than controls (7 of 10, p = .04). Five continuous patients successfully maintained VAPS scores below 20 mm throughout the study vs 3 intermittent and 2 controls (p = .045). Intermittent or continuous intrapleural bupivacaine infused through the chest tube reliably reduces postoperative pain and 24-hour opioid usage in thoracoscopy patients.

  15. The effect of Tc99m Sestamibi scans during acute chest pain on clinical management

    Energy Technology Data Exchange (ETDEWEB)

    Baldey, A.; Cameron, P.; Grigg, L.; Knott, J.; Better, N. [The Royal Melbourne Hospital, Parkville, VIC (Australia). Departments of Nuclear Medicine and Cardiology

    1998-06-01

    Full text: The aim of this study is to assess whether the increased sensitivity and specificity of Tc99m sestamibi scans, during acute chest pain, will lead to alteration in clinical management and potential cost saving in an Australian population. Consecutive patients who presented with acute chest pain were injected 800 MBq of Tc99m sestamibi during pain (Hot MlBI) and SPECT imaging performed 1-6 hours later. The population was those only with a `intermediate risk` of myocardial ischaemia The patients included in patients, those in the Emergency Department, and those with a previous history of cardiac disease. 25% of patients required a second, pain free study the following day to differentiate acute ischaemia from prior infarction. A question sheet was filled out by the requesting physician prior to the study indicating the likelihood of cardiac disease and the proposed management if no `Hot MIBI` scan was available. The treatment that the patient subsequently received was ascertained from the patient`s medical record. Of the 28 patients, a prediction whether to or not to proceed to coronary angiography was made in 13 patients prior to the MIBI study being performed. Of the 13, 5 would have had coronary angiography performed. and in all 5, the decision to proceed to coronary angiography was averted by the `Hot MIBI`. Of note, 3 patients were admitted purely because of an abnormal `Hot MIBI`. The `Hot MIBI` was able to reduce coronary care admissions by 83% reduce all admissions by 17%, and avert coronary angiography in 38% of patients. In this intermediate risk category patient, this translates to not only admissions saved but potential cost saving

  16. Acute non-traumatic gastrothorax: presentation of a case with chest pain and atypical radiologic findings

    Directory of Open Access Journals (Sweden)

    Deepwant\tSingh

    2016-03-01

    Full Text Available Una señora, previamente sana, de 71 años de edad acudió al departamento de emergencia con dolor agudo en el lado izquierdo del pecho. El examen físico no reveló hallazgos importantes y estaba hemodinámicamente estable. El electrocardiograma y la troponina estaban dentro de los límites normales, la radiografía de tórax mostró un diafragma elevado en el lado izquierdo. Dos horas después de ser admitida, esta señora empezó a respirar con dificultad y sufrió un paro cardíaco con actividad eléctrica sin pulso. Después de la reanimación cardiopulmonar, se evidenció el retorno de la circulación espontánea y la paciente recuperó la conciencia. Una segunda evaluación clínica del sistema respiratorio reveló a la percusión, disminución de la resonancia del lado izquierdo del tórax con hiperresonancia contralateral. La radiografía de tórax reveló una opacidad completa en el lado izquierdo del tórax y se obtuvo una mayor definición utilizando la angiografía pulmonar por tomografía computarizada, revelando un gastrotórax a tensión agudo causado por una hernia diafragmática. Se utilizó una sonda nasogástrica para descomprimir el estómago. La paciente se sometió a cirugía laparoscópica de emergencia para reducir la hernia sin complicaciones. Ella permaneció saludable durante un año de seguimiento.

  17. Acute non-traumatic gastrothorax: presentation of a case with chest pain and atypical radiologic findings

    OpenAIRE

    Deepwant Singh; Pieter Mackeith; Dipesh Pravin Gopal

    2016-01-01

    Una señora, previamente sana, de 71 años de edad acudió al departamento de emergencia con dolor agudo en el lado izquierdo del pecho. El examen físico no reveló hallazgos importantes y estaba hemodinámicamente estable. El electrocardiograma y la troponina estaban dentro de los límites normales, la radiografía de tórax mostró un diafragma elevado en el lado izquierdo. Dos horas después de ser admitida, esta señora empezó a respirar con dificultad y sufrió un paro cardíaco con actividad eléctri...

  18. Atypical odontalgia--a form of neuropathic pain that emulates dental pain.

    Science.gov (United States)

    Markman, Stanley; Howard, Jennifer; Quek, Sam

    2008-01-01

    In order for the neuropathic pain associated with AO to occur in the oral or facial area, a deafferentation process must be initiated as previously explained. Deafferentation happens when there is a trauma to tissues including, but not limited to, endodontic therapy, a surgical extraction or even a simple one, a deep scaling, an injurious dental injection, and even the placement of a crown. Thankfully, most patients heal uneventfully. Apparently a small percentage of patients have a genetic predisposition to deafferentation pain. In reviewing articles on this subject, there is often material about the inadvertent dental treatment of patients with AO. Many patients often have undergone numerous invasive procedures in an effort to ameliorate pain. It is not possible to read a research paper about AO without reading about the recurrent theme of either overtreatment or unnecessary treatment. Caution should be exercised when performing endodontic therapy solely for the relief of pain without objective need for such therapy. It is common for the AO patient to undergo many other irreversible dental treatments with no resolution of pain symptoms. When the dentist encounters a patient in pain for which there is no dental connection, he or she should strongly consider referring the patient to a facility or practitioner who has expertise in dealing with the non-dental source of dental pain.

  19. Chest pain and diarrhea: a case of Campylobacter jejuni-associated myocarditis.

    Science.gov (United States)

    Panikkath, Ragesh; Costilla, Vanessa; Hoang, Priscilla; Wood, Joseph; Gruden, James F; Dietrich, Bob; Gotway, Michael B; Appleton, Christopher

    2014-02-01

    Diarrhea and chest pain are common symptoms in patients presenting to the emergency department (ED). However, rarely is a relationship between these two symptoms established in a single patient. Describe a case of Campylobacter-associated myocarditis. A 43-year-old man with a history of hypertension presented to the ED with angina-like chest pain and a 3-day history of diarrhea. Electrocardiogram revealed ST-segment elevation in the lateral leads. Coronary angiogram revealed no obstructive coronary artery disease. Troponin T rose to 1.75 ng/mL. Cardiac magnetic resonance imaging showed subepicardial and mid-myocardial enhancement, particularly in the anterolateral wall and interventricular septum, consistent with a diagnosis of myocarditis. Stool studies were positive for Campylobacter jejuni. Campylobacter-associated myocarditis is rare, but performing the appropriate initial diagnostic testing, including stool cultures, is critical to making the diagnosis. Identifying the etiology of myocarditis as bacterial will ensure that appropriate treatment with antibiotics occurs in addition to any cardiology medications needed for supportive care. Copyright © 2014 Elsevier Inc. All rights reserved.

  20. Tender Endothelium Syndrome: Combination of Hypotension, Bradycardia, Contrast Induced Chest Pain, and Microvascular Angina

    Directory of Open Access Journals (Sweden)

    Shivesh Goberdhan

    2016-01-01

    Full Text Available Hypotension, bradycardia, and contrast induced chest pain are potential complications of cardiac catheterization and coronary angiography. Catheter-induced coronary spasm has been occasionally demonstrated, but its relationship to spontaneous coronary spasm is unclear. We describe a 64-year-old female who underwent coronary artery bypass surgery in 1998 on the basis of an angiographic diagnosis of severe left main disease, who recently presented with increasingly frequent typical angina. Repeat coronary angiography was immediately complicated by severe chest pain, hypotension, and bradycardia but demonstrated only mild disease of the left main artery and entire coronary tree with complete occlusion of her prior grafts. This reaction was almost identical to that observed during her original coronary angiogram. We now believe her original angiogram was complicated by severe catheter-induced left main spasm, with the accompanying contrast reaction attributed to left main disease, and the occlusion of coronary grafts explained by the absence of significant left main disease. The combination of these symptoms has not been documented in the literature. In this instance, these manifestations erroneously led to coronary bypass surgery. It is unknown whether routine, systematic injection of intracoronary nitroglycerin prior to angiography might blunt the severity of such reactions.

  1. Sex differences in clinical presentation, management and outcome in emergency department patients with chest pain.

    Science.gov (United States)

    Hess, Erik P; Perry, Jeffery J; Calder, Lisa A; Thiruganasambandamoorthy, Venkatesh; Roger, Veronique L; Wells, George A; Stiell, Ian G

    2010-09-01

    We sought to assess sex differences in clinical presentation, management and outcome in emergency department (ED) patients with chest pain, and to measure the association between female sex and coronary angiography within 30 days. We conducted a prospective cohort study in an urban academic ED between Jul. 1, 2007, and Apr. 1, 2008. We enrolled patients over 24 years of age with chest pain and possible acute coronary syndrome (ACS). Among the 970 included patients, 386 (39.8%) were female. Compared with men, women had a lower prevalence of known coronary artery disease (21.0% v. 34.2%, p women as having a low (stress testing between sexes, there was a lower rate of acute myocardial infarction (AMI) (4.7% v. 8.4%, p = 0.03) and positive stress test results (4.4% v. 7.9%, p = 0.03) in women. Women were less frequently referred for coronary angiography (9.3% v. 18.9%, p Women had a lower rate of AMI and a lower rate of positive stress test results despite similar rates of testing between sexes. Although women were less frequently referred for coronary angiography, these data suggest that sex differences in management were likely appropriate for the probability of disease.

  2. [Medico-legal features of early discharge in acute myocardial infarction and chest pain].

    Science.gov (United States)

    Montisci, M; Ruscazio, M; Snenghi, R; Nalin, S; Montisci, R; Iliceto, S; Ferrara, S D

    2001-06-01

    The authors' aim is to outline some of the main medico-legal problems in cardiology, especially those regarding the premature hospital discharge of patients with undefined chest pain and/or with acute myocardial infarction. After a brief overview on the etiology and clinical definition of chest pain and myocardial infarction, premature hospital discharge is defined and the incidental medico-legal risks that physicians operating in such situations are exposed to are pointed out. Next, the profiles regarding both the positive and negative views of professional medical responsibility are described. In the negative frame, the authors outline the most frequent civil and penal aspects of the unpremeditated responsibility. Then the physician's error, in both qualitative (generic or specific guilt) and quantitative (degree) terms, is considered; particularly, negligence, imprudence and inexperience, as qualitatively accepted meanings of generic guilt, are dealt with by adopting illustrative cases settled in the light of the right legal interpretation. The phases of the diagnostic or prognostic error are evaluated, and clinical protocols, as a reference parameter for the identification of error, are considered. Lastly, the problem of causality, essential condition for the judgment about the professional responsibility, and the problem of the patient's consent, including an evaluation of the legal capability or incapability about the declaration of consent, are examined closely.

  3. Chest Pain Centers: A Comparison of Accreditation Programs in Germany and the United States.

    Science.gov (United States)

    Breuckmann, Frank; Burt, David R; Melching, Kay; Erbel, Raimund; Heusch, Gerd; Senges, Jochen; Garvey, J Lee

    2015-06-01

    The implementation of chest pain centers (CPC)/units (CPU) has been shown to improve emergency care in patients with suspected cardiac ischemia. In an effort to provide a systematic and specific standard of care for patients with acute chest pain, the Society of Cardiovascular Patient Care (SCPC) as well as the German Cardiac Society (GCS) introduced criteria for the accreditation of specialized units. To date, 825 CPCs in the United States and 194 CPUs in Germany have been successfully certified by the SCPC or GCS, respectively. Even though there are differences in the accreditation processes, the goals are quite similar, focusing on enhanced operational efficiencies in the care of the acute coronary syndrome patients, reduced time delays, improved diagnostic and therapeutic strategies using adapted standard operating procedures, and increased medical as well as community awareness by the implementation of nationwide standardized concepts. In addition to national efforts, both societies have launched international initiatives, accrediting CPCs/CPU in the Middle East and China (SCPC) and Switzerland (GCS). Enhanced collaboration among international bodies interested in promoting high quality care might extend the opportunity for accreditation of facilities that treat cardiovascular patients, with national programs designed to meet local needs and local healthcare system requirements.

  4. [Dissecting intramural hematoma of the esophagus: a rare cause of chest pain].

    Science.gov (United States)

    Kimmoun, Antoine; Abboud, Georges; Steinbach, Gérard; Tellaroli, Jean-Claude; Bemer, Michel

    2008-03-01

    Dissecting intramural hematoma of the esophagus is a rare cause of chest pain that can be misinterpreted as a myocardial infarction. The use of anticoagulants in this case may lead to hemorrhagic complications. A 51-year-old patient, with coronary artery disease, diabetes, hypertension and dependent on both alcohol and tobacco, was admitted for chest pain and an elevated troponin T plasma level. He was treated with anticoagulants. He developed hematemesis on the third day and was transferred to intensive care. Esophageal endoscopy revealed a hematoma with active bleeding, covered by esophageal mucosa from the middle to the lower third of the esophagus (for 13 cm). Computed tomography allowed us to rule out an aortoesophageal fistula. Symptomatic treatment consisted of withdrawing the anticoagulant, mechanical ventilation, intravenous sedation, and blood transfusion. The patient recovered, after a long stay in ICU. Intramural dissecting hematoma of the esophagus is not always easy to diagnose. Administration of anticoagulant treatment after a misdiagnosis of acute coronary syndrome can have serious hemorrhagic consequences. Prognosis is excellent with conservative treatment.

  5. Acute chest pain: the role of MR imaging and MR angiography.

    Science.gov (United States)

    Hunold, Peter; Bischoff, Peter; Barkhausen, Jörg; Vogt, Florian M

    2012-12-01

    MR imaging (MRI) and MR angiography (MRA) have gained a high level of diagnostic accuracy in cardiovascular disease. MRI in cardiac disease has been established as the non-invasive standard of reference in many pathologies. However, in acute chest pain the situation is somewhat special since many of the patients presenting in the emergency department suffer from potentially life-threatening disease including acute coronary syndrome, pulmonary embolism, and acute aortic syndrome. Those patients need a fast and definitive evaluation under continuous monitoring of vital parameters. Due to those requirements MRI seems to be less suitable compared to X-ray coronary angiography and multislice computed tomography angiography (CTA). However, MRI allows for a comprehensive assessment of all clinically stable patients providing unique information on the cardiovascular system including ischemia, inflammation and function. Furthermore, MRI and MRA are considered the method of choice in patients with contraindications to CTA and for regular follow-up in known aortic disease. This review addresses specific features of MRI and MRA for different cardiovascular conditions presenting with acute chest pain. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

  6. The Associated with Mean Platelet Volume of the Presentation Clinical and Anjiographic of Chest Pain

    Directory of Open Access Journals (Sweden)

    Ceren Sen Tanrikulu

    2013-10-01

    Full Text Available Aim: Determination of risk factors in coronary heart disease has a very important place in the prevention of acute coronary syndromes besides in predicting the prognosis. Activated platelets and increased mean platelet volume play an important role in the pathogenesis of acute coronary syndromes. In our study, we investigated the relationship between MPV and chest pain, acute coronary syndromes. Material and Method: 330 patients with chest pain were included to the study. Control group consisted of 112 healthy individuals. Coronary anjiography was performed to 247 patients in in acute coronary syndrome group. The groups are compared in terms of parameters such as platelet counts, MPV, and troponin, according to its clinical and angiographic characteristics. Results: MPV leves was higher in study group than control group and there was statistically significant difference according to levels of MPV (p<0.05. There was no significant difference between groups according to levels of platelet. In clinical evaluation, there was significant difference according to MPV levels between the heart failure and other groups, and MPV levels were higher in heart failure group (p<0.05. In angiographic evaluation, there was no significant difference according to MPV and platelets levels between the groups. Discussion: In conclusion, we detected that mean platelet volumes were increased in patients presenting with acute coronary syndrome and heart failure, but we saw no difference between the subtypes of acute coronary syndrome. Based on these findings, we have concluded that larger platelet volumes may constitute a high risk for acute coronary syndrome.

  7. Acute chest pain: The role of MR imaging and MR angiography

    Energy Technology Data Exchange (ETDEWEB)

    Hunold, Peter, E-mail: peter.hunold@uk-sh.de [Clinic for Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck (Germany); Bischoff, Peter, E-mail: peter.bischoff@uk-sh.de [Clinic for Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck (Germany); Barkhausen, Jörg, E-mail: joerg.barkhausen@uk-sh.de [Clinic for Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck (Germany); Vogt, Florian M., E-mail: florian.vogt@uk-sh.de [Clinic for Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck (Germany)

    2012-12-15

    MR imaging (MRI) and MR angiography (MRA) have gained a high level of diagnostic accuracy in cardiovascular disease. MRI in cardiac disease has been established as the non-invasive standard of reference in many pathologies. However, in acute chest pain the situation is somewhat special since many of the patients presenting in the emergency department suffer from potentially life-threatening disease including acute coronary syndrome, pulmonary embolism, and acute aortic syndrome. Those patients need a fast and definitive evaluation under continuous monitoring of vital parameters. Due to those requirements MRI seems to be less suitable compared to X-ray coronary angiography and multislice computed tomography angiography (CTA). However, MRI allows for a comprehensive assessment of all clinically stable patients providing unique information on the cardiovascular system including ischemia, inflammation and function. Furthermore, MRI and MRA are considered the method of choice in patients with contraindications to CTA and for regular follow-up in known aortic disease. This review addresses specific features of MRI and MRA for different cardiovascular conditions presenting with acute chest pain.

  8. Nursing patients with acute chest pain: practice guided by the Prince Edward Island conceptual model for nursing.

    Science.gov (United States)

    Blanchard, Janelle F; Murnaghan, Donna A

    2010-01-01

    Current research suggests that pain is a relatively common phenomenon with 60-90% of patients presenting to emergency departments reporting pain (e.g., chest pain, trauma, extremity fractures and migraine headache) that require treatment [Hogan, S.L., 2005. Patient satisfaction with pain management in the emergency department. Advanced Emergency Nursing Journal 27(4), 284-294]. This article explores the use of conceptual theoretical empirical (C-T-E) framework to guide a senior nursing student in a case study of patient with chest pain. The Middle Range Theory of Pain described by Good [Good, M., 1998. A middle-range theory of acute pain management: use in research. Nursing Outlook 46(3), 120-124] and Melzack's [Melzack, R., 1987. The short-form McGill pain questionnaire. Pain, 30, 191-197] short form McGill pain questionnaire were applied along with the Prince Edward Island conceptual model (PEICM) for nursing. Results indicate that the nursing student increased her ability to work in partnership, assess relevant and specific information, and identify a number of strategies to help the patient achieve pain control by using a complement of pharmacological and non-pharmacological interventions. Moreover, the C-T-E approach provided an organized and systematic theoretical approach for the nursing student to assist a patient in pain control.

  9. Atypical presentation of macrophagic myofasciitis 10 years post vaccination.

    LENUS (Irish Health Repository)

    Ryan, Aisling M

    2012-02-03

    Macrophagic myofasciitis (MMF) is an uncommon inflammatory disorder of muscle believed to be due to persistence of vaccine-derived aluminium hydroxide at the site of injection. The condition is characterised by diffuse myalgias, arthralgia and fatigue. We describe a patient with histologically confirmed MMF whose presentation was atypical with left chest and upper limb pain beginning more than 10 years post vaccination. Treatment with steroids led to symptomatic improvement. Although rare, clinicians should consider MMF in cases of atypical myalgia.

  10. Long-Term Clinical Impact of Coronary CT Angiography in Patients With Recent Acute-Onset Chest Pain

    DEFF Research Database (Denmark)

    Linde, Jesper J; Hove, Jens D; Sørgaard, Mathias

    2015-01-01

    . BACKGROUND: The prognostic implications of a coronary CTA-guided treatment strategy have not been compared in a randomized fashion to standard care in patients referred for acute-onset chest pain. METHODS: Patients with acute chest pain but normal electrocardiograms and troponin values were randomized...... to treatment guided by either coronary CTA or standard care (bicycle exercise electrocardiogram or myocardial perfusion imaging). In the coronary CTA-guided group, a functional test was included in cases of nondiagnostic coronary CTA images or coronary stenoses of borderline severity. The primary endpoint...... electrocardiograms and troponin values compared to standard care with a functional test. (Cardiac-CT in the Treatment of Acute Chest Pain [CATCH]; NCT01534000)....

  11. Flow-mediated dilatation has no independent prognostic effect in patients with chest pain with or without ischaemic heart disease

    DEFF Research Database (Denmark)

    Ulriksen, Line Skjold; Malmqvist, Beata B; Hansen, Are

    2009-01-01

    OBJECTIVE: The purpose of this study was to assess the prognostic effect of flow-mediated dilatation (FMD) in patients with chest pain admitted to a coronary care unit. METHODS: Endothelium-dependent FMD in the brachial artery was examined in 223 patients with acute chest pain. All patients...... had significantly lower FMD than patients without IHD (p=0.002). During a mean follow-up of 4.2 years, 90 patients had an endpoint event, i.e. cardiovascular death, acute MI, unstable angina pectoris, PCI or CABG. In univariate analysis, FMD ... endpoint (p=0.04). In multivariate analysis, adjusted for age, gender, IHD and body mass index, no association between FMD and the combined endpoint was found (p=0.99). CONCLUSION: FMD is associated with IHD, but has no independent prognostic effect in patients with chest pain....

  12. The Emerging Roles of Coronary Computed Tomographic Angiography: Acute Chest Pain Evaluation and Screening for Asymptomatic Individuals.

    Science.gov (United States)

    Chien, Ning; Wang, Tzung-Dau; Chang, Yeun-Chung; Lin, Po-Chih; Tseng, Yao-Hui; Lee, Yee-Fan; Ko, Wei-Chun; Lee, Bai-Chin; Lee, Wen-Jeng

    2016-03-01

    Coronary computed tomographic angiography (CCTA) has been widely available since 2004. After that, the diagnostic accuracy of CCTA has been extensively validated with invasive coronary angiography for detection of coronary arterial stenosis. In this paper, we reviewed the updated evidence of the role of CCTA in both scenarios including acute chest pain and screening in asymptomatic adults. Several large-scale studies have been conducted to evaluate the diagnostic value of CCTA in the context of acute chest pain patients. CCTA could play a role in delivering more efficient care. For risk stratification of asymptomatic patients using CCTA, latest studies have revealed incremental benefits. Future studies evaluating the totality of plaque characteristics may be useful for determining the role of noncalcified plaque for risk stratification in asymptomatic individuals. Acute chest pain • Computed tomography • Coronary artery disease • Health screening • Stable angina.

  13. Effectiveness of using the front door score to enhance the chest pain triage accuracy of emergency nurse triage decisions.

    Science.gov (United States)

    Ho, Jonathan K M; Suen, Lorna K P

    2013-01-01

    Nurses lack a standard tool to stratify the risk of chest pain in triage patients. The type of risk stratification may correspond to the type of acuity rating of the 5-level triage scale adopted by nurses for chest pain triage, based on the Front Door Score, simplified from the Thrombolysis in Myocardial Infarction Risk Score for unstable angina or non-ST-segment elevation myocardial infarction. This study aimed to evaluate the ability of using the Front Door Score to enhance the accuracy of emergency nurse triage decisions for patients who present with chest pain. A cross-sectional descriptive design was used. A convenience sample of 200 subjects was obtained from an emergency department in Hong Kong. Data were collected via a questionnaire. The final physician diagnoses were used as the gold standard in justifying the appropriateness of the risk stratification of chest pain. The agreement rates among the final physician diagnoses, Thrombolysis in Myocardial Infarction Risk Score for unstable angina or non-ST-segment elevation myocardial infarction, nurses using the triage scale, and nurses using the Front Door Score were computed using κ statistics. A significant substantial agreement was observed between the final physician diagnoses and nurses using the Front Door Score. In comparison, the agreement between the final physician diagnoses and nurses using the triage scale was poor. The chest pain triage reliability of nurses using the Front Door Score was found to be much more credible than that of nurses using the triage scale. A suggested conversion of the scales of Front Door Score was established. The Front Door Score should be considered as a standard tool to enhance the chest pain triage accuracy of emergency nurse triage decisions.

  14. Fast assessment and management of chest pain without ST-elevation in the pre-hospital gateway: rationale and design.

    Science.gov (United States)

    Ishak, Maycel; Ali, Danish; Fokkert, Marion J; Slingerland, Robbert J; Dikkeschei, Bert; Tolsma, Rudolf T; Lichtveld, Rob A; Bruins, Wendy; Boomars, René; Bruheim, Kim; van Eenennaam, Fred; Timmers, Leo; Voskuil, Michiel; Doevendans, Pieter A; Mosterd, Arend; Hoes, Arno W; ten Berg, Jurriën M; van 't Hof, Arnoud W J

    2015-04-01

    For chest pain patients without ST-segment elevation in the pre-hospital setting, current clinical guidelines merely offer in-hospital risk stratification and management, as opposed to chest pain patients with ST-segment elevation for whom there is a straightforward pre-hospital strategy for diagnosis, medication regimen and logistics. The FAMOUS TRIAGE study will assess the effects of introducing a pre-hospital triage system that reliably stratifies chest pain patients without ST-segment elevation into 1) patients at high risk for NSTEMI requiring a direct transfer to a PCI-hospital; 2) patients at intermediate risk for a major adverse cardiac event (MACE) who could be evaluated at the nearest non-PCI hospital; and 3) patients at low risk for MACE (benign non-cardiac chest pain) who could have further evaluation at home or in a primary care setting. The FAMOUS TRIAGE study will be performed in three phases. In the first phase an appropriate pre-hospital risk stratification tool will be designed for chest pain patients without ST-segment elevation by means of a retrospective and a prospective study. The second phase of the project represents the external validation of the risk stratification models, and in the third and final phase an optimal risk stratification tool will be implemented into clinical practice. Clinical and economical endpoints before and after implementation of the pre-hospital risk stratification tool will be compared to assess clinical benefit and cost-effectiveness. The FAMOUS TRIAGE project is a triple phase study that aims to optimize the pre-hospital management of chest pain patients without ST-segment elevation by providing tools for pre-hospital identification of NSTEMI or exclusion of acute coronary syndrome at home. NTR4205. Dutch Trial Register [http://www.trialregister.nl]: trial number 4205. © The European Society of Cardiology 2014.

  15. Guided Internet-delivered cognitive behavioural therapy in patients with non-cardiac chest pain - a pilot randomized controlled study.

    Science.gov (United States)

    Mourad, Ghassan; Strömberg, Anna; Jonsbu, Egil; Gustafsson, Mikael; Johansson, Peter; Jaarsma, Tiny

    2016-07-26

    Patients with recurrent episodes of non-cardiac chest pain may experience cardiac anxiety and avoidance behavior, leading to increased healthcare utilization. These patients might benefit from help and support to evaluate the perception and management of their chest pain. The purpose of this study was to test the feasibility of a short guided Internet-delivered cognitive behavioural therapy (CBT) program and explore the effects on cardiac anxiety, fear of body sensations, depressive symptoms, and chest pain in patients with non-cardiac chest pain, compared with usual care. A pilot randomized controlled study was conducted. Fifteen patients with non-cardiac chest pain with cardiac anxiety or fear of body sensations, aged 22-76 years, were randomized to intervention (n = 7) or control (n = 8) groups. The four-session CBT program contained psychoeducation, physical activity, and relaxation. The control group received usual care. Data were collected before and after intervention. Five of seven patients in the intervention group completed the program, which was perceived as user-friendly with comprehensible language, adequate and varied content, and manageable homework assignments. Being guided and supported, patients were empowered and motivated to be active and complete the program. Patients in both intervention and control groups improved with regard to cardiac anxiety, fear of body sensations, and depressive symptoms, but no significant differences were found between the groups. The Internet-delivered CBT program seems feasible for patients with non-cardiac chest pain, but needs to be evaluated in larger groups and with a longer follow-up period. Clinicaltrials.gov NCT02336880 . Registered on 8 January 2015.

  16. Management of chest pain: exploring the views and experiences of chiropractors and medical practitioners in a focus group interview

    Directory of Open Access Journals (Sweden)

    Rowell Robert M

    2005-09-01

    Full Text Available Abstract Background We report on a multidisciplinary focus group project related to the appropriate care of chiropractic patients who present with chest pain. The prevalence and clinical management, both diagnosis and treatment, of musculoskeletal chest pain in ambulatory medical settings, was explored as the second dimension of the focus group project reported here. Methods This project collected observational data from a multidisciplinary focus group composed of both chiropractic and medical professionals. The goals of the focus group were to explore the attitudes and experiences of medical and chiropractic clinicians regarding their patients with chest pain who receive care from both medical and chiropractic providers, to identify important clinical or research questions that may inform the development of 'best practices' for coordinating or managing care of chest pain patients between medical and chiropractic providers, to identify important clinical or research questions regarding the diagnosis and treatment of chest pain of musculoskeletal origin, to explore various methods that might be used to answer those questions, and to discuss the feasibility of conducting or coordinating a multidisciplinary research effort along this line of inquiry. The convenience-sample of five focus group participants included two chiropractors, two medical cardiologists, and one dual-degreed chiropractor/medical physician. The focus group was audiotaped and transcripts were prepared of the focus group interaction. Content analysis of the focus group transcripts were performed to identify key themes and concepts, using categories of narratives. Results Six key themes emerged from the analysis of the focus group interaction, including issues surrounding (1 Diagnosis; (2 Treatment and prognosis; (3 Chest pain as a chronic, multifactorial, or comorbid condition; (4 Inter-professional coordination of care; (5 Best practices and standardization of care; and (6

  17. Chest CT findings in patients with non-cardiovascular causes of chest pain: Focusing on pulmonary tuberculosis in a tuberculosis endemic country

    Energy Technology Data Exchange (ETDEWEB)

    Lee, So Won; Shim, Sung Shine; Kim, Yoo Kyung; Ryu, Yon Ju [Mokdong Hospital, Ewha Womans University School of Medicine, Seoul (Korea, Republic of)

    2015-10-15

    To review the common causes of non-cardiovascular chest pain (NCCP) according to the location and lesion type as seen on chest CT, and to evaluate CT findings in tuberculosis (TB) as a cause of NCCP. In the period 2009 to 2012, patients having NCCP without definitive evidence of acute myocardial infarction, pulmonary thromboembolism, and aortic dissection, were included. In total, 162 patients (60.5% male; 39.5% female), with a mean age of 51 years, were enrolled. CT images were evaluated by location and lesion type, for causes of NCCP. Chest CT revealed that the most common location for the cause of NCCP was the pleura (45.1%), followed by the subpleural lung parenchyma (30.2%). The most common lesion causing NCCP was TB (33.3%), followed by pneumonia (19.1%). Of the 54 TB cases, 40 (74.1%) were stable TB and 14 (25.9%) were active TB; among these 54 patients, NCCP was most commonly the result of fibrotic pleural thickening (55.6%), followed by subpleural stable pulmonary TB (14.8%). Results of chest CT revealed that TB was a major cause of NCCP in a TB endemic area. Among the TB patients, fibrotic pleural thickening in patients with stable TB was the most common cause of NCCP.

  18. Compliance with stress testing in patients discharged from the emergency department following a diagnosis of low-risk chest pain.

    Science.gov (United States)

    Robinson, Kent; Prabhala, Shreyas

    2014-01-01

    To determine rates of compliance with outpatient stress testing in patients with a diagnosis of low-risk chest pain, reasons for non-compliance and incidence of adverse cardiac events (ACE). This was a prospective study of 79 patients who were discharged from the emergency department with low-risk chest pain. Patients were followed-up by phone interview. 36.7% of patients completed EST within 30 days, 2.5% of patients completed their EST within the recommended 72 h. A lack of time was the most common reason for non-compliance and was seen in 32.0% of patients. 20% of ESTs were cancelled by the primary care physician (PCP). 12% of patients were non-compliant, as they believed the pain to be non-cardiac. There were no documented ACEs in the study. Compliance with EST is poor in patients with low-risk chest pain. Non-compliance is related to a number of factors including work commitments, cancellation of studies by the PCP and patients beliefs about the nature of their chest pain.

  19. Differential effect of intravenous S-ketamine and fentanyl on atypical odontalgia and capsaicin-evoked pain

    DEFF Research Database (Denmark)

    Baad-Hansen, Lene; Juhl, Gitte Irene; Jensen, Troels Staehelin

    2007-01-01

    Atypical odontalgia (AO) is an intraoral pain condition of currently unknown mechanisms. In 10 AO patients and 10 matched healthy controls, we examined the effect of intravenous infusion of an N-methyl-D-aspartate (NMDA) receptor antagonist S-ketamine and a mu-opioid agonist fentanyl on spontaneous...

  20. Treatment efficacy for non-cardiovascular chest pain: a systematic review and meta-analysis.

    Directory of Open Access Journals (Sweden)

    Jakob M Burgstaller

    Full Text Available BACKGROUND: Non-cardiovascular chest pain (NCCP leads to impaired quality of life and is associated with a high disease burden. Upon ruling out cardiovascular disease, only vague recommendations exist for further treatment. OBJECTIVES: To summarize treatment efficacy for patients presenting with NCCP. METHODS: Systematic review and meta-analysis. In July 2013, Medline, Web of Knowledge, Embase, EBSCOhost, Cochrane Reviews and Trials, and Scopus were searched. Hand and bibliography searches were also conducted. Randomized controlled trials (RCTs evaluating non-surgical treatments in patients with NCCP were included. Exclusion criteria were poor study quality and small sample size (<10 patients per group. RESULTS: Thirty eligible RCT's were included. Most studies assessed PPI efficacy for gastroesophageal reflux disorders (GERD, n = 10. Two RCTs included musculoskeletal chest pain, seven psychotropic drugs, and eleven various psychological interventions. Study quality was high in five RCTs and acceptable in 25. PPI treatment in patients with GERD (5 RCTs, 192 patients was more effective than placebo [pooled OR 11.7 (95% CI 5.5 to 25.0, heterogeneity I2 = 6.1%]. The pooled OR in GERD negative patients (4 RCTs, 156 patients was 0.8 (95% CI 0.2 to 2.8, heterogeneity I2 = 50.4%. In musculoskeletal NCCP (2 RCTs, 229 patients manual therapy was more effective than usual care but not than home exercise [pooled mean difference 0.5 (95% CI -0.3 to 1.3, heterogeneity I2 = 46.2%]. The findings for cognitive behavioral treatment, serotonin reuptake inhibitors, tricyclic antidepressants were mixed. Most evidence was available for cognitive behavioral treatment interventions. LIMITATIONS: Only a small number of studies were available. CONCLUSIONS: Timely diagnostic evaluation and treatment of the disease underlying NCCP is important. For patients with suspected GERD, high-dose treatment with PPI is effective. Only limited evidence was available

  1. Triple rule-out computed tomography for risk stratification of patients with acute chest pain.

    Science.gov (United States)

    Chae, Minjung Kathy; Kim, Eun Kyoung; Jung, Ka-Young; Shin, Tae Gun; Sim, Min Seob; Jo, Ik-Joon; Song, Keun Jeong; Chang, Sung-A; Song, Young Bin; Hahn, Joo-Yong; Choi, Seung Hyuk; Gwon, Hyeon-Cheol; Lee, Sang-Hoon; Kim, Sung Mok; Eo, Hong; Choe, Yeon Hyeon; Choi, Jin-Ho

    2016-01-01

    Clinical evidence supporting triple rule-out computed tomography (TRO-CT) for rapid screening of cardiovascular disease is limited. We investigated the clinical value of TRO-CT in patients with acute chest pain. We retrospectively enrolled 1024 patients who visited the emergency department (ED) with acute chest pain and underwent TRO-CT using a 128-slice CT system. TRO-CT was classified as "positive" if it revealed clinically significant cardiovascular disease including obstructive coronary artery disease, pulmonary thromboembolism, or acute aortic syndrome. The clinical endpoint was occurrence of a major adverse cardiovascular event (MACE) within 30 days, defined by a composite of all cause death, myocardial infarction, revascularization, major cardiovascular surgery, or thrombolytic therapy. Clinical risk scores for acute chest pain including TIMI, GRACE, Diamond-Forrester, and HEART were determined and compared to the TRO-CT findings. TRO-CT revealed clinically significant cardiovascular disease in 239 patients (23.3%). MACE occurred in 119 patients (49.8%) with positive TRO-CT and in 7 patients (0.9%) with negative TRO-CT (p < 0.001). Sensitivity, specificity, positive predictive value, and negative predictive value of TRO-CT was 95%, 88%, 54%, and 99%, respectively. TRO-CT was a better discriminator between patients with vs. without events as compared to clinical risk scores (c-statistics = 0.91 versus 0.64 to 0.71; integrated discrimination improvement = 0.31 to 0.37; p < 0.001 for all comparisons). Patients with a negative TRO-CT showed shorter ED stay times and admission rates compared to patients with positive TRO-CT, irrespective of clinical risk scores (p < 0.001 for all comparisons). Triple rule-out CT has high predictive performance for 30-day MACE and permits rapid triage and low admission rates irrespective of clinical risk scores. Copyright © 2016 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights

  2. Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department

    NARCIS (Netherlands)

    Poldervaart, J M; Langedijk, M; Backus, B E; Dekker, I M C; Six, A.J.; Doevendans, P A; Hoes, A W; Reitsma, J B

    BACKGROUND: The performance of the GRACE, HEART and TIMI scores were compared in predicting the probability of major adverse cardiac events (MACE) in chest pain patients presenting at the emergency department (ED), in particular their ability to identify patients at low risk. METHODS: Chest pain

  3. Personality subtypes and chest pain in patients with nonobstructive coronary artery disease from the TweeSteden Mild Stenosis study : Mediating effect of anxiety and depression

    NARCIS (Netherlands)

    Mommersteeg, P.M.C.; Widdershoven, J.W.M.G.; Aarnoudse, W.; Denollet, Johan

    2016-01-01

    Background Patients presenting with chest pain in nonobstructive coronary artery disease (CAD, luminal narrowing <60%) are at risk for emotional distress and future events. We aimed to examine the association of personality subtypes with persistent chest pain, and investigated the potential

  4. Acute coronary syndrome critical pathway: chest PAIN caremap: a qualitative research study--provider-level intervention.

    Science.gov (United States)

    Saint-Jacques, Henock; Burroughs, Valentine J; Watkowska, Justyna; Valcarcel, Michelle; Moreno, Pedro; Maw, Myo

    2005-09-01

    Recently published data on healthcare performance continue to show a substantial gap between evidence-based guidelines and management of patients in real-world settings. This article describes an operational model that will be used to test whether a critical pathway applied in a secondary care-level institution may improve the process of care related to acute coronary syndromes (ACS). We have developed the pathway for management of all patients who present to our emergency department with a chief complaint of acute chest pain. Based on individual immediate ischemic event risk, patients are categorized according to a prespecified algorithm under the acronym of "PAIN" (P-Priority risk, A-Advanced risk, I-Intermediate risk, and N-Negative/low risk) as prespecified in an algorithm. Along with the algorithm come 2 detailed order sets, 1 for ST-elevation ACS and another for non ST-elevation ACS. The pathway, together with the 2 order sets, are color-coded with the "PAIN" acronym (P-red, A-yellow, I-yellow, N-green) that will guide patient management according to his or her risk stratification. These colors, similar to the road traffic light code, have been chosen as an easy reference for the provider about the sequential risk level of patients with ACS. This experimental model intends, with its unique structured approach, to increase awareness and improve adherence to the published American Heart Association/American College of Cardiology guidelines for the management of ACS.

  5. Non-invasive assessment of low- and intermediate-risk patients with chest pain.

    Science.gov (United States)

    Balfour, Pelbreton C; Gonzalez, Jorge A; Kramer, Christopher M

    2017-04-01

    Coronary artery disease (CAD) remains a significant global public health burden despite advancements in prevention and therapeutic strategies. Common non-invasive imaging modalities, anatomic and functional, are available for the assessment of patients with stable chest pain. Exercise electrocardiography is a long-standing method for evaluation for CAD and remains the initial test for the majority of patients who can exercise adequately with a baseline interpretable electrocardiogram. The addition of cardiac imaging to exercise testing provides incremental benefit for accurate diagnosis for CAD and is particularly useful in patients who are unable to exercise adequately and/or have uninterpretable electrocardiograms. Radionuclide myocardial perfusion imaging and echocardiography with exercise or pharmacological stress provide high sensitivity and specificity in the detection and further risk stratification of patients with CAD. Recently, coronary computed tomography angiography has demonstrated its growing role to rule out significant CAD given its high negative predictive value. Although less available, stress cardiac magnetic resonance provides a comprehensive assessment of cardiac structure and function and provides a high diagnostic accuracy in the detection of CAD. The utilization of non-invasive testing is complex due to various advantages and limitations, particularly in the assessment of low- and intermediate-risk patients with chest pain, where no single study is suitable for all patients. This review will describe currently available non-invasive modalities, along with current evidence-based guidelines and appropriate use criteria in the assessment of low- and intermediate-risk patients with suspected, stable CAD. Copyright © 2017 Elsevier Inc. All rights reserved.

  6. Prevalence of Coronary Microvascular Dysfunction Among Patients With Chest Pain and Nonobstructive Coronary Artery Disease.

    Science.gov (United States)

    Sara, Jaskanwal D; Widmer, R Jay; Matsuzawa, Yasushi; Lennon, Ryan J; Lerman, Lilach O; Lerman, Amir

    2015-09-01

    This study assessed the prevalence of coronary microvascular abnormalities in patients presenting with chest pain and nonobstructive coronary artery disease (CAD). Coronary microvascular abnormalities mediate ischemia and can lead to an increased risk of cardiovascular events. Using an intracoronary Doppler guidewire, endothelial-dependent microvascular function was examined by evaluating changes in coronary blood flow in response to acetylcholine, whereas endothelial-independent microvascular function was examined by evaluating changes in coronary flow velocity reserve in response to intracoronary adenosine. Patients were divided into 4 groups depending on whether they had a normal (+) or abnormal (-) coronary blood flow (CBF) in response to acetylcholine (Ach) and a normal (+) or abnormal (-) coronary flow velocity reserve (CFR) in response to adenosine (Adn): CBFAch+, CFRAdn+ (n = 520); CBFAch-, CFRAdn+ (n = 478); CBFAch+, CFRAdn- (n = 173); and CBFAch-, CFRAdn- (n = 268). Two-thirds of all patients had some sort of microvascular dysfunction. Women were more prevalent in each group (56% to 82%). Diabetes was uncommon in all groups (7% to 12%), whereas hypertension and hyperlipidemia were relatively more prevalent in each group, although rates for most conventional cardiovascular risk factors did not differ significantly between groups. There were no significant differences in the findings of noninvasive functional testing between groups. In a multivariable analysis, age was the only variable that independently predicted abnormal microvascular function. Patients with chest pain and nonobstructive CAD have a high prevalence of coronary microvascular abnormalities. These abnormalities correlate poorly with conventional cardiovascular risk factors and are dissociated from the findings of noninvasive functional testing. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

  7. Incremental value of exercise echocardiography over exercise electrocardiography in a chest pain unit.

    Science.gov (United States)

    Bouzas-Mosquera, Alberto; Peteiro, Jesús; Broullón, Francisco J; Álvarez-García, Nemesio; Rodríguez-Garrido, Jorge L; Mosquera, Víctor X; Martínez, Dolores; Yáñez, Juan C; Vázquez-Rodríguez, José M

    2015-11-01

    Limited data are available on the added value of exercise echocardiography (ExEcho) over exercise electrocardiography (ExECG) in patients with suspected acute coronary syndromes (ACS) referred to a chest pain unit. We aimed to assess the incremental value of ExEcho over ExECG in this setting. ExECG and ExEcho were performed in parallel in 1052 patients with suspected ACS, nondiagnostic but interpretable electrocardiograms, and negative serial troponin results. The primary outcome was a composite of coronary death, nonfatal myocardial infarction or unstable angina with angiographic documentation of significant coronary artery disease within 6 months. The primary outcome occurred in 2/614 patients (0.3%) with both negative ExECG and ExEcho, 3/60 (5%) with positive ExECG and negative ExEcho, 73/135 (54.1%) with negative ExECG and positive ExEcho, 106/136 (77.9%) with both positive ExECG and ExEcho, and 8/107 (7.5%) with inconclusive results. The addition of ExEcho data to a model based on clinical and ExECG data significantly increased the c statistic from 0.898 to 0.968 (change +0.070, 95% confidence interval 0.052-0.092), with a continuous net reclassification improvement of 1.56 and an integrated discrimination improvement of 22% (p<0.001). Decision curve analysis showed that a strategy of referral to coronary angiography based on ExEcho was associated with the highest net benefit and with the largest reduction in unnecessary coronary angiographies. ExEcho provides significant incremental prognostic information and higher net clinical benefit than a strategy based on ExECG in patients referred to a chest pain unit for suspected ACS and negative troponin levels. Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

  8. Diagnostic evaluation of the MRP-8/14 for the emergency assessment of chest pain.

    Science.gov (United States)

    Vora, Amit N; Bonaca, Marc P; Ruff, Christian T; Jarolim, Petr; Murphy, Sabina; Croce, Kevin; Sabatine, Marc S; Simon, Daniel I; Morrow, David A

    2012-08-01

    Elevated levels of myeloid-related protein (MRP)-8/14 (S100A8/A9) are associated with first cardiovascular events in healthy individuals and worse prognosis in patients with acute coronary syndrome (ACS). The diagnostic utility of MRP-8/14 in patients presenting to the emergency room with symptoms concerning for ACS is uncertain. MRP-8/14 was measured in serial serum and plasma samples in a single center prospective cohort-study of patients presenting to the emergency room with non-traumatic chest pain concerning for ACS. Final diagnosis was adjudicated by an endpoint committee. Of patients with baseline MRP-8/14 results (n = 411), the median concentration in serum was 1.57 μg/ml (25th, 75th: 0.87, 2.68) and in plasma was 0.41 μg/ml (MRP-8/14 was higher in patients presenting with MI (p MRP-8/14 was poor: sensitivity 28% (95% CI 20-38), specificity 82% (78-86), positive predictive value 36% (26-47), and negative predictive value 77% (72-81). The area under the ROC curve for diagnosis of MI with MRP-8/14 was 0.55 (95% CI 0.51-0.60) compared with 0.95 for cTnI. The diagnostic performance was not improved in early-presenters, patients with negative initial cTnI, or using later MRP-8/14 samples. Patients presenting with MI had elevated levels of serum MRP-8/14 compared to patients with non-cardiac chest pain. However, overall diagnostic performance of MRP-8/14 was poor and neither plasma nor serum MRP-8/14 offered diagnostic utility comparable to cardiac troponin.

  9. Exercise echocardiography and multidetector computed tomography for the evaluation of acute chest pain.

    Science.gov (United States)

    Mas-Stachurska, Aleksandra; Miró, Oscar; Sitges, Marta; de Caralt, Teresa M; Perea, Rosario J; López, Beatriz; Sánchez, Miquel; Paré, Carles; Bosch, Xavier; Ortiz-Pérez, José T

    2015-01-01

    Up to 4% of patients with acute chest pain, normal electrocardiogram, and negative troponins present major adverse cardiac events as a result of undiagnosed acute coronary syndrome. Our aim was to compare the diagnostic performance of multidetector computed tomography and exercise echocardiography in patients with a low-to-intermediate probability of coronary artery disease. We prospectively included 69 patients with acute chest pain, normal electrocardiogram, and negative troponins who underwent coronary tomography angiography and exercise echocardiography. Patients with coronary stenosis ≥ 50% or Agatston calcium score ≥ 400 on coronary tomography angiography or positive exercise echocardiography, or with inconclusive results, were admitted to rule out acute coronary syndrome. An acute coronary syndrome was confirmed in 17 patients (24.6%). This was lower than the suspected 42% based on coronary tomography angiography (Ppatients with pathological findings on coronary tomography angiography. The latter technique provided a higher sensitivity (100% vs 82.3%; P=.21) but lower specificity (76.9% vs 88.4%; P=.12) than exercise echocardiography for the diagnosis of acute coronary syndrome, although without reaching statistical significance. Increasing the stenosis cutoff point to 70% increased the specificity of coronary tomography angiography to 88.4%, while maintaining high sensitivity. Coronary tomography angiography offers a valid alternative to exercise echocardiography for the diagnosis of acute coronary syndrome among patients with low-to-intermediate probability of coronary artery disease. A combination of both techniques could improve the diagnosis of acute coronary syndrome. Copyright © 2014 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.

  10. Identifying patients for early discharge: performance of decision rules among patients with acute chest pain.

    Science.gov (United States)

    Mahler, Simon A; Miller, Chadwick D; Hollander, Judd E; Nagurney, John T; Birkhahn, Robert; Singer, Adam J; Shapiro, Nathan I; Glynn, Ted; Nowak, Richard; Safdar, Basmah; Peberdy, Mary; Counselman, Francis L; Chandra, Abhinav; Kosowsky, Joshua; Neuenschwander, James; Schrock, Jon W; Plantholt, Stephen; Diercks, Deborah B; Peacock, W Frank

    2013-09-30

    The HEART score and North American Chest Pain Rule (NACPR) are decision rules designed to identify acute chest pain patients for early discharge without stress testing or cardiac imaging. This study compares the clinical utility of these decision rules combined with serial troponin determinations. A secondary analysis was conducted of 1005 participants in the Myeloperoxidase In the Diagnosis of Acute coronary syndromes Study (MIDAS). MIDAS is a prospective observational cohort of Emergency Department (ED) patients enrolled from 18 US sites with symptoms suggestive of acute coronary syndrome (ACS). The ability to identify participants for early discharge and the sensitivity for ACS at 30 days were compared among an unstructured assessment, NACPR, and HEART score, each combined with troponin measures at 0 and 3h. ACS, defined as cardiac death, acute myocardial infarction, or unstable angina, occurred in 22% of the cohort. The unstructured assessment identified 13.5% (95% CI 11.5-16%) of participants for early discharge with 98% (95% CI 95-99%) sensitivity for ACS. The NACPR identified 4.4% (95% CI 3-6%) for early discharge with 100% (95% CI 98-100%) sensitivity for ACS. The HEART score identified 20% (95% CI 18-23%) for early discharge with 99% (95% CI 97-100%) sensitivity for ACS. The HEART score had a net reclassification improvement of 10% (95% CI 8-12%) versus unstructured assessment and 19% (95% CI 17-21%) versus NACPR. The HEART score with 0 and 3 hour serial troponin measures identifies a substantial number of patients for early discharge while maintaining high sensitivity for ACS. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

  11. Impact of Coronary Calcification on Clinical Management in Patients With Acute Chest Pain.

    Science.gov (United States)

    Bittner, Daniel O; Mayrhofer, Thomas; Bamberg, Fabian; Hallett, Travis R; Janjua, Sumbal; Addison, Daniel; Nagurney, John T; Udelson, James E; Lu, Michael T; Truong, Quynh A; Woodard, Pamela K; Hollander, Judd E; Miller, Chadwick; Chang, Anna Marie; Singh, Harjit; Litt, Harold; Hoffmann, Udo; Ferencik, Maros

    2017-05-01

    Coronary artery calcification (CAC) may impair diagnostic assessment of coronary computed tomography angiography (CTA). We determined whether CAC affects efficiency of coronary CTA in patients with suspected acute coronary syndrome (ACS). This is a pooled analysis of ACRIN-PA (American College of Radiology Imaging Network-Pennsylvania) 4005 and the ROMICAT-II trial (Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography) comparing an initial coronary CTA strategy to standard of care in acute chest pain patients. In the CTA arms, we investigated appropriateness of downstream testing, cost, and diagnostic yield to identify patients with obstructive coronary artery disease on subsequent invasive coronary angiography across CAC score strata (Agatston score: 0, >0-10, >10-100, >100-400, >400). Out of 1234 patients (mean age 51±8.8 years), 80 (6.5%) had obstructive coronary artery disease (≥70% stenosis) and 68 (5.5%) had ACS. Prevalence of obstructive coronary artery disease (1%-64%), ACS (1%-44%), downstream testing (4%-72%), and total (2337-8484 US$) and diagnostic cost (2310-6678 US$) increased across CAC strata (P400, cost to diagnose one ACS was lowest in this group (19 283 US$ versus 464 399 US$) as compared with patients without CAC. The diagnostic yield of invasive coronary angiography was highest in patients with CAC>400 (87% versus 38%). Downstream testing, total, and diagnostic cost increased with increasing CAC, but were found to be appropriate because obstructive coronary artery disease and ACS were more prevalent in patients with high CAC. In patients with acute chest pain undergoing coronary CTA, cost-efficient testing and excellent diagnostic yield can be achieved even with high CAC burden. URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01084239 and NCT00933400. © 2017 American Heart Association, Inc.

  12. BNP was Associated with Ischemic Myocardial Scintigraphy and Death in Patients at Chest Pain Unit

    Energy Technology Data Exchange (ETDEWEB)

    Azevedo, Jader Cunha de, E-mail: jadercazevedo@gmail.com [Universidade Federal Fluminense, Niterói, Rio de Janeiro, RJ (Brazil); Hospital Pró-Cardíaco, Rio de Janeiro, RJ (Brazil); Centro Universitário de Volta Redonda, Rio de Janeiro, RJ (Brazil); Reis, Bruno Cezario Costa; Barreto, Nathalia Monerat P.B. [Centro Universitário de Volta Redonda, Rio de Janeiro, RJ (Brazil); F, Diogenes S. Junior; Prezotti, Lais S. [Universidade Federal Fluminense, Niterói, Rio de Janeiro, RJ (Brazil); Procaci, Victor Rebelo; Octaviano, Vivian Werneck [Centro Universitário de Volta Redonda, Rio de Janeiro, RJ (Brazil); Volschan, Andre [Hospital Pró-Cardíaco, Rio de Janeiro, RJ (Brazil); Mesquita, Evandro Tinoco; Mesquita, Claudio Tinoco [Universidade Federal Fluminense, Niterói, Rio de Janeiro, RJ (Brazil); Hospital Pró-Cardíaco, Rio de Janeiro, RJ (Brazil)

    2015-01-15

    Recent studies have suggested that B-type Natriuretic Peptide (BNP) is an important predictor of ischemia and death in patients with suspected acute coronary syndrome. Increased levels of BNP are seen after episodes of myocardial ischemia and may be related to future adverse events. To determine the prognostic value of BNP for major cardiac events and to evaluate its association with ischemic myocardial perfusion scintigraphy (MPS). This study included retrospectively 125 patients admitted to the chest pain unit between 2002 and 2006, who had their BNP levels measured on admission and underwent CPM for risk stratification. BNP values were compared with the results of the MPS. The chi-square test was used for qualitative variables and the Student t test, for quantitative variables. Survival curves were adjusted using the Kaplan-Meier method and analyzed by using Cox regression. The significance level was 5%. The mean age was 63.9 ± 13.8 years, and the male sex represented 51.2% of the sample. Ischemia was found in 44% of the MPS. The mean BNP level was higher in patients with ischemia compared to patients with non-ischemic MPS (188.3 ± 208.7 versus 131.8 ± 88.6; p = 0.003). A BNP level greater than 80 pg/mL was the strongest predictor of ischemia on MPS (sensitivity = 60%, specificity = 70%, accuracy = 66%, PPV = 61%, NPV = 70%), and could predict medium-term mortality (RR = 7.29, 95% CI: 0.90-58.6; p = 0.045) independently of the presence of ischemia. BNP levels are associated with ischemic MPS findings and adverse prognosis in patients presenting with acute chest pain to the emergency room, thus, providing important prognostic information for an unfavorable clinical outcome.

  13. A randomized clinical trial of chiropractic treatment and self-management in patients with acute musculoskeletal chest pain

    DEFF Research Database (Denmark)

    Stochkendahl, Mette J; Christensen, Henrik W; Vach, Werner

    2012-01-01

    We have previously reported short-term follow-up from a pragmatic randomized clinical trial comparing 2 treatments for acute musculoskeletal chest pain: (1) chiropractic treatment and (2) self-management. Results indicated a positive effect in favor of the chiropractic treatment after 4 and 12...

  14. Point-of-Care Testing and Cardiac Biomarkers: The Standard of Care and Vision for Chest Pain Centers.

    Science.gov (United States)

    Kost, Gerald J; Tran, Nam K

    2005-11-01

    Point-of-care testing (POCT) is defined as testing at or near the site of patient care. POCTdecreases therapeutic turnaround time (TTAT), increases clinical efficiency, and improves medical and economic outcomes. TTAT represents the time from test ordering to patient treatment. POC technologies have become ubiquitous in the United States, and, therefore,so has the potential for speed, convenience, and satisfaction, strong advantages for physicians, nurses, and patients in chest pain centers. POCT is applied most beneficially through the collaborative teamwork of clinicians and laboratorians who use integrative strategies, performance maps, clinical algorithms, and care paths (critical pathways). For example, clinical investigators have shown that on-site integration of testing for cardiac injury markers (myoglobin, creatinine kinase myocardial band [CKMB],and cardiac troponin I [cTnI]) in accelerated diagnostic algorithms produces effective screening, less hospitalization, and substantial savings. Chest pain centers, which now total over 150 accredited in the United States, incorporate similar types of protocol-driven performance enhancements. This optimization allows chest pain centers to improve patient evaluation, treatment, survival, and discharge. This article focuses on cardiac biomarker POCT for chest pain centers and emergency medicine.

  15. Drug-induced chest pain and myocardial infarction. Reports to a national centre and review of the literature

    NARCIS (Netherlands)

    J.P. Ottervanger (Jan Paul); J.H.P. Wilson (Paul); B.H.Ch. Stricker (Bruno)

    1997-01-01

    textabstractObjectives: To analyse reports of drug-induced myocardial infarction and chest pain sent to a national reporting centre. To review which drugs were suspected of exhibiting these adverse events and what mechanisms were involved. Methods: During the 20-year period 1975 through 1994, a

  16. Comparison of the diagnostic accuracy of ischemia-modified albumin and echocardiography in patients with acute chest pain.

    Science.gov (United States)

    Kountana, Evangelia; Tziomalos, Konstantinos; Semertzidis, Panagiotis; Dogrammatzi, Fani; Slavakis, Aristidis; Douma, Stella; Zamboulis, Chrysanthos; Geleris, Paraschos

    2013-01-01

    Several imaging tests and biomarkers have been proposed for the identification of patients with unstable angina among those presenting to the emergency department with acute chest pain. Preliminary data suggest that ischemia-modified albumin (IMA) may represent a potentially useful biomarker in these patients. To compare IMA and echocardiography in excluding unstable angina in patients with acute chest pain. Thirty-three patients (mean [± SD] age 59.8±10.8 years; 28 men) presenting to the emergency department with acute chest pain lasting acute coronary syndrome, with normal or non-diagnostic electrocardiograms, and creatine kinase MB and troponin levels within the normal range, were included in the present study. After further diagnostic evaluation, five patients (15.2%) were diagnosed with unstable angina. The sensitivity, specificity, positive predictive value and negative predictive (NPV) value of echocardiography for diagnosing unstable angina was 60.0%, 89.3%, 50.0% and 92.6%, respectively. The area under the ROC curve for diagnosing unstable angina based on the serum IMA levels was 0.193 (95% CI 0.047 to 0.339; Ppatients presenting to the emergency department with acute chest pain. Moreover, IMA shows an NPV that is comparable with echocardiography.

  17. Dual-source CT in chest pain diagnosis; Dual-source-CT in der Diagnostik des Thoraxschmerzes

    Energy Technology Data Exchange (ETDEWEB)

    Johnson, Thorsten R.C.; Nikolaou, K.; Fink, C.; Rist, C.; Reiser, M.F.; Becker, C.R. [Klinikum Grosshadern der Ludwig-Maximilians-Universitaet Muenchen, Institut fuer Klinische Radiologie, Muenchen (Germany); Becker, A.; Knez, A. [Klinikum Grosshadern der Ludwig-Maximilians-Universitaet Muenchen, Abteilung Kardiologie, Medizinische Klinik I, Muenchen (Germany)

    2007-04-15

    With the depiction of pulmonary arteries, coronary arteries, and the aorta, CT angiography of the chest offers a comprehensive diagnostic work-up of unclear chest pain. The aim of this study was to assess the diagnostic accuracy of dual-source CT in this patient group. A total of 47 patients suffering from unclear chest pain were examined with a Siemens Somatom Definition. Volume and flow of contrast media (Ultravist, Schering) were adapted to the body weight. The examinations were evaluated with regard to image quality and contrast opacification and to the diagnostic accuracy with reference to the final clinical diagnosis. Adequate contrast opacification was achieved in all examinations. The depiction of the coronary arteries was diagnostic in all cases. The cause of chest pain could be identified in 41 cases. Among the diagnoses were coronary and myocardial pathologies, valvular disease, aortic aneurysms and dissections, pulmonary embolism, and pneumonic consolidation. DSCT angiography of the chest offers a very good image quality even at high heart rates so that a high diagnostic accuracy is achieved in patients with acute chest pain. (orig.) [German] Die EKG-getriggerte CT-Angiographie kann mit der Darstellung von Koronar-, Lungenarterien und Aorta eine umfassende Abklaerung des unklaren Thoraxschmerzes leisten. Ziel unserer Untersuchungen war es, die diagnostische Wertigkeit des Dual-source-CT in diesem Patientenkollektiv festzustellen. 47 Patienten mit unklarem Thoraxschmerz wurden an einem Siemens Somatom Definition untersucht. Menge und Injektionsgeschwindigkeit des Kontrastmittels (Ultravist, Schering) wurden auf das Koerpergewicht adaptiert. Die Untersuchungen wurden hinsichtlich der Bildqualitaet und Kontrastierung sowie der diagnostischen Genauigkeit im Vergleich zur endgueltigen klinischen Diagnose beurteilt. Bei allen Untersuchungen wurde eine ausreichende Kontrastierung erzielt. Die Darstellung der Koronararterien war in allen Faellen diagnostisch

  18. Triple Rule Out versus CT Angiogram Plus Stress Test for Evaluation of Chest Pain in the Emergency Department

    Directory of Open Access Journals (Sweden)

    Kelly N. Sawyer

    2015-10-01

    Full Text Available Introduction: Undifferentiated chest pain in the emergency department (ED is a diagnostic challenge. One approach includes a dedicated chest computed tomography (CT for pulmonary embolism or dissection followed by a cardiac stress test (TRAD. An alternative strategy is a coronary CT angiogram with concurrent chest CT (Triple Rule Out, TRO. The objective of this study was to describe the ED patient course and short-term safety for these evaluation methods. Methods: This was a retrospective observational study of adult patients presenting to a large, community ED for acute chest pain who had non-diagnostic electrocardiograms (ECGs and normal biomarkers. We collected demographics, ED length of stay, hospital costs, and estimated radiation exposures. We evaluated 30-day return visits for major adverse cardiac events. Results: A total of 829 patients underwent TRAD, and 642 patients had TRO. Patients undergoing TRO tended to be younger (mean 52.3 vs 56.5 years and were more likely to be male (42.4% vs. 30.4%. TRO patients tended to have a shorter ED length of stay (mean 14.45 vs. 21.86 hours, to incur less cost (median $449.83 vs. $1147.70, and to be exposed to less radiation (median 7.18 vs. 16.6mSv. No patient in either group had a related 30-day revisit. Conclusion: Use of TRO is feasible for assessment of chest pain in the ED. Both TRAD and TRO safely evaluated patients. Prospective studies investigating this diagnostic strategy are needed to further assess this approach to ED chest pain evaluation.

  19. Triple Rule Out versus CT Angiogram Plus Stress Test for Evaluation of Chest Pain in the Emergency Department.

    Science.gov (United States)

    Sawyer, Kelly N; Shah, Payal; Qu, Lihua; Kurz, Michael C; Clark, Carol L; Swor, Robert A

    2015-09-01

    Undifferentiated chest pain in the emergency department (ED) is a diagnostic challenge. One approach includes a dedicated chest computed tomography (CT) for pulmonary embolism or dissection followed by a cardiac stress test (TRAD). An alternative strategy is a coronary CT angiogram with concurrent chest CT (Triple Rule Out, TRO). The objective of this study was to describe the ED patient course and short-term safety for these evaluation methods. This was a retrospective observational study of adult patients presenting to a large, community ED for acute chest pain who had non-diagnostic electrocardiograms (ECGs) and normal biomarkers. We collected demographics, ED length of stay, hospital costs, and estimated radiation exposures. We evaluated 30-day return visits for major adverse cardiac events. A total of 829 patients underwent TRAD, and 642 patients had TRO. Patients undergoing TRO tended to be younger (mean 52.3 vs 56.5 years) and were more likely to be male (42.4% vs. 30.4%). TRO patients tended to have a shorter ED length of stay (mean 14.45 vs. 21.86 hours), to incur less cost (median $449.83 vs. $1147.70), and to be exposed to less radiation (median 7.18 vs. 16.6 mSv). No patient in either group had a related 30-day revisit. Use of TRO is feasible for assessment of chest pain in the ED. Both TRAD and TRO safely evaluated patients. Prospective studies investigating this diagnostic strategy are needed to further assess this approach to ED chest pain evaluation.

  20. Chest pain in an out-of-hospital emergency setting: no relationship between pain severity and diagnosis of acute myocardial infarction.

    Science.gov (United States)

    Galinski, Michel; Saget, Diane; Ruscev, Mirko; Gonzalez, Geraldine; Ameur, Lydia; Lapostolle, Frédéric; Adnet, Frédéric

    2015-04-01

    Chest pain frequently prompts emergency medical services (EMS) call-outs. Early management of acute coronary syndrome (ACS) cases is crucial, but there is still controversy over the relevance of pain severity as a diagnostic criterion. The aim of this study was to determine whether there is a relationship between the severity of chest pain at the time of out-of-hospital emergency care and diagnosis of acute myocardial infarction (AMI). This was a subsidiary analysis of prehospital data collated prospectively by EMS in a large suburb. It concerned patients with chest pain taken to hospital by a mobile intensive care unit. Pain was rated on EMS arrival using a visual analog, numeric or verbal rating scale and classified on severe or not severe according to the pain score. A diagnosis of AMI was confirmed or ruled out on the basis of 2 plasma troponin measurements and/or coronary angiography results. Among the cohort of 2,279 patients included, 234 were suitable for analysis, of which 109 (47%) were diagnosed with AMI. The rate of severe pain on EMS arrival was not significantly different between AMI patients and no myocardial infarction patients (49% [95% CI 40 to 58] and 43% [34 to 52], respectively; P = 0.3; odds ratio 1.3 [0.8 - 2.3] after adjustment for age and gender). In our out-of-hospital emergency setting, the severity of chest pain was not a useful diagnostic criterion for AMI. © 2014 World Institute of Pain.

  1. Best Clinical Practice: Current Controversies in the Evaluation of Low-Risk Chest Pain with Risk Stratification Aids. Part 2.

    Science.gov (United States)

    Long, Brit; Koyfman, Alex

    2017-01-01

    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). We investigated controversies in the evaluation of patients with low-risk chest pain, including clinical scores, decision pathways, and shared decision-making. ED patients with chest pain who have negative biomarker results and nonischemic electrocardiograms are at low risk for MACE. With the large number of chest pain patients evaluated in the ED, several risk scores and pathways are in use based on history, electrocardiographic results, and biomarker results. The Thrombolysis in Myocardial Infarction and Global Registry of Acute Coronary Events scores are older rules with validation; however, they do not have adequate sensitivity or are not easy to use in the ED. The Vancouver chest pain and North American chest pain rules may be used for patients with undifferentiated chest pain in the ED. The Manchester Acute Coronary Syndromes rule uses eight factors, several of which are not available in the United States. The history, electrocardiography, age, risk factors, and troponin (HEART) score and pathway are easy to use, have high sensitivity and negative predictive values, and have better discriminatory capability for categorization. The use of pathways with shared decision-making involves the patient in management, shortens the duration of stay, and decreases risk to both the patient and the provider. Risk stratification of ED patients with chest pain has evolved, and there are many tools available. The HEART pathway, designed for ED use, has several attributes that provide safe and efficient care for patients with chest pain. Copyright © 2016 Elsevier Inc. All rights reserved.

  2. Sudden death after chest pain: feasibility of virtual autopsy with postmortem CT angiography and biopsy.

    Science.gov (United States)

    Ross, Steffen G; Thali, Michael J; Bolliger, Stephan; Germerott, Tanja; Ruder, Thomas D; Flach, Patricia M

    2012-07-01

    To determine the potential of minimally invasive postmortem computed tomographic (CT) angiography combined with image-guided tissue biopsy of the myocardium and lungs in decedents who were thought to have died of acute chest disease and to compare this method with conventional autopsy as the reference standard. The responsible justice department and ethics committee approved this study. Twenty corpses (four female corpses and 16 male corpses; age range, 15-80 years), all of whom were reported to have had antemortem acute chest pain, were imaged with postmortem whole-body CT angiography and underwent standardized image-guided biopsy. The standard included three biopsies of the myocardium and a single biopsy of bilateral central lung tissue. Additional biopsies of pulmonary clots for differentiation of pulmonary embolism and postmortem organized thrombus were performed after initial analysis of the cross-sectional images. Subsequent traditional autopsy with sampling of histologic specimens was performed in all cases. Thereafter, conventional histologic and autopsy reports were compared with postmortem CT angiography and CT-guided biopsy findings. A Cohen κ coefficient analysis was performed to explore the effect of the clustered nature of the data. In 19 of the 20 cadavers, findings at postmortem CT angiography in combination with CT-guided biopsy validated the cause of death found at traditional autopsy. In one cadaver, early myocardial infarction of the papillary muscles had been missed. The Cohen κ coefficient was 0.94. There were four instances of pulmonary embolism, three aortic dissections (Stanford type A), three myocardial infarctions, three instances of fresh coronary thrombosis, three cases of obstructive coronary artery disease, one ruptured ulcer of the ascending aorta, one ruptured aneurysm of the right subclavian artery, one case of myocarditis, and one pulmonary malignancy with pulmonary artery erosion. In seven of 20 cadavers, CT-guided biopsy

  3. Chest pain control with kinesiology taping after lobectomy for lung cancer: initial results of a randomized placebo-controlled study.

    Science.gov (United States)

    Imperatori, Andrea; Grande, Annamaria; Castiglioni, Massimo; Gasperini, Laura; Faini, Agnese; Spampatti, Sebastiano; Nardecchia, Elisa; Terzaghi, Lorena; Dominioni, Lorenzo; Rotolo, Nicola

    2016-08-01

    Kinesiology taping (KT) is a rehabilitative technique performed by the cutaneous application of a special elastic tape. We tested the safety and efficacy of KT in reducing postoperative chest pain after lung lobectomy. One-hundred and seventeen consecutive patients, both genders, age 18-85, undergoing lobectomy for lung cancer between January 2013 and July 2015 were initially considered. Lobectomies were performed by the same surgical team, with thoracotomy or video-assisted thoracoscopic surgery (VATS) access. Exclusion criteria (n = 25 patients) were: previous KT exposure, recent trauma, pre-existing chest pain, lack of informed consent, >24-h postoperative intensive care unit treatment. After surgery, the 92 eligible patients were randomized to KT experimental group (n = 46) or placebo control group (n = 46). Standard postoperative analgesia was administered in both groups (paracetamol/non-steroidal anti-inflammatory drugs, epidural analgesia including opioids), with supplemental analgesia boluses at patient request. On postoperative day 1 in addition, in experimental group patients a specialized physiotherapist applied KT, with standardized tape length, tension and shape, over three defined skin areas: at the chest access site pain trigger point; over the ipsilateral deltoid/trapezius; lower anterior chest. In control group, usual dressing tape mimicking KT was applied over the same areas, as placebo. Thoracic pain severity score [visual analogue scale (VAS) ranging 0-10] was self-assessed by all patients on postoperative days 1, 2, 5, 8, 9 and 30. The KT group and the control group had similar demographics, lung cancer clinico-pathological features and thoracotomy/VATS ratio. Postoperatively, the two groups also resulted similar in supplemental analgesia, complication rate, mean duration of chest drainage and length of stay. There were no adverse events with KT application. After tape application, KT patients reported overall less thoracic pain than the

  4. Primary atypical sacral meningioma- not always benign

    Energy Technology Data Exchange (ETDEWEB)

    Bhadra, A.K.; Casey, A.T.H.; Saifuddin, A.; Briggs, T.W. [Royal National Orthopaedic Hospital, Stanmore, London (United Kingdom)

    2007-06-15

    We present a case of an atypical recurrent meningioma of the sacrum with pulmonary metastasis in a 31-year-old man. He presented with deep-seated buttock pain and urinary hesitancy for 3 months. MRI revealed a lesion occupying the central and left side of the sacral canal at the S1-S2 level. Surgical excision of the lesion via a posterior approach was undertaken, and the patient became symptom-free post-operatively. Histology confirmed atypical meningioma. Eight months later he re-presented with similar symptoms, and MRI confirmed local recurrence. The patient underwent left hemisacrectomy. Six months later he again presented with low back pain and MRI confirmed a second local recurrence. A CT scan of the chest showed multiple lung metastases. The patient died of a severe chest infection 18 months later. (orig.)

  5. Correlation of serum visfatin level with chest pain scoring as an indication of myocardial ischemia in chronic kidney disease patients

    Directory of Open Access Journals (Sweden)

    Mohamed F Almaghraby

    2014-01-01

    Conclusion It could be concluded that patients with CKD are at an actual risk of developing CP secondary to myocardial ischemic attack, presenting either as typical or as atypical anginal pain. Elevated serum visfatin levels may be the cornerstone for the relationship between CKD and coronary heart disease. Serum visfatin levels in range of 12.4-16.4 ng/ml could predict the possibility of developing an anginal attack in patients with atypical anginal CP, with high sensitivity and specificity for diagnosis.

  6. Protocol Adherence in Prehospital Medical Care Provided for Patients with Chest Pain and Loss of Consciousness; a Brief Report

    Directory of Open Access Journals (Sweden)

    Mostafa Mehrara

    2017-01-01

    Full Text Available Introduction: Although many protocols are available in the field of the prehospital medical care (PMC, there is still a notable gap between protocol based directions and applied clinical practice. This study measures the rate of protocol adherence in PMC provided for patients with chest pain and loss of consciousness (LOC.Method: In this cross-sectional study, 10 educated research assistants audited the situation of provided PMC for non-traumatic chest pain and LOC patients, presenting to the emergency department of a tertiary level teaching hospital, compare to national recommendations in these regards.Results: 101 cases with the mean age of 56.7 ± 12.3 years (30-78 were audited (55.4% male. 61 (60.3% patients had chest pain and 40 (39.7% cases had LOC. Protocol adherence rates for cardiac monitoring (62.3%, O2 therapy (32.8%, nitroglycerin administration (60.7%, and aspirin administration (52.5% in prehospital care of patients with chest pain were fair to poor. Protocol adherence rates for correct patient positioning (25%, O2 therapy (75%, cardiac monitoring (25%, pupils examination (25%, bedside glucometery (50%, and assessing for naloxone administration (55% in prehospital care of patients with LOC were fair to poor.Conclusion: There were more than 20% protocol violation regarding prehospital care of chest pain patients regarding cardiac monitoring, O2 therapy, and nitroglycerin and aspirin administration. There were same situation regarding O2 therapy, positioning, cardiac monitoring, pupils examination, bedside glucometery, and assessing for naloxone administration of LOC patients in prehospital setting.

  7. Characteristics of chest pain and its acute management in a low-middle income country: analysis of emergency department surveillance data from Pakistan.

    Science.gov (United States)

    Paichadze, Nino; Afzal, Badar; Zia, Nukhba; Mujeeb, Rakshinda; Khan, Muhammad; Razzak, Junaid A

    2015-01-01

    Chest pain is one of the most frequent causes of emergency department (ED) visits in high-income countries. Little is known about chest pain patients presenting to EDs of low- and middle-income countries (LMICs). The objective of this study was to describe the characteristics of chest pain patients presenting to emergency departments (EDs) of Pakistan and to determine the utilization of ED resources in the management of chest pain patients and their outcomes. This study used pilot active surveillance data from seven major EDs in Pakistan. Data were collected on all patients presenting to the EDs of the participating sites to seek emergency care for chest pain. A total of 20,435 patients were admitted to the EDs with chest pain. The majority were males (M 60%, F 40%) and the mean age was 42 years (SD+/- 14). The great majority (97%, n = 19,164) of patients were admitted to the EDs of public hospitals compared to private hospitals and only 3% arrived by ambulance. Electrocardiograms (ECGs) were used in more than half of all chest pain patients (55%, n = 10,890) while cardiac enzymes were performed in less than 5% of cases. Chest X-rays were the most frequently performed radiological procedure (21%, n = 4,135); more than half of the admitted chest pain patients were discharged from the EDs and less than 1% died in the ED. Chest pain is a common presenting complaint in EDs in Pakistan. The majority received an ECG and the use of diagnostic testing, such as cardiac enzymes, is quite uncommon.

  8. Diagnostic importance of admission platelet volume indices in patients with acute chest pain suggesting acute coronary syndrome.

    Science.gov (United States)

    Dehghani, Mohammad Reza; Taghipour-Sani, Leila; Rezaei, Yousef; Rostami, Rahim

    2014-01-01

    Acute coronary syndrome (ACS) is a challenging issue in cardiovascular medicine. Given platelet role in atherothrombosis, we sought to determine whether platelet indices can be used as diagnostic tests for patients who suffered from an acute chest discomfort. We prospectively enrolled 862 patients with an acute chest pain and 184 healthy matched controls. They were divided into four groups: 184 controls, 249 of non-ACS, 421 of unstable angina (UA), and 192 of myocardial infarction (MI) cases. Blood samples were collected at admission to the emergency department for routine hematologic tests. The mean platelet volume (MPV), platelet distribution width (PDW), and platelet large cell ratio (P-LCR) were significantly greater in patients with MI compared with those of non-ACS or control subjects. Negative and significant correlations existed between MPV, PDW, and P-LCR values and platelet count (P chest discomfort. The sensitivities and specificities were found to be 72% and 40%, 73% and 37%, and 68% and 44% for MPV, PDW, and P-LCR, respectively. An elevated admission MPV, PDW, and P-LCR may be of benefit to detect chest pain resulting in MI from that of non-cardiac one, and also for risk stratification of patients who suffered from an acute chest discomfort. Copyright © 2014 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

  9. Physical therapy intervention in patients with non-cardiac chest pain following a recent cardiac event: A randomized controlled trial

    Directory of Open Access Journals (Sweden)

    Astrid T Berg

    2015-04-01

    Full Text Available Objectives: To assess the effect of two different physical therapy interventions in patients with stable coronary heart disease and non-cardiac chest pain. Methods: A randomized controlled trial was carried out at a university hospital in Norway. A total of 30 patients with known and stable coronary heart disease and self-reported persistent chest pain reproduced by palpation of intercostal trigger points were participating in the study. The intervention was deep friction massage and heat pack versus heat pack only. The primary outcome was pain intensity after the intervention period and 3 months after the last treatment session, measured by Visual Analogue Scale, 0 to 100. Secondary outcome was health-related quality of life. Results: Treatment with deep friction massage and heat pack gave significant pain reduction compared to heat pack only (–17.6, 95% confidence interval: –30.5, –4.7; p < 0.01, and the reduction was persistent at 3 months’ follow-up (–15.2, 95% confidence interval: –28.5, –1.8; p = 0.03. Health-related quality of life improved in all three domains in patients with no significant difference between groups. Conclusion: Deep friction massage combined with heat pack is an efficient treatment of musculoskeletal chest pain in patients with stable coronary heart disease.

  10. A simple statistical model for prediction of acute coronary syndrome in chest pain patients in the emergency department

    Directory of Open Access Journals (Sweden)

    Edenbrandt Lars

    2006-07-01

    Full Text Available Abstract Background Several models for prediction of acute coronary syndrome (ACS among chest pain patients in the emergency department (ED have been presented, but many models predict only the likelihood of acute myocardial infarction, or include a large number of variables, which make them less than optimal for implementation at a busy ED. We report here a simple statistical model for ACS prediction that could be used in routine care at a busy ED. Methods Multivariable analysis and logistic regression were used on data from 634 ED visits for chest pain. Only data immediately available at patient presentation were used. To make ACS prediction stable and the model useful for personnel inexperienced in electrocardiogram (ECG reading, simple ECG data suitable for computerized reading were included. Results Besides ECG, eight variables were found to be important for ACS prediction, and included in the model: age, chest discomfort at presentation, symptom duration and previous hypertension, angina pectoris, AMI, congestive heart failure or PCI/CABG. At an ACS prevalence of 21% and a set sensitivity of 95%, the negative predictive value of the model was 96%. Conclusion The present prediction model, combined with the clinical judgment of ED personnel, could be useful for the early discharge of chest pain patients in populations with a low prevalence of ACS.

  11. Significance of an Indeterminate Troponin I in Patients Evaluated for Chest Pain in an Emergency Department Observation Unit.

    Science.gov (United States)

    Madsen, Troy E; Stewart, Matthew; Smyres, Cameron; Beal, Angus; Hamilton, David; Vlasic, Kajsa; Oates, Alexis

    2015-12-01

    Previous studies have suggested that patients with an indeterminate troponin I (TnI) in the emergency department (ED) are significantly more likely to be diagnosed with acute myocardial infarction (MI). The role of the ED observation unit (EDOU) in the evaluation of these patients is unclear. We sought to determine the risk of MI and revascularization in chest pain patients with an indeterminate TnI in the ED, who were placed in an EDOU. We performed a prospective evaluation with 30-day follow-up for all chest pain patients placed in the University of Utah EDOU between June 1, 2009 and May 31, 2012. The EDOU excludes patients with a positive TnI, significant electrocardiogram changes, or active chest pain; however, the EDOU is utilized for further evaluation of patients who have an initial indeterminate TnI (0.06 ng/mL-0.49 ng/mL) with serial TnI measurements, cardiology consult, and potential provocative testing. We identified all patients who had an indeterminate TnI on initial testing in the ED. Primary outcomes were MI, revascularization with cardiac stent or coronary artery bypass graft, and death. We evaluated 1276 chest pain patients in the EDOU over the 3-year study period (average age: 54.1 years, 54% female). Fifty-eight patients (4.5%) had an initial indeterminate TnI. There were no deaths or adverse outcomes in the EDOU among those with an indeterminate TnI, and none of these patients developed a positive TnI during their hospital stay or 30-day follow-up. Patients with an indeterminate TnI had a higher rate of inpatient admission from the EDOU (24.1% vs. 10.3%; P=0.001). Among those with an indeterminate TnI, 8.6% underwent revascularization, while the rate of revascularization or MI was 2.9% among those who did not have an initial indeterminate TnI (P=0.032). Patients evaluated in our EDOU for chest pain with an initial indeterminate TnI did not develop subsequent MI. However, these patients had an increased rate of revascularization and inpatient

  12. Implementation of a Risk Stratification and Management Pathway for Acute Chest Pain in the Emergency Department.

    Science.gov (United States)

    Baugh, Christopher W; Greenberg, Jeffrey O; Mahler, Simon A; Kosowsky, Joshua M; Schuur, Jeremiah D; Parmar, Siddharth; Ciociolo, George R; Carr, Christina W; Ghazinouri, Roya; Scirica, Benjamin M

    2016-12-01

    Chest pain is a common complaint in the emergency department, and a small but important minority represents an acute coronary syndrome (ACS). Variation in diagnostic workup, risk stratification, and management may result in underuse, misuse, and/or overuse of resources. From July to October 2014, we conducted a prospective cohort study in an academic medical center by implementing a Standardized Clinical Assessment and Management Plan (SCAMP) for chest pain based on the HEART score. In addition to capturing adherence to the SCAMP algorithm and reasons for any deviations, we measured troponin sample timing; rates of stress test utilization; length of stay (LOS); and 30-day rates of revascularization, ACS, and death. We identified 239 patients during the enrollment period who were eligible to enter the SCAMP, of whom 97 patients were entered into the pathway. Patients were risk stratified into one of 3 risk tiers: high (n = 3), intermediate (n = 40), and low (n = 54). Among low-risk patients, recommendations for troponin testing were not followed in 56%, and 11% received stress tests contrary to the SCAMP recommendation. None of the low-risk patients had elevated troponin measurements, and none had an abnormal stress test. Mean LOS in low-risk patients managed with discordant plans was 22:26 h/min, compared with 9:13 h/min in concordant patients (P stress testing was 25:53 h/min, compared with 7:55 h/min for those without (P < 0.001). At 30 days, 10% of intermediate-risk patients and 0% of low-risk patients experienced an ACS event (risk difference 10% [0.7%-19%]); none experienced revascularization or death. The most frequently cited reason for deviation from the SCAMP was lack of confidence in the tool. Compliance with SCAMP recommendations for low- and intermediate-risk patients was poor, largely due to lack of confidence in the tool. However, in our study population, outcomes suggest that deviation from the SCAMP yielded no additional clinical benefit

  13. Chest pain after percutaneous coronary intervention in patients with stable angina

    Directory of Open Access Journals (Sweden)

    Chang CC

    2016-08-01

    Full Text Available Chao-Chien Chang,1–3 Yueh-Chung Chen,4,5 Eng-Thiam Ong,1 Wei-Cheng Chen,1 Chia-Hsiu Chang,1 Kuan-Jen Chen,1 Cheng-Wen Chiang1 1Division of Cardiology, Department of Internal Medicine, Cathay General Hospital, Taipei, Taiwan, ROC; 2Graduate Institute of Medical Sciences, Taipei Medical University, Taipei, Taiwan, ROC; 3Department of Pharmacology, Taipei Medical University, Taipei, Taiwan, ROC; 4Division of Cardiology, Department of Internal Medicine, Taipei City Hospital Ren-Ai branch, Taipai, Taiwan, ROC; 5Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC Background: Percutaneous coronary intervention (PCI has been widely used to treat acute coronary syndrome but is only recommended as an additional treatment to medical therapy and risk modification in patients with refractory or progressing angina. The number of PCI in this patient population is still increasing. Post-PCI chest pain (PPCP is one of the common problems of PCI. Its presentation and causes in patients with stable angina are poorly understood.Patients and methods: This study retrospectively collected clinical information of 167 patients who had stable angina and underwent elective PCI, including 70 patients with PPCP 24 hours after procedure and 97 patients without PPCP. The incidence and predictors of PPCP were analyzed.Results: The incidence of PPCP was 41.9% (70/167. Compared with non-PPCP patients, PPCP patients had more abnormal post-PCI electrocardiogram (ECG changes (new Q-waves, ST-segment shifts, or T-waves inversion and serum cardiac troponin I (cTnI elevation, more PCI vessels, and stent placement (all P<0.05. More PPCP patients required repeat revascularization than non-PPCP patients after PCI (P=0.043. PPCP was correlated with abnormal post-PCI ECG changes (P<0.0001, cTnI elevation (P<0.0001, post-PCI serum level of cTnI (P<0.0001, number of stents placed (P=0.009, and pre-PCI cTnI level (P=0.049. The strongest predictors of

  14. What decides the suspicion of acute coronary syndrome in acute chest pain patients?

    Science.gov (United States)

    2014-01-01

    Background Physicians assessing chest pain patients in the emergency department (ED) base the likelihood of acute coronary syndrome (ACS) mainly on ECG, symptom history and blood markers of myocardial injury. Among these, the ECG has been stated to be the most important diagnostic tool. We aimed to analyze the relative contributions of these three diagnostic modalities to the ED physicians’ evaluation of ACS likelihood in clinical practice. Methods 1151 consecutive ED chest pain patients were prospectively included. The ED physician’s subjective assessment of the patient’s likelihood of ACS (obvious ACS, strong, vague or no suspicion of ACS), the symptoms and the ECG were recorded on a special form. The ED TnT value was retrieved from the medical records. Frequency tables and logistic regression models were used to evaluate the contributions of the diagnostic tests to the level of ACS suspicion. Results Symptoms determined whether the physician had any suspicion of ACS (odds ratio, OR 526 for symptoms typical compared to not suspicious of ACS) since neither ECG nor TnT contributed significantly (ORs not significantly different from 1) to this assessment. ACS was suspected in only one in ten patients with symptoms not suspicious of ACS. Symptoms were also more important (OR 620 for typical symptoms) than ECG (OR 31 for ischemic ECG) and TnT (OR 3.4 for a positive TnT) for the assessment of obvious ACS/strong suspicion versus vague/no suspicion. Of the patients with ST-elevation on ECG, 71% were considered to have an obvious ACS, as opposed to only 6% of those with symptoms typical of ACS and 10% of those with a positive TnT. Conclusion The ED physicians used symptoms as the most important assessment tool and applied primarily the symptoms to determine the level of ACS suspicion and to rule out ACS. The ECG was primarily used to rule in ACS. The TnT level played a minor role for the assessment of ACS likelihood. Further studies regarding ACS prediction based on

  15. Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial.

    Science.gov (United States)

    Hess, Erik P; Hollander, Judd E; Schaffer, Jason T; Kline, Jeffrey A; Torres, Carlos A; Diercks, Deborah B; Jones, Russell; Owen, Kelly P; Meisel, Zachary F; Demers, Michel; Leblanc, Annie; Shah, Nilay D; Inselman, Jonathan; Herrin, Jeph; Castaneda-Guarderas, Ana; Montori, Victor M

    2016-12-05

     To compare the effectiveness of shared decision making with usual care in choice of admission for observation and further cardiac testing or for referral for outpatient evaluation in patients with possible acute coronary syndrome.  Multicenter pragmatic parallel randomized controlled trial.  Six emergency departments in the United States.  898 adults (aged >17 years) with a primary complaint of chest pain who were being considered for admission to an observation unit for cardiac testing (451 were allocated to the decision aid and 447 to usual care), and 361 emergency clinicians (emergency physicians, nurse practitioners, and physician assistants) caring for patients with chest pain.  Patients were randomly assigned (1:1) by an electronic, web based system to shared decision making facilitated by a decision aid or to usual care. The primary outcome, selected by patient and caregiver advisers, was patient knowledge of their risk for acute coronary syndrome and options for care; secondary outcomes were involvement in the decision to be admitted, proportion of patients admitted for cardiac testing, and the 30 day rate of major adverse cardiac events.  Compared with the usual care arm, patients in the decision aid arm had greater knowledge of their risk for acute coronary syndrome and options for care (questions correct: decision aid, 4.2 v usual care, 3.6; mean difference 0.66, 95% confidence interval 0.46 to 0.86), were more involved in the decision (observing patient involvement scores: decision aid, 18.3 v usual care, 7.9; 10.3, 9.1 to 11.5), and less frequently decided with their clinician to be admitted for cardiac testing (decision aid, 37% v usual care, 52%; absolute difference 15%; Ppatients at low risk for acute coronary syndrome increased patient knowledge about their risk, increased engagement, and safely decreased the rate of admission to an observation unit for cardiac testing.Trial registration ClinicalTrials.gov NCT01969240. Published by the BMJ

  16. Diagnostic and prognostic value of circulating microRNAs in patients with acute chest pain.

    Science.gov (United States)

    Devaux, Y; Mueller, M; Haaf, P; Goretti, E; Twerenbold, R; Zangrando, J; Vausort, M; Reichlin, T; Wildi, K; Moehring, B; Wagner, D R; Mueller, C

    2015-02-01

    To address the diagnostic value of circulating microRNAs (miRNAs) in patients presenting with acute chest pain. In a prospective, international, multicentre study, six miRNAs (miR-133a, miR-208b, miR-223, miR-320a, miR-451 and miR-499) were simultaneously measured in a blinded fashion in 1155 unselected patients presenting with acute chest pain to the emergency department. The final diagnosis was adjudicated by two independent cardiologists. The clinical follow-up period was 2 years. Acute myocardial infarction (AMI) was the adjudicated final diagnosis in 224 patients (19%). Levels of miR-208b, miR-499 and miR-320a were significantly higher in patients with AMI compared to those with other final diagnoses. MiR-208b provided the highest diagnostic accuracy for AMI (area under the receiver operating characteristic curve 0.76, 95% confidence interval 0.72-0.80). This diagnostic value was lower than that of the fourth-generation cardiac troponin T (cTnT; 0.84) or the high-sensitivity cTnT (hs-cTnT; 0.94; both P < 0.001 for comparison). None of the six miRNAs provided added diagnostic value when combined with cTnT or hs-cTnT (ns for the comparison of combinations vs. cTnT or hs-cTnT alone). During follow-up, 102 (9%) patients died. Levels of MiR-208b were higher in patients who died within 30 days, but the prognostic accuracy was low to moderate. None of the miRNAs predicted long-term mortality. The miRNAs investigated in this study do not seem to provide incremental diagnostic or prognostic value in patients presenting with suspected AMI. © 2013 The Association for the Publication of the Journal of Internal Medicine.

  17. Chiropractic Treatment vs Self-Management in Patients With Acute Chest Pain: A Randomized Controlled Trial of Patients Without Acute Coronary Syndrome

    DEFF Research Database (Denmark)

    Stochkendahl, Mette J; Christensen, Henrik W; Vach, Werner

    2012-01-01

    OBJECTIVE: The musculoskeletal system is a common but often overlooked cause of chest pain. The purpose of the present study is to evaluate the relative effectiveness of 2 treatment approaches for acute musculoskeletal chest pain: (1) chiropractic treatment that included spinal manipulation and (2......) self-management as an example of minimal intervention. METHODS: In a nonblinded, randomized, controlled trial set at an emergency cardiology department and 4 outpatient chiropractic clinics, 115 consecutive patients with acute chest pain and no clear medical diagnosis at initial presentation were...... included. After a baseline evaluation, patients with musculoskeletal chest pain were randomized to 4 weeks of chiropractic treatment or self-management, with posttreatment questionnaire follow-up 4 and 12 weeks later. Primary outcome measures were numeric change in pain intensity (11-point box numerical...

  18. Practice guidelines and reminders to reduce duration of hospital stay for patients with chest pain. An interventional trial.

    Science.gov (United States)

    Weingarten, S R; Riedinger, M S; Conner, L; Lee, T H; Hoffman, I; Johnson, B; Ellrodt, A G

    1994-02-15

    The acceptability, safety, and efficacy of practice guidelines have rarely been evaluated. Moreover, despite the recent development of guidelines and decision aids for patients admitted to coronary care and intermediate care units, few have been tested in clinical practice. A prospective, controlled clinical trial with an alternate-month design. A large teaching community hospital. Patients admitted to coronary care and intermediate care units with chest pain who were considered at low risk for complications according to a practice guideline (n = 375). Physicians caring for patients with chest pain who were at low risk for complications received concurrent, personalized written and verbal reminders regarding a guideline that recommended a 2-day hospital stay. Use of the practice guideline recommendation with concurrent reminders was associated with a 50% to 69% increase in guideline compliance (P pain considered at low risk for complications. The intervention was associated with a total (direct and indirect) cost reduction of $1397 per patient (CI, $176 to $2618; P = 0.03). No significant difference was found in the hospital complication rate between patients admitted to the hospital during control and intervention periods, and no significant difference was noted in complications, patient health status, or patient satisfaction when measured 1 month after hospital discharge. These results suggest that implementation of this practice guideline through concurrent reminders reduced hospital costs for patients with chest pain considered at low risk for complications. Further study of the guideline is warranted.

  19. Does a minimal invasive approach reduce anterior chest wall numbness and postoperative pain in plate fixation of clavicle fractures?

    Science.gov (United States)

    Beirer, Marc; Postl, Lukas; Crönlein, Moritz; Siebenlist, Sebastian; Huber-Wagner, Stefan; Braun, Karl F; Biberthaler, Peter; Kirchhoff, Chlodwig

    2015-05-28

    Fractures of the clavicle present very common injuries with a peak of incidence in young active patients. Recently published randomized clinical trials demonstrated an improved functional outcome and a lower rate of nonunions in comparison to non-operative treatment. Anterior chest wall numbness due to injury of the supraclavicular nerve and postoperative pain constitute common surgery related complications in plate fixation of displaced clavicle fractures. We recently developed a technique for mini open plating (MOP) of the clavicle to reduce postoperative numbness and pain. The purpose of this study was to analyze the size of anterior chest wall numbness and the intensity of postoperative pain in MOP in comparison to conventional open plating (COP) of clavicle fractures. 24 patients (mean age 38.2 ± 14.2 yrs.) with a displaced fracture of the clavicle (Orthopaedic Trauma Association B1.2-C1.2) surgically treated using a locking compression plate (LCP) were enrolled. 12 patients underwent MOP and another 12 patients COP. Anterior chest wall numbness was measured with a transparency grid on the second postoperative day and at the six months follow-up. Postoperative pain was evaluated using the Visual Analog Scale (VAS). Mean ratio of skin incision length to plate length was 0.61 ± 0.04 in the MOP group and 0.85 ± 0.06 in the COP group (p VAS was 2.6 ± 1.4 points in the MOP group and 3.4 ± 1.6 points in the COP group (p = 0.20). In our study, MOP significantly reduced anterior chest wall numbness in comparison to a conventional open approach postoperative as well as at the six months follow-up. Postoperative pain tended to be lower in the MOP group, however this difference was not statistically significant. ClinicalTrials.gov NCT02247778 . Registered 21 September 2014.

  20. Implementation of NICE Clinical Guideline 95 for assessment of stable chest pain in a rapid access chest pain clinic reduces the mean number of investigations and cost per patient

    OpenAIRE

    2015-01-01

    Objective In 2010, the National Institute for Health and Care Excellence (NICE) in the UK published Clinical Guideline 95 (CG95) advocating risk stratification of patients using ?CADScore? to guide appropriate cardiac investigations for chest pain of recent onset. Implementation of the guideline in the University College London Hospitals NHS Foundation Trust was evaluated to see if it led to a reduction in the average cost of the diagnostic journey per patient and fewer investigations per pat...

  1. Treatment of ankylosing spondylitis with biologics and targeted physical therapy: positive effect on chest pain, diminished chest mobility, and respiratory function.

    Science.gov (United States)

    Gyurcsik, Z; Bodnár, N; Szekanecz, Z; Szántó, S

    2013-12-01

    Biologics are highly effective in ankylosing spondylitis (AS). In this self-controlled study, we assessed the additive value of complex physiotherapy in decreasing chest pain and tenderness and improving respiratory function in AS patients treated with tumor necrosis factor α (TNF-α) inhibitors. The trial consisted of 2 parts. In study I, clinical data of AS patients with (n=55) or without biological therapy (n=20) were retrospectively analyzed and compared. Anthropometrical data, duration since diagnosis and patient assessment of disease activity, pain intensity, tender points, sacroiliac joint involvement determined by X-ray, functional condition, and physical activity level were recorded. Subjective, functional, and physical tests were performed. In study II, 10 voluntary patients (6 men and 4 women, age 52.4 ± 13.6 years) with definite AS and receiving anti-TNF therapy were recruited. It was a prospective, non-randomized physiotherapeutic trial. BASFI (Bath Ankylosing Spondylitis Functional Index), BASDAI (Bath Ankylosing Spondylitis Disease Activity Index), modified Schober Index, occiput-to-wall distance, and fingertip-to-floor distance were evaluated. Forced vital capacity, forced 1-s expiratory volume, peak expiratory flow, and maximum voluntary ventilation were recorded. Furthermore, typical tender points were recorded. A targeted physiotherapy program was conducted twice a week for 12 weeks and all above parameters were recorded at baseline and after 12 weeks. Differences in patient assessment of disease activity (p=0.019) and pain intensity (p=0.017) were found in study I. Pain and tenderness of the thoracic spine were observed in both groups. Back pain without biologic therapy was slightly higher than other group. In study II, we found that patient assessment of disease activity and pain intensity significantly improved after the physical therapy program (p=0.002 and pfunctional parameters showed a tendency towards improvement. AS patients already

  2. CPDX (Chest Pain Diagnostic) - A Decision Support System for the Management of Acute Chest Pain Version 3.0. Programmer’s Manual

    Science.gov (United States)

    1989-10-23

    rhonchi typically do not clear with coughing. A lung infiltrate is usually visible on chest roentgenogram. Ihis study being unavailable aboard...po qid. If the patient appears particularly ill: Penicillin G Procaine 500,000 units IM, followed by the oral regimen. The penicillin-allergic

  3. Dor torácica não-cardiogênica Non-cardiac chest pain

    Directory of Open Access Journals (Sweden)

    Gerson Ricardo de Souza Domingues

    2009-09-01

    ão ocupar lugar no cenário do tratamento destes pacientes.CONTEXT: Non-cardiac chest pain or functional chest pain is a syndrome with high prevalence in ocidental world. Findings on 15%-30% of coronary angiograms performed in patients with chest pain are normal. Causes significant impact in quality of life of patients and is associated with increased use of the health care facilities. DATA SOURCES: To this review the following data base were accessed: Medline, the Cochrane Library, LILACS. The limit was the last 5 years publications and were selected relevant original articles, reviews, consensus, guidelines and meta-analysis. RESULTS: Forty-four papers were selected, 28 original articles, 12 reviews, 2 guidelines, 1 consensus and 1 meta-analysis. CONCLUSIONS: Exclusion of cardiac disease is of crucial importance. On the other hand non-cardiac chest pain could be related to gastrointestinal, muscular and respiratory causes and/or psychological disturbances. Treatment aims to attack mechanism generator in order to relieve or to eliminate symptoms. Drugs are the cornerstone of treatment, exception to achalasia patients because those have better response to dilation of the esophagus or surgery, and to those who need intensive pyschological therapy. The most important drugs used are proton pump inhibitors and triciclic antidepressants, the latter, to modulate central signal process (visceral hypersensitivity and autonomic response. Recently, new diagnostic facilities, and also therapeutic modalities, such as esophageal botulin toxin injection and hypnosis are under investigations. In the near future, maybe some of them would take a place in the therapeutic scenario of these patients.

  4. Self-referral to chest pain units: results of the German CPU-registry.

    Science.gov (United States)

    Nowak, Bernd; Giannitsis, Evangelos; Riemer, Thomas; Münzel, Thomas; Haude, Michael; Maier, Lars S; Schmitt, Claus; Schumacher, Burghard; Mudra, Harald; Hamm, Christian; Senges, Jochen; Voigtländer, Thomas

    2012-12-01

    Chest pain units (CPUs) are increasingly established in emergency cardiology services. With improved visibility of CPUs in the population, patients may refer themselves directly to these units, obviating emergency medical services (EMS). Little is known about characteristics and outcomes of self-referred patients, as compared with those referred by EMS. Therefore, we described self-referral patients enrolled in the CPU-registry of the German Cardiac Society and compared them with those referred by EMS. From 2008 until 2010, the prospective CPU-registry enrolled 11,581 consecutive patients. Of those 3789 (32.7%) were self-referrals (SRs), while 7792 (67.3%) were referred by EMS. SR-patients were significantly younger (63.6 vs. 70.1 years), had less prior myocardial infarction or coronary artery bypass surgery, but more previous percutaneous coronary interventions (PCIs). Acute coronary syndromes were diagnosed less frequently in the SR-patients (30.3 vs. 46.9%; pCPU as a self-referral are younger, less severely ill and have more non-coronary problems than those calling an emergency medical service. Nevertheless, 30% of self-referral patients had an acute coronary syndrome.

  5. Current strategies in the evaluation and management of cocaine-induced chest pain.

    Science.gov (United States)

    Agrawal, Pratik R; Scarabelli, Tiziano M; Saravolatz, Louis; Kini, Annapoorna; Jalota, Abhijay; Chen-Scarabelli, Carol; Fuster, Valentin; Halperin, Jonathan L

    2015-01-01

    With each successive year, the number of Emergency Department (ED) visits related to illicit drug abuse has progressively increased. Cocaine is the most common illegal drug to cause a visit to the ED. Cocaine use results in a variety of pathophysiological changes with regards to the cardiovascular system, such as constriction of coronary vessels, dysfunction of vascular endothelium, decreased aortic elasticity, hemodynamic disruptions, a hypercoagulable state, and direct toxicity to myocardial and vascular tissue. The clinical course of patients with cocaine-induced chest pain (CCP) is often challenging, and electrocardiographic findings can be potentially misleading in terms of diagnosing a myocardial infarction. In addition, there is no current satisfactory study regarding outcomes of use of various pharmacological drug therapies to manage CCP. At present, calcium-channel blockers and nitroglycerin are two pharmacological agents that are advocated as first-line drugs for CCP management, although the role of labetalol has been controversial and warrants further investigation. We performed an extensive search of available literature through a large number of scholarly articles previously published and listed on Index Medicus. In this review, we put forward a concise summary of the current approach to a patient presenting to the ED with CCP and management of the clinical scenario. The purpose of this review is to summarize the understanding of cocaine's cardiovascular pathophysiology and to examine the current approach for proper evaluation and management of CCP.

  6. The use of the biomarker “copeptin” for the diagnosis of acute chest pain in the Emergency Department

    Directory of Open Access Journals (Sweden)

    Elisa Conti

    2011-09-01

    Full Text Available The aim of the study is to assess if copeptin, in combination with negative troponin, is able to accelerate the rule-out of AMI in patients with chest pain. The study was retrospectively conducted on three groups of patients selected according to their discharge diagnoses: patients with non-ST elevation myocardial infarction (NSTEMI, non-cardiac chest pain (NCCP, unstable angina (UA. Comparing the levels of copeptin, we found that the diagnosis of AMI is associated more often with copeptin positive values (> 14 pmol/l than the diagnosis of NCCP and UA. However, about a quarter of our patients in which the combination of copeptin and troponin in the first blood sample was negative, the final diagnosis was AMI. According to our results, the combination of the two negative markers does not allow a safe rule out of AMI at time zero.

  7. FLAIL CHEST

    Directory of Open Access Journals (Sweden)

    Anton Crnjac

    2003-12-01

    Full Text Available Background. Major thoracic trauma is consistent with high mortality rate because of associated injuries of vital thoracic organs and dangerous complications. The flail chest occurs after disruption of the skeletal continuity of chest wall and demands because of its pathophysiological complexity rapid and accurate diagnosis and treatment.Conclusions. Basic pathophysiological mechanism of the flail chest is respiratory distress, which is provoked by pulmonary contusions and paradoxical chest wall motion. The treatment should be pointed to improvement and support of respiratory functions and include aggressive pain control, pulmonary physiotherapy and selective mechanical ventilation. Views about operative fixation of the flail chest are still controversial. Neither mortality rate neither long-term disability are improved after operative fixation.

  8. Acute Chest Pain and Broad Complex Tachycardia. A Non-typical Case of Pre-excited Atrial Fibrillation

    OpenAIRE

    Arias, Ramon Suarez; Villanueva, Nuria Perez; Cubero, Gustavo Iglesias; Lopez, Jose Rubin

    2011-01-01

    Wolff-Parkinson-White syndrome is a common condition in the emergency department. A case is presented of a 76-year-old patient with acute chest pain and broad complex tachycardia. Despite the fact that previous and post cardioversion ECG tracings in sinus rhythm showed no signs of pre-excitation, the characteristic pattern of pre-excited atrial fibrillation (AF) is recognized and after successful DC cardioversion the patient is referred for catheter ablation of the accessory pathway. This cas...

  9. Comparison of TIMI and Gensini score in patients admitted to the emergency department with chest pain, who underwent coronary angiography

    OpenAIRE

    İşcanlı, Murat Doğan; Aksu, Nalan Metin; Evranos, Banu; Aytemir, Kudret; Özmen, Mehmet Mahir

    2014-01-01

    Background In patients admitted to the emergency department with complaints of chest pain and unstable angina pectoris, ST-elevation MI scoring is done according to risk factors used to calculate risks of urgent revascularization, MI, and death within 14 days. For this calculation, the most widely used scoring system is TIMI risk score. Materila/Methods In this prospective, cross-sectional descriptive study, we evaluated and compared the effectiveness of TIMI and Gensini scores of patients wi...

  10. Cardiac troponin I as a predictor of major cardiac events in emergency department patients with acute chest pain.

    Science.gov (United States)

    Polanczyk, C A; Lee, T H; Cook, E F; Walls, R; Wybenga, D; Printy-Klein, G; Ludwig, L; Guldbrandsen, G; Johnson, P A

    1998-07-01

    We sought to evaluate the diagnostic and prognostic value of cardiac troponin I (cTnI) in emergency department (ED) patients with chest pain. Although cTnI has been shown to correlate with an increased risk for complications in patients with unstable angina, the prognostic significance of this assay in the heterogeneous population of patients who present to the ED with chest pain is unclear. cTnI and creatine kinase-MB fraction (CK-MB) mass concentration were collected serially during the first 48 h from onset of symptoms in 1,047 patients > or =30 years old admitted for acute chest pain. Sensitivity, specificity and receiver operating characteristic curves were calculated for cTnI and CK-MB collected in the first 24 h. The sensitivity, specificity and positive predictive value of cTnI for major cardiac events were 47%, 80% and 19%, respectively. Among patients were who ruled out for myocardial infarction, cTnI was elevated in 26% who had major cardiac complications compared with 5% for CK-MB; the positive predictive value for an abnormal cTnI result was 8%. Elevated cTnI in the presence of ischemia on the electrocardiogram was associated with an adjusted odds ratio of 1.8 (95% confidence interval 1.1 to 2.9) for major cardiac events within 72 h. Among patients without a myocardial infarction or unstable angina, cTnI was not an independent correlate of complications. In patients presenting to the ED with acute chest pain, cTnI was an independent predictor of major cardiac events, However, the positive predictive value of an abnormal assay result was not high in this heterogeneous cohort.

  11. Coronary Artery Diseasein Association withDepression or Anxiety among Patients Undergoing Angiography to Investigate Chest Pain

    OpenAIRE

    Vural, Mutlu; Satiroglu, Omer; Akbas, Berfu; Goksel, Isin; Karabay, Ocal

    2009-01-01

    In search of associations between coronary artery disease and symptoms of depression and anxiety, we conducted a prospective cross-sectional study of 314 patients (age range, 19–79 yr) who had presented with chest pain. Coronary angiographic findings were classified into 5 categories (0–4), in which higher numbers indicated more severe disease. Symptoms of depression and anxiety were evaluated by the Beck depression and anxiety inventories, in which higher scores indicated more severe symptom...

  12. Determinants of coronary flow reserve in non-diabetic patients with chest pain without myocardial perfusion defects.

    Directory of Open Access Journals (Sweden)

    Helena U Westergren

    Full Text Available Microvascular dysfunction could be responsible for chest pain in patients without myocardial perfusion defects. We evaluated microvascular function using ultrasound-assessed coronary flow reserve (CFR in patients with chest pain and normal myocardial perfusion scintigram. Secondly, we investigated association between cardiovascular parameters and decreased CFR in a sex specific manner.A total of 202 (128 women non-diabetic patients with chest pain and suspected myocardial ischemia, but without myocardial perfusion defects on myocardial perfusion scintigram, were enrolled and underwent CFR examination and blood sampling. All patients were followed-up for cardiovascular events. We used a supervised principal component analysis including 66 variables such as clinical parameters, ongoing medication, coronary artery disease history, lipids, metabolic parameters, inflammatory and other cardiovascular parameters.During a median follow-up time of 5.4 years, 25 cardiovascular events occurred; (men;18, women;7. Average CFR of the study cohort was 2.7±1.2 and 14% showed impaired CFR<2.0. In an adjusted Cox regression analysis, CFR<2.0 independently predicted event-free survival (HR:2.5, p = 0.033. In the supervised principal component analysis high insulin resistance assessed by Homeostatic model assessment for insulin resistance was the strongest biochemical marker associated with decreased CFR. Interestingly, upon sex specific multivariable linear regression analysis, the association was only significant in men (β = -0.132, p = 0.041 while systolic blood pressure remained an independent predictor in women (β = -0.009, p = 0.011.In non-diabetic patients with chest pain without myocardial perfusion defects, low CFR has prognostic value for future cardiovascular events. Insulin resistance appears to be a marker for decreased CFR in men. Indeed, in the context of contribution of traditional risk factors in this patient population, the value of systolic

  13. Using the Electronic Medical Record to Reduce Unnecessary Ordering of Coagulation Studies for Patients with Chest Pain

    Directory of Open Access Journals (Sweden)

    Jeremiah S. Hinson

    2017-02-01

    Full Text Available Introduction: Our goal was to reduce ordering of coagulation studies in the emergency department (ED that have no added value for patients presenting with chest pain. We hypothesized this could be achieved via implementation of a stopgap measure in the electronic medical record (EMR. Methods: We used a pre and post quasi-experimental study design to evaluate the impact of an EMRbased intervention on coagulation study ordering for patients with chest pain. A simple interactive prompt was incorporated into the EMR of our ED that required clinicians to indicate whether patients were on anticoagulation therapy prior to completion of orders for coagulation studies. Coagulation order frequency was measured via detailed review of randomly sampled encounters during two-month periods before and after intervention. We classified existing orders as clinically indicated or non-value added. Order frequencies were calculated as percentages, and we assessed differences between groups by chi-square analysis. Results: Pre-intervention, 73.8% (76/103 of patients with chest pain had coagulation studies ordered, of which 67.1% (51/76 were non-value added. Post-intervention, 38.5% (40/104 of patients with chest pain had coagulation studies ordered, of which 60% (24/40 were non-value added. There was an absolute reduction of 35.3% (95% confidence interval [CI]: 22.7%, 48.0% in the total ordering of coagulation studies and 26.4% (95% CI: 13.8%, 39.0% in non-value added order placement. Conclusion: Simple EMR-based interactive prompts can serve as effective deterrents to indiscriminate ordering of diagnostic studies. [West J Emerg Med. 2017;18(2267-269.

  14. Using the Electronic Medical Record to Reduce Unnecessary Ordering of Coagulation Studies for Patients with Chest Pain.

    Science.gov (United States)

    Hinson, Jeremiah S; Mistry, Binoy; Hsieh, Yu-Hsiang; Risko, Nicholas; Scordino, David; Paziana, Karolina; Peterson, Susan; Omron, Rodney

    2017-02-01

    Our goal was to reduce ordering of coagulation studies in the emergency department (ED) that have no added value for patients presenting with chest pain. We hypothesized this could be achieved via implementation of a stopgap measure in the electronic medical record (EMR). We used a pre and post quasi-experimental study design to evaluate the impact of an EMR-based intervention on coagulation study ordering for patients with chest pain. A simple interactive prompt was incorporated into the EMR of our ED that required clinicians to indicate whether patients were on anticoagulation therapy prior to completion of orders for coagulation studies. Coagulation order frequency was measured via detailed review of randomly sampled encounters during two-month periods before and after intervention. We classified existing orders as clinically indicated or non-value added. Order frequencies were calculated as percentages, and we assessed differences between groups by chi-square analysis. Pre-intervention, 73.8% (76/103) of patients with chest pain had coagulation studies ordered, of which 67.1% (51/76) were non-value added. Post-intervention, 38.5% (40/104) of patients with chest pain had coagulation studies ordered, of which 60% (24/40) were non-value added. There was an absolute reduction of 35.3% (95% confidence interval [CI]: 22.7%, 48.0%) in the total ordering of coagulation studies and 26.4% (95% CI: 13.8%, 39.0%) in non-value added order placement. Simple EMR-based interactive prompts can serve as effective deterrents to indiscriminate ordering of diagnostic studies.

  15. Clinical assessment and health-related quality of life in patients with non-cardiac chest pain.

    Science.gov (United States)

    Ortiz-Garrido, O; Ortiz-Olvera, N X; González-Martínez, M; Morán-Villota, S; Vargas-López, G; Dehesa-Violante, M; Ruiz-de León, A

    2015-01-01

    Non-cardiac chest pain (NCCP) is mainly related to oesophageal disease, and in spite of being a common condition in Mexico, information regarding it is scarce. To assess the clinical characteristics and health-related quality of life of patients with NCCP of presumed oesophageal origin. Patients with NCCP of presumed oesophageal origin with no previous treatment were included in the study. Associated symptoms were assessed and upper gastrointestinal endoscopy and 24-hour oesophageal pH monitoring were performed to diagnose gastroesophageal reflux disease, while oesophageal manometry was used to determine oesophageal motility disorders. The SF-36 Health-Related Quality of Life (HR-QoL) questionnaire was completed and its results compared to a control group without oesophageal symptoms. The study included 33 patients, of which 61% were women, and the mean age was 46.1 (±11.6) years. Causes of NCCP were gastroesophageal reflux disease in 48%, achalasia in 34%, and functional chest pain in 18%. The average progression time for chest pain was 24 (2-240) months, with ≤ 3 events/week in 52% of the patients. The most frequent accompanying symptoms were: regurgitation (81%), dysphagia (72%) and heartburn (66%). Patients with NCCP show deterioration in HR-QoL compared to the control group (P=.01), regardless of chest pain aetiology. The most affected areas were general perception of health, emotional issues, and mental health sub-scale (P>0.05). In our population, patients with NCCP show deterioration in HR-QoL regardless of the aetiology, frequency, and accompanying symptoms. Published by Masson Doyma México S.A.

  16. The role of multi slice computed tomography in the evaluation of acute non-cardiac chest pain

    Directory of Open Access Journals (Sweden)

    Sandra Vegar Zubović

    2012-12-01

    Full Text Available Introduction: Differential diagnosis of acute chest pain encompasses a broad spectrum of illnesses which are most likely followed by benign outcomes (pneumonia, pneumothorax, pleurisy, pericardial effusion, hiatus hernia, but also illnesses of lethal outcomes (pulmonary embolism, myocardial infarction, aortic dissection,thoracic aortic aneurysms, thoracic aortic aneurysm rupture, etc. Illnesses associated with benign and lethal outcomes may present very similar if not the same symptoms, resulting in a diffi cult establishment of accurate diagnosis.Methods: During the period of one year, 123 patients presented with non-cardiac acute chest pain were referred for the multi slice computed tomography (MSCT examination. Scanning of thorax was conductedin two series: unenhanced and contrast-enhanced, using a window for pulmonary parenchyma and mediastinum.Results: From a total number of patients 21.1% had normal results while the other 79.9% had pathological results. Out of the total number of patients with pathological result MSCT established potentially lethal outcome for 35.0%, out of which 83.7% was contributed to vascular territory of pulmonary artery, while 16.3% was contributed to aorta.Conclusion: MSCT scanning, owe to its ability of simultaneous analysis of vascular and non-vascular thoracic structures, represents a very effi cient and reliable method for establishing accurate diagnosis and appropriatetriage of patients with acute chest pain. Accurate and effi cient diagnosis enables benefi cial outcome for the patient in this group of illness. MSCT enables the differentiation of etiological factors, which present as acute onset of non-cardiac chest pain.

  17. High-sensitivity versus conventional troponin for management and prognosis assessment of patients with acute chest pain.

    Science.gov (United States)

    Sanchis, Juan; García-Blas, Sergio; Mainar, Luis; Mollar, Anna; Abellán, Lidia; Ventura, Silvia; Bonanad, Clara; Consuegra-Sánchez, Luciano; Roqué, Mercé; Chorro, Francisco J; Núñez, Eduardo; Núñez, Julio

    2014-10-01

    High-sensitivity troponin (hs-cTn) is substituting conventional cTn for evaluation of chest pain. Our aim was to assess the impact on patient management and outcome. A total of 1372 consecutive patients presenting at the emergency department with non-ST-elevation acute chest pain were divided into two periods according to the cTn assay used, conventional (n=699, March 2008 to July 2010) or hs-cTn (n=673, November 2010 to March 2013). Management policies were similar and according to guidelines. The primary endpoint was major adverse cardiac events (MACE) at 6 months (death, myocardial infarction, readmission by unstable angina or postdischarge revascularisation). There were minor differences in baseline characteristics. In the hs-cTn period, more patients elevated cTn (73% vs 37%, p=0.0001) leading to more coronary angiograms (77% vs 55%, p=0.0001) and revascularisations (45% vs 31%, p=0.0001); conversely, fewer patients were initially assigned to exercise testing (14% vs 36%, p=0.0001) and, therefore, discharged early after a negative result (7% vs 22%, p=0.0001). At 6 months, 135 patients suffered MACE, including 54 deaths. After adjusting for a Propensity Score, hs-cTn use was not significantly associated with MACE (HR=0.99; 95% CI 0.70 to 1.41; p=0.98) or mortality (HR=1.02; 95% CI 0.59 to 1.77; p=0.95), though the risk of longer hospitalisation stay increased at the index episode (OR=1.35, 95% CI 1.07 to 1.71, p=0.02). hs-cTn simplified chest pain triage on avoiding a more complex evaluation with non-invasive tests in the chest pain unit, but prompted longer hospitalisations and more invasive procedures without impacting on the 6-month outcomes.

  18. The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) trial.

    Science.gov (United States)

    Goldstein, James A; Chinnaiyan, Kavitha M; Abidov, Aiden; Achenbach, Stephan; Berman, Daniel S; Hayes, Sean W; Hoffmann, Udo; Lesser, John R; Mikati, Issam A; O'Neil, Brian J; Shaw, Leslee J; Shen, Michael Y H; Valeti, Uma S; Raff, Gilbert L

    2011-09-27

    The purpose of this study was to compare the efficiency, cost, and safety of a diagnostic strategy employing early coronary computed tomographic angiography (CCTA) to a strategy employing rest-stress myocardial perfusion imaging (MPI) in the evaluation of acute low-risk chest pain. In the United States, >8 million patients require emergency department evaluation for acute chest pain annually at an estimated diagnostic cost of >$10 billion. This multicenter, randomized clinical trial in 16 emergency departments ran between June 2007 and November 2008. Patients were randomly allocated to CCTA (n = 361) or MPI (n = 338) as the index noninvasive test. The primary outcome was time to diagnosis; the secondary outcomes were emergency department costs of care and safety, defined as freedom from major adverse cardiac events in patients with normal index tests, including 6-month follow-up. The CCTA resulted in a 54% reduction in time to diagnosis compared with MPI (median 2.9 h [25th to 75th percentile: 2.1 to 4.0 h] vs. 6.3 h [25th to 75th percentile: 4.2 to 19.0 h], p acute, low-risk chest pain patients, the use of CCTA results in more rapid and cost-efficient safe diagnosis than rest-stress MPI. Further studies comparing CCTA to other diagnostic strategies are needed to optimize evaluation of specific patient subsets. (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment [CT-STAT]; NCT00468325). Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

  19. Emergency Department Cardiopulmonary Evaluation of Low-Risk Chest Pain Patients with Self-Reported Stress and Anxiety.

    Science.gov (United States)

    Musey, Paul I; Kline, Jeffrey A

    2017-03-01

    Chest pain is a high-risk emergency department (ED) chief complaint; the majority of clinical resources are directed toward detecting and treating cardiopulmonary emergencies. However, at follow-up, 80%-95% of these patients have only a symptom-based diagnosis; a large number have undiagnosed anxiety disorders. Our aim was to measure the frequency of self-identified stress or anxiety among chest pain patients, and compare their pretest probabilities, care processes, and outcomes. Patients were divided into two groups: explicitly self-reported anxiety and stress or not at 90-day follow-up, then compared on several variables: ultralow (acute coronary syndrome (ACS) and pulmonary embolism (PE), radiation exposure, total costs at 30 days, and 90-day recidivism. Eight hundred and forty-five patients were studied. Sixty-seven (8%) explicitly attributed their chest pain to "stress" or "anxiety"; their mean ACS pretest probability was 4% (95% confidence interval 2.9%-5.7%) and 49% (33/67) had ultralow pretest probability (0/33 with ACS or PE). None (0/67) were diagnosed with anxiety. Seven hundred and seventy-eight did not report stress or anxiety and, of these, 52% (403/778) had ultralow ACS pretest probability. Only one patient (0.2%; 1/403) was diagnosed with ACS and one patient (0.4%; 1/268) was diagnosed with PE. Patients with self-reported anxiety had similar radiation exposure, associated costs, and nearly identical (25.4% vs. 25.7%) ED recidivism to patients without reported anxiety. Without prompting, 8% of patients self-identified "stress" or "anxiety" as the etiology for their chest pain. Most had low pretest probability, were over-investigated for ACS and PE, and not investigated for anxiety syndromes. Copyright © 2016 Elsevier Inc. All rights reserved.

  20. The role of multi slice computed tomography in the evaluation of acute non-cardiac chest pain

    OpenAIRE

    Sandra Vegar Zubović; Spomenka Kristić

    2012-01-01

    Introduction: Differential diagnosis of acute chest pain encompasses a broad spectrum of illnesses which are most likely followed by benign outcomes (pneumonia, pneumothorax, pleurisy, pericardial effusion, hiatus hernia), but also illnesses of lethal outcomes (pulmonary embolism, myocardial infarction, aortic dissection,thoracic aortic aneurysms, thoracic aortic aneurysm rupture, etc). Illnesses associated with benign and lethal outcomes may present very similar if not the same symptoms, res...

  1. Prehospital factors associated with an acute life-threatening condition in non-traumatic chest pain patients - A systematic review.

    Science.gov (United States)

    Wibring, Kristoffer; Herlitz, Johan; Christensson, Lennart; Lingman, Markus; Bång, Angela

    2016-09-15

    Chest pain is a common symptom among patients contacting the emergency medical services (EMS). Risk stratification of these patients is warranted before arrival in hospital, regarding likelihood of an acute life-threatening condition (LTC). To identify factors associated with an increased risk of acute LTC among patients who call the EMS due to non-traumatic chest pain. Several databases were searched for relevant articles. Identified articles were quality-assessed using the Scottish Intercollegiate Guidelines Network checklists. Extracted data was analysed using a semi-quantitative synthesis evaluating the level of evidence of each identified factor. In total, 10 of 1245 identified studies were included. These studies provided strong evidence for an increased risk of an acute LTC with increasing age, male gender, elevated heart rate, low systolic blood pressure and ST elevation or ST depression on a 12-lead ECG. The level of evidence regarding the history of myocardial infarction, angina pectoris or presence of a Q wave or a Left Bundle Branch Block on the ECG was moderate. The evidence was inconclusive regarding dyspnoea, cold sweat/paleness, nausea/vomiting, history of chronic heart failure, smoking, Right Bundle Branch Block or T-inversions on the ECG. Factors reflecting age, gender, myocardial ischemia and a compromised cardiovascular system predicted an increased risk of an acute life-threatening condition in the prehospital setting in cases of acute chest pain. These factors may form the basis for prehospital risk stratification in acute chest pain. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  2. A clinical score to obviate the need for cardiac stress testing in patients with acute chest pain and negative troponins.

    Science.gov (United States)

    Bouzas-Mosquera, Alberto; Peteiro, Jesús; Broullón, Francisco J; Álvarez-García, Nemesio; Maneiro-Melón, Nicolás; Pardo-Martinez, Patricia; Sagastagoitia-Fornie, Marta; Martínez, Dolores; Yáñez, Juan C; Vázquez-Rodríguez, José Manuel

    2016-08-01

    Although cardiac stress testing may help establish the safety of early discharge in patients with suspected acute coronary syndromes and negative troponins, more cost-effective strategies are necessary. We aimed to develop a clinical prediction rule to safely obviate the need for cardiac stress testing in this setting. A decision rule was derived in a prospective cohort of 3001 patients with acute chest pain and negative troponins, and validated in a set of 1473 subjects. The primary end point was a composite of positive cardiac stress testing (in the absence of a subsequent negative coronary angiogram), positive coronary angiography, or any major coronary events within 3 months. A score chart was built based on 7 variables: male sex (+2), age (+1 per decade from the fifth decade), diabetes mellitus (+2), hypercholesterolemia (+1), prior coronary revascularization (+2), type of chest pain (typical angina, +5; non-specific chest pain, -3), and non-diagnostic repolarization abnormalities (+2). In the validation set, the model showed good discrimination (c statistic = 0.84; 95% confidence interval, 0.82-0.87) and calibration (Hosmer-Lemeshow goodness-of-fit test, P= .34). If stress tests were avoided in patients in the validation sample with a sum score of 0 or lower, the number of referrals would be reduced by 23.4%, yielding a negative predictive value of 98.8% (95% confidence interval, 97.0%-99.7%). This novel prediction rule based on a combination of readily available clinical characteristics may be a valuable tool to decide whether stress testing can be reliably avoided in patients with acute chest pain and negative troponins. Copyright © 2016 Elsevier Inc. All rights reserved.

  3. Personality subtypes and chest pain in patients with nonobstructive coronary artery disease from the TweeSteden Mild Stenosis study: mediating effect of anxiety and depression.

    Science.gov (United States)

    Mommersteeg, P M C; Widdershoven, J W; Aarnoudse, W; Denollet, J

    2016-03-01

    Patients presenting with chest pain in nonobstructive coronary artery disease (CAD, luminal narrowing patients with nonobstructive CAD (mean age 61.4 years, SD = 9.4; 48% men), who participate in the TweeSteden Mild Stenosis (TWIST) observational cohort. Personality was categorized into a 'reference group', a high social inhibition ('SI only'), a high negative affectivity ('NA only') and a 'Type D' (NA and SI) group. Negative mood states included symptoms of depression and anxiety (Hospital Anxiety and Depression Scale) and cognitive and somatic depression (Beck Depression Inventory). The PROCESS macro was used to examine the relation between personality subtypes and chest pain presence, with the negative mood states as potential mediators. Persistent chest pain was present in 44% of the patients with nonobstructive CAD. Type D personality (OR = 1.91, 95% CI 1.24-2.95), but not the 'NA only' (OR = 1.48, 95% CI 0.89-2.44) or the 'SI only' (OR = 0.93, 95% CI 0.53-1.64) group was associated with chest pain, adjusted for age and sex. Negative mood states mediated the association between personality and chest pain. Type D personality, but not negative affectivity or social inhibition, was related to chest pain in nonobstructive CAD, which was mediated by negative mood states. © 2015 European Pain Federation - EFIC®

  4. Usefulness of delta troponin for diagnosis and prognosis assessment of non-ST-segment elevation acute chest pain.

    Science.gov (United States)

    Sanchis, Juan; Abellán, Lidia; García-Blas, Sergio; Mainar, Luis; Mollar, Anna; Valero, Ernesto; Consuegra-Sánchez, Luciano; Roqué, Mercé; Bertomeu-González, Vicente; Chorro, Francisco J; Núñez, Eduardo; Núñez, Julio

    2016-09-01

    The additional diagnostic and prognostic information provided by delta high-sensitivity troponin T (hs-cTnT) in patients with acute chest pain and hs-cTnT elevation remains unclear. The study group consisted of 601 patients presenting at the emergency department with non-ST-segment elevation acute chest pain and hs-cTnT elevation after two determinations (admission and within the first six hours). Maximum hs-cTnT and delta hs-cTnT (absolute or percentage change between the two measurements) were considered. Cutoff values were optimized using the quartile distribution for the endpoints. The endpoints were diagnostic (significant stenosis in the coronary angiogram) and prognostic (death or recurrent myocardial infarction at one year). Regarding the diagnostic endpoint, 114 patients showed a normal angiogram. Both maximum hs-cTnT ⩾80 ng/ml (OR 2.5, 95% CI 1.3-4.8, P=0.005) and delta hs-cTnT ⩾20 ng/l (OR 2.1, 95% CI 1.1-4.0, P=0.02) median value cutoffs were related to significant coronary stenosis. Furthermore, the combination of hs-cTn acute chest pain. Low maximum and low delta hs-cTnT are associated with a normal coronary angiogram, which could make the final diagnosis challenging in some cases. © The European Society of Cardiology 2015.

  5. Prospectively gated coronary computed tomography angiography: uncompromised quality with markedly reduced radiation exposure in acute chest pain evaluation.

    Science.gov (United States)

    Goitein, Orly; Beigel, Roy; Matetzky, Shlomi; Kuperstein, Rafael; Brosh, Sella; Eshet, Yael; Di Segni, Elio; Konen, Eli

    2011-08-01

    Coronary computed tomography angiography (CCTA) is an established modality for ruling out coronary artery disease. However, it has been suggested that CCTA may be a source of non-negligible radiation exposure. To evaluate the potential degradation in coronary image quality when using prospective gated (PG) CCTA as compared with retrospective gated (RG) CCTA in chest pain evaluation. The study cohort comprised 216 patients: 108 consecutive patients in the PG CCTA arm and 108 patients matched for age, gender and heart rate in the RG CCTA arm. Scans were performed using a 64-slice multidetector CT scanner. All 15 coronary segments were evaluated subjectively for image quality using a 5-point visual scale. Dose-length product was recorded for each patient and the effective radiation dose was calculated The PG CCTA technique demonstrated a significantly higher incidence of step artifacts in the middle and distal right coronary artery, the distal left anterior descending artery, the second diagonal, the distal left circumflex artery, and the second marginal branches. Nevertheless, the diagnostic performance of these scans was not adversely affected. The mean effective radiation doses were 3.8 +/- 0.9 mSv vs.17.2 +/- 3 mSv for PG CCTA and RG CCTA, respectively (P acute chest pain "fast track" evaluation targeted at relatively young subjects in a chest pain unit.

  6. Impact of chest pain protocol in the use of fibrinolytic therapy in a private hospital network with access to telemedicine in a middle income country

    National Research Council Canada - National Science Library

    Pedro Gabriel MB Silva; Antonio Baruzzi; Giuliano Generoso; Henrique Ribeiro; Jose Carlos Teixeira; Marcelo Jamus; Mariana Y Okada; Sheila Simoes; Thiago A Macedo; Valter Furlan

    2015-01-01

    Objective To evaluate the hypothesis of improving the use of reperfusion therapy and benefit in clinical outcomes in patients with STEMI after 2 years of implementation of the protocol in a large chest pain network...

  7. Risk of gastrointestinal cancer in patients with unexplained chest/epigastric pain and normal upper endoscopy: a Danish 10-year follow-up study

    DEFF Research Database (Denmark)

    Munk, Estrid Muff; Drewes, Asbjørn Mohr; Gorst-Rasmussen, Anders

    2007-01-01

    patients with chest/epigastric pain, normal upper endoscopy, and no prior discharge diagnosis of ischemic heart disease (N = 386), compared with population controls (N = 3860). The overall 10-year risk of gastrointestinal cancer (stomach, colorectal, liver, and pancreas) was 2.9% for patients...... with unexplained chest/epigastric pain vs. 1.5% for controls. The adjusted relative risks or =1 year after upper endoscopy were 8.4 (95% confidence interval [CI], 2.6-27.5) and 1.2 (95% CI, 0.5-2.9), respectively. We found that patients with unexplained chest/epigastric pain have an increased risk...... of gastrointestinal cancer within the first year after upper endoscopy. Consequently, unexplained chest/epigastric pain might be an early gastrointestinal cancer symptom....

  8. Impact of community-based education on health care evaluation in patients with acute chest pain syndromes: the Wabasha Heart Attack Team (WHAT) project

    National Research Council Canada - National Science Library

    Wright, R S; Kopecky, S L; Timm, M; Pflaum, D D; Carr, C; Evers, K; Bell, J

    2001-01-01

    ...). After an intensive 1-month education period, we compared presentations for emergency evaluation of chest pain during the study period with baseline data from the same seasonal period of the preceding year...

  9. Computed Tomography Diagnosis of Nonspecific Acute Chest Pain in the Emergency Department: From Typical Acute Coronary Syndrome to Various Unusual Mimics.

    Science.gov (United States)

    Yoo, Seung Min; Chun, Eun Ju; Lee, Hwa Yeon; Min, Daniel; White, Charles S

    2017-01-01

    It is a challenging task for emergency department physicians to establish a precise and rapid diagnosis based only on clinical and laboratory findings in patients who present with nonspecific acute chest pain. In this circumstance, CT angiography can provide important clues to the diagnosis. To provide a rapid diagnosis of acute coronary syndrome (ACS) and its various mimics, the physician should enumerate each possible cause of acute chest pain on the basis of an objective assessment of pretest probability. On the basis of clinical suspicion, the appropriate CT protocol should then be performed. Moreover, radiologists should be familiar with typical CT findings of ACS and its various mimics to assist the emergency department physician in diagnosing patients with nonspecific acute chest pain. This review article presents an overview on choosing an appropriate CT protocol in patients with nonspecific acute chest pain and provides specific CT findings of ACS and various mimics of ACS.

  10. Chest X-Ray

    Medline Plus

    Full Text Available ... breath, persistent cough, fever, chest pain or injury. It may also be useful to help diagnose and ... have some concerns about chest x-rays. However, it’s important to consider the likelihood of benefit to ...

  11. Chest X-Ray

    Medline Plus

    Full Text Available ... evaluate the lungs, heart and chest wall and may be used to help evaluate shortness of breath, persistent cough, fever, chest pain or injury. It may also be useful to help diagnose and monitor ...

  12. Platelet function testing to predict hyporesponsiveness to clopidogrel in patients with chest pain seen in the emergency department

    Directory of Open Access Journals (Sweden)

    Sharma RK

    2013-05-01

    Full Text Available Rakesh K Sharma,1 Stephen W Erickson,1 Rohit Sharma,2 Donald J Voelker,1 Hanumanth K Reddy,1 Harvinder Dod,2 James D Marsh1 1Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, 2Medical Center of South Arkansas, El Dorado, AR, USA Background: A dual antiplatelet regimen has been shown to reduce the risk of major adverse cardiovascular events after percutaneous coronary intervention. However, there is little information available on inhibition of platelet aggregation in patients with a prior coronary stent presenting with chest pain. This study evaluated the prevalence of hyporesponsiveness to clopidogrel and factors associated with this in patients presenting to our emergency department with chest pain who had previously undergone coronary stent placement and were prescribed dual antiplatelet therapy. Methods: Responsiveness to clopidogrel was evaluated in a cohort of 533 consecutive stented patients presenting to the emergency department with chest pain. P2Y12 reaction units (PRU and percent P2Y12 inhibition with clopidogrel were measured in all patients. Of 533 patients, 221 (41.6% had PRU ≥ 230. A multivariate logistic regression model was used to determine the relationship between hyporesponsiveness to clopidogrel (defined as PRU ≥ 230 and several potential risk factors, ie, gender, age, race, type 1 or type 2 diabetes, hypertension, smoking, chronic renal failure, and obesity. Results: There was a greater risk of hyporesponsiveness in African Americans than in non-African American patients (adjusted odds ratio [OR] = 2.165, in patients with type 2 diabetes than in those without (adjusted OR = 2.109, and in women than in men (adjusted OR = 1.813, as well as a greater risk of hyporesponsiveness with increasing age (adjusted OR = 1.167 per decade. Conclusion: There was a high prevalence of hyporesponsiveness to clopidogrel in patients presenting with chest pain and a prior coronary stent. Non

  13. A Multivariate Model for Prediction of Obstructive Coronary Disease in Patients with Acute Chest Pain: Development and Validation

    Directory of Open Access Journals (Sweden)

    Luis Cláudio Lemos Correia

    Full Text Available Abstract Background: Currently, there is no validated multivariate model to predict probability of obstructive coronary disease in patients with acute chest pain. Objective: To develop and validate a multivariate model to predict coronary artery disease (CAD based on variables assessed at admission to the coronary care unit (CCU due to acute chest pain. Methods: A total of 470 patients were studied, 370 utilized as the derivation sample and the subsequent 100 patients as the validation sample. As the reference standard, angiography was required to rule in CAD (stenosis ≥ 70%, while either angiography or a negative noninvasive test could be used to rule it out. As predictors, 13 baseline variables related to medical history, 14 characteristics of chest discomfort, and eight variables from physical examination or laboratory tests were tested. Results: The prevalence of CAD was 48%. By logistic regression, six variables remained independent predictors of CAD: age, male gender, relief with nitrate, signs of heart failure, positive electrocardiogram, and troponin. The area under the curve (AUC of this final model was 0.80 (95% confidence interval [95%CI] = 0.75 - 0.84 in the derivation sample and 0.86 (95%CI = 0.79 - 0.93 in the validation sample. Hosmer-Lemeshow's test indicated good calibration in both samples (p = 0.98 and p = 0.23, respectively. Compared with a basic model containing electrocardiogram and troponin, the full model provided an AUC increment of 0.07 in both derivation (p = 0.0002 and validation (p = 0.039 samples. Integrated discrimination improvement was 0.09 in both derivation (p < 0.001 and validation (p < 0.0015 samples. Conclusion: A multivariate model was derived and validated as an accurate tool for estimating the pretest probability of CAD in patients with acute chest pain.

  14. Differential effect of intravenous S-ketamine and fentanyl on atypical odontalgia and capsaicin-evoked pain.

    Science.gov (United States)

    Baad-Hansen, Lene; Juhl, Gitte Irene; Jensen, Troels Staehelin; Brandsborg, Birgitte; Svensson, Peter

    2007-05-01

    Atypical odontalgia (AO) is an intraoral pain condition of currently unknown mechanisms. In 10 AO patients and 10 matched healthy controls, we examined the effect of intravenous infusion of an N-methyl-D-aspartate (NMDA) receptor antagonist S-ketamine and a mu-opioid agonist fentanyl on spontaneous AO pain and on an acute intraoral nociceptive input evoked by topical application of capsaicin. The drugs were administered in a randomized, placebo-controlled, cross-over manner. Furthermore, measures of intraoral sensitivity to mechanical and thermal quantitative sensory testing (QST) including temporal summation were compared between groups and sides. Both drugs failed to produce an analgesic effect on spontaneous AO pain, but fentanyl effectively reduced capsaicin-evoked pain. AO patients showed increased sensitivity to capsaicin and heat pain, but no significant differences in cold and mechanical sensitivity compared with healthy controls. No side-to-side differences in QST measures were found in AO patients. The present study demonstrates that AO is unlikely to be primarily due to a persistent afferent barrage from the peripheral region. Furthermore, in contrast to studies on various neuropathic pain conditions, fentanyl and S-ketamine in the present doses failed to attenuate AO pain.

  15. Noncardiac chest pain after acute myocardial infarction: Frequency and association with health status outcomes.

    Science.gov (United States)

    Qintar, Mohammed; Spertus, John A; Tang, Yuanyuan; Buchanan, Donna M; Chan, Paul S; Amin, Amit P; Salisbury, Adam C

    2017-04-01

    The frequency of noncardiac chest pain (CP) hospitalization after acute myocardial infarction (AMI) is unknown, and its significance from patients' perspectives is not studied. To assess the frequency of noncardiac CP admissions after AMI and its association with patients' self-reported health status. We identified cardiac and noncardiac CP hospitalizations in the year after AMI from the 24-center TRIUMPH registry. Hierarchical repeated-measures regression was used to identify the association of these hospitalizations with patients' self-reported health status using the Seattle Angina Questionnaire Quality of Life domain (SAQ QoL) and Short Form 12 (SF-12) physical (PCS) and mental (MCS) component summary scores. Of 3,099 patients, 318 (10.3%) were hospitalized with CP, of whom 92 (28.9%) were hospitalized for noncardiac CP. Compared with patients not hospitalized with CP, noncardiac CP hospitalization was associated with poorer health status (SAQ QoL-adjusted differences: -8.9 points [95% CI -12.1 to -5.6]; SF-12 PCS: -2.5 points [95% CI -4.2 to -0.8] and SF-12 MCS: -3.5 points [95% CI -5.1 to -1.9]). The SAQ QoL for patients hospitalized with noncardiac CP was similar to patients hospitalized with cardiac CP (adjusted difference: 0.6 points [95% CI -3.2 to 4.5]; SF-12 PCS (0.9 points [95% CI -1.1 to 2.9]), but was worse with regard to SF-12 MCS (adjusted difference: -2.0 points [95% CI -3.9 to -0.2]). Noncardiac CP accounted for a third of CP hospitalizations within 1 year of AMI and was associated with similar disease-specific QoL as well as general physical and mental health status impairment compared with cardiac CP hospitalization. Copyright © 2017 Elsevier Inc. All rights reserved.

  16. Psychological traits influence autonomic nervous system recovery following esophageal intubation in health and functional chest pain.

    Science.gov (United States)

    Farmer, A D; Coen, S J; Kano, M; Worthen, S F; Rossiter, H E; Navqi, H; Scott, S M; Furlong, P L; Aziz, Q

    2013-12-01

    Esophageal intubation is a widely utilized technique for a diverse array of physiological studies, activating a complex physiological response mediated, in part, by the autonomic nervous system (ANS). In order to determine the optimal time period after intubation when physiological observations should be recorded, it is important to know the duration of, and factors that influence, this ANS response, in both health and disease. Fifty healthy subjects (27 males, median age 31.9 years, range 20-53 years) and 20 patients with Rome III defined functional chest pain (nine male, median age of 38.7 years, range 28-59 years) had personality traits and anxiety measured. Subjects had heart rate (HR), blood pressure (BP), sympathetic (cardiac sympathetic index, CSI), and parasympathetic nervous system (cardiac vagal tone, CVT) parameters measured at baseline and in response to per nasum intubation with an esophageal catheter. CSI/CVT recovery was measured following esophageal intubation. In all subjects, esophageal intubation caused an elevation in HR, BP, CSI, and skin conductance response (SCR; all p < 0.0001) but concomitant CVT and cardiac sensitivity to the baroreflex (CSB) withdrawal (all p < 0.04). Multiple linear regression analysis demonstrated that longer CVT recovery times were independently associated with higher neuroticism (p < 0.001). Patients had prolonged CSI and CVT recovery times in comparison to healthy subjects (112.5 s vs 46.5 s, p = 0.0001 and 549 s vs 223.5 s, p = 0.0001, respectively). Esophageal intubation activates a flight/flight ANS response. Future studies should allow for at least 10 min of recovery time. Consideration should be given to psychological traits and disease status as these can influence recovery. © 2013 John Wiley & Sons Ltd.

  17. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge.

    Science.gov (United States)

    Mahler, Simon A; Riley, Robert F; Hiestand, Brian C; Russell, Gregory B; Hoekstra, James W; Lefebvre, Cedric W; Nicks, Bret A; Cline, David M; Askew, Kim L; Elliott, Stephanie B; Herrington, David M; Burke, Gregory L; Miller, Chadwick D

    2015-03-01

    The HEART Pathway is a decision aid designed to identify emergency department patients with acute chest pain for early discharge. No randomized trials have compared the HEART Pathway with usual care. Adult emergency department patients with symptoms related to acute coronary syndrome without ST-elevation on ECG (n=282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, emergency department providers used the HEART score, a validated decision aid, and troponin measures at 0 and 3 hours to identify patients for early discharge. Usual care was based on American College of Cardiology/American Heart Association guidelines. The primary outcome, objective cardiac testing (stress testing or angiography), and secondary outcomes, index length of stay, early discharge, and major adverse cardiac events (death, myocardial infarction, or coronary revascularization), were assessed at 30 days by phone interview and record review. Participants had a mean age of 53 years, 16% had previous myocardial infarction, and 6% (95% confidence interval, 3.6%-9.5%) had major adverse cardiac events within 30 days of randomization. Compared with usual care, use of the HEART Pathway decreased objective cardiac testing at 30 days by 12.1% (68.8% versus 56.7%; P=0.048) and length of stay by 12 hours (9.9 versus 21.9 hours; P=0.013) and increased early discharges by 21.3% (39.7% versus 18.4%; P<0.001). No patients identified for early discharge had major adverse cardiac events within 30 days. The HEART Pathway reduces objective cardiac testing during 30 days, shortens length of stay, and increases early discharges. These important efficiency gains occurred without any patients identified for early discharge suffering MACE at 30 days. URL: http://www.clinicaltrials.gov. Unique Identifier: NCT01665521. © 2015 American Heart Association, Inc.

  18. How Effective Is the Use of Metaphor Therapy on Reducing Psychological Symptoms and Pain Discomfort in Patients with Non-Cardiac Chest Pain: A Randomized, Controlled Trial

    Directory of Open Access Journals (Sweden)

    Mostafa Bahremand

    2016-06-01

    Full Text Available Introduction: Psychological symptoms of non-cardiac chest pain (NCCP including perceptual, emotional, and behavioral problems can effect patient perception of chest pain. This study was conducted to determine the effect of metaphor therapy on mitigating depression, anxiety, stress, and pain discomfort in patients with NCCP. Materials and Methods: This randomized, controlled, trial was conducted on 28 participants, who had visited the emergency department of Kermanshah Imam Ali Heart Hospital because of experiencing NCCP during the June to September 2014. The patients were randomly assigned to metaphor therapy and control groups (n=14 for each group during a four-week period. Our data collection questionnaires included Pain Discomfort Scale (PDS and Depression, Anxiety and Stress Scale (DASS. Chi-square and MANCOVA tests were run, using SPSS version 20. Results: Twenty patients (71.4% completed the trial period until the final assessment. Our findings showed that metaphor therapy couldn’t lower depression, anxiety, stress, and pain discomfort; In fact, there was not a significant difference between the metaphor therapy and control groups regarding the aforementioned variables (P>0.05. Conclusions: Although the study results did not support the effectiveness of metaphor therapy for NCCP, further studies on the potential role of metaphor therapy in attenuating NCCP symptoms seem to be necessary.

  19. Evaluation and outcomes of patients admitted to a tertiary medical assessment unit with acute chest pain of possible coronary origin.

    Science.gov (United States)

    Sander, Rebecca L; Scott, Ian A; Aggarwal, Leena

    2013-12-01

    The study aims to (i) profile clinical characteristics, risk estimates of acute coronary syndrome (ACS), use and yield of non-invasive cardiac testing, discharge diagnosis and 30-day outcomes among patients admitted with acute chest pain of possible coronary origin; and (ii) construct a risk stratification algorithm that informs management decisions. This is a retrospective cohort study of 130 consecutive patients admitted to a tertiary hospital medical assessment unit between 24 January and 22 March 2012. Estimates of ACS risk were based on Australian guidelines and Thrombolysis in Myocardial Infarction (TIMI) scores. Patients were of mean age 61 years, 45% had known coronary artery disease (CAD), 58% presented with typical ischaemic pain, 82% had intermediate to high ACS risk and 61% underwent testing. Myocardial ischaemia was cardiologist-confirmed discharge diagnosis in 29% of patients, and was associated with known CAD, typical pain, multiple risk factors and high TIMI risk scores (P patients capable of rapid discharge from EDs without further investigation, and classifying the remainder into risk groups that informs choice of investigations and need for telemetry. In patients with indeterminate chest pain, clinical features and risk scores identify most with myocardial ischaemia. An algorithm is presented that might inform triaging, early discharge, choice of testing and need for telemetry. © 2013 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

  20. Chiropractic treatment vs self-management in patients with acute chest pain: a randomized controlled trial of patients without acute coronary syndrome.

    Science.gov (United States)

    Stochkendahl, Mette J; Christensen, Henrik W; Vach, Werner; Høilund-Carlsen, Poul F; Haghfelt, Torben; Hartvigsen, Jan

    2012-01-01

    The musculoskeletal system is a common but often overlooked cause of chest pain. The purpose of the present study is to evaluate the relative effectiveness of 2 treatment approaches for acute musculoskeletal chest pain: (1) chiropractic treatment that included spinal manipulation and (2) self-management as an example of minimal intervention. In a nonblinded, randomized, controlled trial set at an emergency cardiology department and 4 outpatient chiropractic clinics, 115 consecutive patients with acute chest pain and no clear medical diagnosis at initial presentation were included. After a baseline evaluation, patients with musculoskeletal chest pain were randomized to 4 weeks of chiropractic treatment or self-management, with posttreatment questionnaire follow-up 4 and 12 weeks later. Primary outcome measures were numeric change in pain intensity (11-point box numerical rating scale) and self-perceived change in pain (7-point ordinal scale). Both groups experienced decreases in pain, self-perceived positive changes, and increases in Medical Outcomes Study Short Form 36-Item Health Survey scores. Observed between-group significant differences were in favor of chiropractic treatment at 4 weeks regarding the primary outcome of self-perceived change in chest pain and at 12 weeks with respect to the primary outcome of numeric change in pain intensity. To the best of our knowledge, this is the first randomized trial assessing chiropractic treatment vs minimal intervention in patients without acute coronary syndrome but with musculoskeletal chest pain. Results suggest that chiropractic treatment might be useful; but further research in relation to patient selection, standardization of interventions, and identification of potentially active ingredients is needed. Copyright © 2012 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.

  1. The feasibility and diagnostic accuracy by multiple cardiac biomarkers in emergency chest pain patients: a clinical analysis to compare 290 suspected acute coronary syndrome cases stratified by age and gender in Taiwan.

    Science.gov (United States)

    Hung, Chung-Lieh; Chien, Ding-Kuo; Shih, Shou-Chuan; Chang, Wen-Han

    2016-10-07

    Accurate diagnosis of acute coronary syndrome (ACS) in a timely fashion is challenging in the elderly population, especially elderly women, who usually exhibit atypical clinical symptoms. A multiple cardiac biomarker (MCB) based approach has been shown to improve diagnostic efficacy of ACS. However, data in various age groups and sex differences remain largely unexplored. Point-of-care testing (POCT) was performed on 290 patients (aged ≥18 years) who were admitted to the emergency department (ED) with symptoms of acute chest pain under suspicion of acute coronary syndrome (ACS). The MCB approach in current work assessed four cardiac biomarkers: myoglobin, troponin I, creatine kinase-myocardial band isoenzyme fraction (CK-MB), and brain natriuretic peptide (BNP). Overall, the MCB approach demonstrated considerably higher sensitivity for elderly patients than for younger patients in identifying ACS (80.0 % [64.1-90.0] vs. 52.6 % [37.3-67.5] for ≥65 years and chest pain was 87.5 % [95 % CI: 64-96.5]). In general, the sensitivity of this approach was higher for female patients than for male patients (80 % [58.4-91.9] vs. 61 % [47.8-73.0]). The MCB approach can provide a quick and accurate clinical diagnosis in elderly and female patients, both of whom have traditionally proven to be challenging to diagnose from suspected acute coronary syndrome.

  2. Sudden death after chest pain: feasibility of virtual autopsy with postmortem CT angiography and biopsy

    National Research Council Canada - National Science Library

    Ross, Steffen G; Thali, Michael J; Bolliger, Stephan; Germerott, Tanja; Ruder, Thomas D; Flach, Patricia M

    2012-01-01

    ...) angiography combined with image-guided tissue biopsy of the myocardium and lungs in decedents who were thought to have died of acute chest disease and to compare this method with conventional autopsy...

  3. Diagnostic performance of reproducible chest wall tenderness to rule out acute coronary syndrome in acute chest pain: a prospective diagnostic study.

    Science.gov (United States)

    Gräni, Christoph; Senn, Oliver; Bischof, Manuel; Cippà, Pietro E; Hauffe, Till; Zimmerli, Lukas; Battegay, Edouard; Franzen, Daniel

    2015-01-28

    Acute chest pain (ACP) is a leading cause of hospital emergency unit consultation. As there are various underlying conditions, ranging from musculoskeletal disorders to acute coronary syndrome (ACS), thorough clinical diagnostics are warranted. The aim of this prospective study was to assess whether reproducible chest wall tenderness (CWT) on palpation in patients with ACP can help to rule out ACS. In this prospective, double-blinded diagnostic study, all consecutive patients assessed in the emergency unit at the University Hospital Zurich because of ACP between July 2012 and December 2013 were included when a member of the study team was present. Reproducible CWT on palpation was the initial step and was recorded before further examinations were initiated. The final diagnosis was adjudicated by a study-independent physician. 121 patients (60.3% male, median age 47 years, IQR 34-66.5 years) were included. The prevalence of ACS was 11.6%. Non-reproducible CWT had a high sensitivity of 92.9% (95% CI 66.1% to 98.8%) for ACS and the presence of reproducible CWT ruled out ACS (p=0.003) with a high negative predictive value (98.1%, 95% CI 89.9% to 99.7%). Conversely non-reproducible CWT ruled in ACS with low specificity (48.6%, 95% CI 38.8% to 58.5%) and low positive predictive value (19.1%, 95% CI 10.6% to 30.5%). This prospective diagnostic study supports the concept that reproducible CWT helps to rule out ACS in patients with ACP in an early stage of the evaluation process. However, ACS and other diagnoses should be considered in patients with a negative CWT test. ClinicalTrial.gov: NCT01724996. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

  4. A new score for the diagnosis of acute coronary syndrome in acute chest pain with non-diagnostic ECG and normal troponin.

    Science.gov (United States)

    Boubaker, Hamdi; Grissa, Mohamed Habib; Beltaief, Kaouther; Amor, Mohamed Haj; Mdimagh, Zouhaier; Boukhris, Amor; Ben Amor, Mehdi; Dridi, Zohra; Letaief, Mondher; Bouida, Wahid; Boukef, Riadh; Najjar, Fadhel; Nouira, Semir

    2015-10-01

    Acute coronary syndrome (ACS) represents a difficult diagnostic challenge in patients with undifferentiated chest pain. There is a need for a valid clinical score to improve diagnostic accuracy. To compare the performance of a model combining the Thrombolysis in Myocardial Infarction (TIMI) score and a score describing chest pain (ACS diagnostic score: ACSD score) with that of both scores alone in the diagnosis of ACS in ED patients with chest pain associated with a non-diagnostic ECG and normal troponin. In this observational cohort study, we enrolled 809 patients admitted to a chest pain unit with normal ECG and normal troponin. They were prospectively evaluated in order to calculate TIMI score, chest pain characteristics score and ACSD score. Diagnosis of ACS was the primary outcome and defined on the basis of 2 cardiologists after reviewing the patient medical records and follow-up data. Mortality and major cardiovascular events were followed for 1 month for patients discharged directly from ED. Discriminative power of scores was evaluated by the area under the ROC curve. ACS was confirmed in 90 patients (11.1%). The area under the ROC curve for ACSD score was 0.85 (95% CI 0.80 to 0.90) compared with 0.74 (95% CI 0.67 to 0.81) for TIMI and 0.79 (95% CI 0.74 to 0.84) for chest pain characteristics score. A threshold value of 9 appeared to optimise sensitivity (92%) and negative predictive value (99%) without excessively compromising specificity (62%) and positive predictive value (23%). The ACSD score showed a good discrimination performance and an excellent negative predictive value which allows safely ruling out ACS in ED patients with undifferentiated chest pain. Our findings should be validated in a larger multicentre study. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

  5. Risk stratification in patients with acute chest pain using three high-sensitivity cardiac troponin assays.

    Science.gov (United States)

    Haaf, Philip; Reichlin, Tobias; Twerenbold, Raphael; Hoeller, Rebeca; Rubini Gimenez, Maria; Zellweger, Christa; Moehring, Berit; Fischer, Catherine; Meller, Bernadette; Wildi, Karin; Freese, Michael; Stelzig, Claudia; Mosimann, Tamina; Reiter, Miriam; Mueller, Mira; Hochgruber, Thomas; Sou, Seoung Mann; Murray, Karsten; Minners, Jan; Freidank, Heike; Osswald, Stefan; Mueller, Christian

    2014-02-01

    Several high-sensitivity cardiac troponin (hs-cTn) assays have recently been developed. It is unknown which hs-cTn provides the most accurate prognostic information and to what extent early changes in hs-cTn predict mortality. In a prospective, international multicentre study, cTn was simultaneously measured with three novel [high-sensitivity cardiac Troponin T (hs-cTnT), Roche Diagnostics; hs-cTnI, Beckman-Coulter; hs-cTnI, Siemens] and a conventional assay (cTnT, Roche Diagnostics) in a blinded fashion in 1117 unselected patients with acute chest pain. Patients were followed up 2 years regarding mortality. Eighty-two (7.3%) patients died during the follow-up. The 2-year prognostic accuracy of hs-cTn was most accurate for hs-cTnT [area under the receivers operating characteristic curve (AUC) 0.78 (95% CI: 0.73-0.83) and outperformed both hs-cTnI (Beckman-Coulter, 0.71 (95% CI: 0.65-0.77; P = 0.001 for comparison), hs-cTnI (Siemens) 0.70 (95% CI: 0.64-0.76; P < 0.001 for comparison)] and cTnT 0.67 (95% CI: 0.61-0.74; P < 0.001 for comparison). Absolute changes of hs-cTnT were more accurate than relative changes in predicting mortality, but inferior to presentation values of hs-cTnT. Combining changes of hs-cTnT within the first 6 h with their presentation values did not further improve prognostic accuracy. Similar results were obtained for both hs-cTnI assays regarding the incremental value of changes. Hs-cTn concentrations remained predictors of death in clinically challenging subgroups such as patients with pre-existing coronary artery disease, impaired renal function, and patients older than 75 years. High-sensitivity cardiac Troponin T is more accurate than hs-cTnI in the prediction of long-term mortality. Changes of hs-cTn do not seem to further improve risk stratification beyond initial presentation values.

  6. Value of serum pregnancy-associated plasma protein A for predicting cardiovascular events among patients presenting with cardiac chest pain

    Science.gov (United States)

    von Haehling, Stephan; Doehner, Wolfram; Jankowska, Ewa A.; Ponikowski, Piotr; Stellos, Konstantinos; Puntmann, Valentina O.; Nagel, Eike; Anker, Stefan D.; Gawaz, Meinrad; Bigalke, Boris

    2013-01-01

    Background: Pregnancy-associated plasma protein A (PAPP-A) has been suggested as a candidate marker for the identification of unstable plaques in coronary arteries. We assessed the value of PAPP-A for predicting short-term cardiovascular events in a large cohort of patients presenting with cardiac chest pain. Methods: We included consecutive patients who presented to a teaching hospital in Germany with chest pain of cardiac origin confirmed by coronary angiography. We analyzed PAPP-A levels from serum samples drawn within 30 minutes after arrival in the emergency department or in the catheterization laboratory. Patients were followed for 90 days or until death for major adverse cardiovascular events, defined as the combined outcome of stent thrombosis, myocardial (re)infarction, ischemic stroke or cardiovascular-related death. Results: A total of 2568 patients (mean age [± standard deviation (SD)] 68 ± 11 years; 74% male) presented with cardiac chest pain: 55% had stable angina and 45% had acute coronary syndrome. The PAPP-A levels ranged from 4 to 2154 mIU/L (median 14.0 mIU/L, interquartile range 9.3–25.2 mIU/L). Major adverse cardiovascular events occurred in 203 patients (7.9%). The mean PAPP-A level was higher among patients who had an event than among those who did not (62 ± 156 v. 21 ± 23 mIU/L, p PAPP-A remained a significant independent predictor of the primary outcome within 90 days (hazard ratio per 1 SD increase in PAPP-A level 1.96, 95% confidence interval 1.74–2.21). The optimal prognostic cutoff value was a PAPP-A level of 34.6 mIU/L. Interpretation: Higher levels of serum PAPP-A were independently associated with an increased short-term risk of cardiovascular events in patients presenting with cardiac chest pain. Further studies are required to validate the use of PAPP-A in routine clinical practice to predict future cardiovascular events. PMID:23509133

  7. The efficacy and safety of a chest pain protocol for short stay unit patients: A one year follow-up.

    Science.gov (United States)

    Lee, Geraldine; Dix, Samantha; Mitra, Biswadev; Coleridge, John; Cameron, Peter

    2015-10-01

    The Alfred Emergency Short Stay Unit initiated a chest pain protocol for patients presenting with chest pain to risk stratify for acute coronary syndrome (ACS). A 30-day follow-up of patients discharged with low-or-intermediate risk of ACS demonstrated no deaths or ACS. The purpose of this study was to evaluate the long-term safety of the chest pain protocol, a one year follow-up was undertaken. A questionnaire was designed for the one-year follow-up and it was administered via a telephone interview by emergency nurses to document adverse cardiac events and health care utilisation. From 297 patients, 224 (75%) were contacted 12 months following discharge. There was one death from stroke (0.4%; 95% confidence interval (CI): 0.01-2.5%) and another from an unknown cause. Five patients had been diagnosed with atrial fibrillation (2.2%; 95% CI: 0.7-5.1%), two patients had an acute myocardial infarction (0.9%; 95% CI: 0.03-2.1%) and four were diagnosed with angina (1.8%; 95% CI: 0.9-3.2%). Nearly half (n=103, 46%; 95% CI: 39.5-52.5%) had returned to the emergency department (ED) for various conditions including 42 patients with further chest pain. Ninety-six patients (43%; 95% CI: 39.3-52.7%) had specialist referrals and 124 investigations were performed. Thirty-four patients had cardiology referrals (15%; 95% CI: 10.7-20.5%) and 25 patients had gastroenterology referrals (11%; 95% CI: 7.3-16.0%). Diagnostic cardiac tests were performed on 38 patients: coronary angiography (n=10), 24-hour Holter monitoring (n=17), 24-hour blood pressure (BP) monitoring (n=4), thallium scans (n=5), exercise stress test (n=1) and CT scan (n=1). Patients had a low risk of adverse events 12 months after discharge but substantial continuing health care utilization was observed. Complete assessment by health care professionals prior to discharge may help mitigate representations. © The European Society of Cardiology 2014.

  8. [Atypical odontalgia].

    Science.gov (United States)

    Türp, Jens Christoph

    2005-01-01

    In spite of its first description by the English surgeon JOHN HUNTER more than 200 years ago, atypical odontalgia (AO), or phantom tooth pain, is not universally known among dentists. AO is a persistent neuropathic pain which may be initiated after deafferentiation of trigeminal nerve fibers following root canal treatment, apicectomy, or tooth extraction. In the absence of pathological clinical or radiological findings, the diagnosis is made by exclusion. After a thorough patient education about the condition, pharmacological and psychological pain management is required. Invasive and irreversible treatment attempts are contraindicated.

  9. Reducing Irrational Beliefs and Pain Severity in Patients Suffering from Non-Cardiac Chest Pain (NCCP): A Comparison of Relaxation Training and Metaphor Therapy

    Science.gov (United States)

    Bahremand, Mostafa; Moradi, Gholamreza; Saeidi, Mozhgan; Mohammadi, Samira

    2015-01-01

    Background Patients suffering from non-cardiac chest pain (NCCP) can interpret their chest pain wrongly despite having received a correct diagnosis. The objective of this study was to compare the efficacy of the relaxation method with metaphor therapy for reducing irrational beliefs and pain severity in patients with NCCP. Methods Using a randomized controlled trial, 33 participants were randomly divided into a relaxation training group (n= 13), a metaphor therapy group (n = 10), and a control group (n = 10), and were studied for 4 weeks. The two tools used in this research were the Brief Pain Inventory (BPI) index for determining the degree of pain and the short version of the Jones Irrational Belief Test. Metaphor therapy and a relaxation technique based on Öst's treatment were used as the interventions. The collected data were analyzed with a multivariate analysis of covariance (MANCOVA), a Chi-square test, and the Bonferroni procedure of post-hoc analysis. Results The relaxation training method was significantly more effective than both metaphor therapy and the lack of treatment in reducing the patients' beliefs of hopelessness in the face of changes and emotional irresponsibility, as well as the pain severity. Metaphor therapy was not effective on any of these factors. In fact, the results did not support the effectiveness of metaphor therapy. Conclusions Regarding the effectiveness of the relaxation method as compared with metaphor therapy and the lack of treatment in the control group, this study suggests that relaxation should be paid greater attention as a method for improving the status of patients. In addition, more studies are needed to determine the effectiveness of metaphor therapy in this area. PMID:25852829

  10. A 15-Year-Old Boy with Anterior Chest Pain, Progressive Dyspnea, and Subcutaneous Emphysema of the Neck

    Directory of Open Access Journals (Sweden)

    Nicola Scichilone

    2009-01-01

    Full Text Available We describe the case of an adolescent who was admitted to the hospital because of sudden occurrence of chest pain, dyspnea and subcutaneous emphysema. On admission, physical examination revealed subcutaneous crepitations in the superior part of the rib cage, and auscultation of the chest showed widespread wheezing. The radiological assessment confirmed the diagnosis of pneumomediastinum and pneumothorax. A follow-up CT scan performed one week after the admission showed almost complete resolution of the radiological alterations. At the following visits, the patient was asymptomatic, but reported to have suffered from frequent episodes of rhinorrea, sneezing, nasal blockage, and sometimes, chest tightness, especially during exposure to pets and/or windy weather. Skin prick testing showed sensitivities to dermatophagoides pteronyssinus and farinae, grass pollen and dog dander. Spirometry documented significant improvement in lung function after short-acting bronchodilator, allowing for the diagnosis of asthma to be made. Although pneumomediastinum may be a complication of various respiratory diseases, including asthma, it has never been reported as the first presentation of underlying bronchial asthma. Herein, the physiopathological mechanisms, the diagnostic procedures and treatment of pneumomediastinum in asthma are discussed. We suggest that the diagnosis of asthma should be considered in the differential diagnosis of pneumomediastinum in adolescence.

  11. Acid-suppressive therapy with esomeprazole for relief of unexplained chest pain in primary care: a randomized, double-blind, placebo-controlled trial.

    Science.gov (United States)

    Flook, Nigel W; Moayyedi, Paul; Dent, John; Talley, Nicholas J; Persson, Tore; Karlson, Björn W; Ruth, Magnus

    2013-01-01

    High-quality data regarding the efficacy of acid-suppressive treatment for unexplained chest pain are lacking. The aim of this study was to evaluate the efficacy of esomeprazole in primary-care treatment of patients with unexplained chest pain stratified for frequency of reflux/regurgitation symptoms. Patients with a ≥ 2-week history of unexplained chest pain (unrelated to gastroesophageal reflux) who had at least moderate pain on ≥ 2 of the last 7 days were stratified by heartburn/regurgitation frequency (≤ 1 day/week (stratum 1) vs. ≥ 2 days/week (stratum 2)) and randomized to 4 weeks of double-blind treatment with twice-daily esomeprazole 40 mg or placebo. Chest pain relief during the last 7 days of treatment (≤ 1 day with minimal symptoms assessed daily using a 7-point scale) was analyzed by stratum in keeping with the predetermined analysis plan. Overall, 599 patients (esomeprazole: 297, placebo: 302) were randomized. In stratum 1, more esomeprazole than placebo recipients achieved chest pain relief (38.7% vs. 25.5%; P=0.018); no between-treatment difference was observed in stratum 2 (27.2% vs. 24.2%; P=0.54). However, esomeprazole was superior to placebo in a post-hoc analysis of the whole study population (combined strata; 33.1% vs. 24.9%; P=0.035). A 4-week course of high-dose esomeprazole provided statistically significant relief of unexplained chest pain in primary-care patients who experienced infrequent or no heartburn/regurgitation, but there was no such significant reduction in patients with more frequent reflux symptoms.

  12. A randomized clinical trial of chiropractic treatment and self-management in patients with acute musculoskeletal chest pain: 1-year follow-up.

    Science.gov (United States)

    Stochkendahl, Mette J; Christensen, Henrik W; Vach, Werner; Høilund-Carlsen, Poul F; Haghfelt, Torben; Hartvigsen, Jan

    2012-05-01

    We have previously reported short-term follow-up from a pragmatic randomized clinical trial comparing 2 treatments for acute musculoskeletal chest pain: (1) chiropractic treatment and (2) self-management. Results indicated a positive effect in favor of the chiropractic treatment after 4 and 12 weeks. The current article investigates the hypothesis that the advantage observed at 4 and 12 weeks would be sustained after 1 year. In addition, we describe self-reported consequences of acute musculoskeletal chest pain at 1-year follow-up. In a nonblinded, randomized controlled trial undertaken at an emergency cardiology department and 4 outpatient chiropractic clinics, 115 consecutive patients with acute chest pain of musculoskeletal origin were included. After the baseline evaluation, patients were randomized to 4 weeks of either chiropractic treatment or self-management, with posttreatment questionnaire follow-up 52 weeks later. The primary outcome measures were change in pain intensity (11-point box numerical rating scale) and self-perceived change in pain (7-point ordinal scale). Both groups experienced decreases in pain, positive global, self-perceived treatment effect, and increases in the 36-Item Short Form Health Survey scores. No statistically significant differences were observed between groups at the 1-year follow-up, and we could not deduce a common trend in favor of either intervention. At the 1-year follow-up, we found no difference between groups in terms of pain intensity and self-perceived change in chest pain in the first randomized clinical trial assessing chiropractic treatment vs minimal intervention for patients with acute musculoskeletal chest pain. Further research into health care utilization and use of prescriptive medication is warranted. Copyright © 2012 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.

  13. Conditioned Pain Modulation and Situational Pain Catastrophizing as Preoperative Predictors of Pain following Chest Wall Surgery: A Prospective Observational Cohort Study

    OpenAIRE

    Kasper Grosen; Lene Vase; Pilegaard, Hans K.; Mogens Pfeiffer-Jensen; Drewes, Asbjørn M

    2014-01-01

    BACKGROUND: Variability in patients' postoperative pain experience and response to treatment challenges effective pain management. Variability in pain reflects individual differences in inhibitory pain modulation and psychological sensitivity, which in turn may be clinically relevant for the disposition to acquire pain. The aim of this study was to investigate the effects of conditioned pain modulation and situational pain catastrophizing on postoperative pain and pain persistency. METHODS: P...

  14. How goal disturbance, coping and chest pain relate to quality of life: A study among patients waiting for PTCA.

    Science.gov (United States)

    Echteld, M A; van Elderen, T M; van der Kamp, L J

    2001-01-01

    This article describes psychological correlates of quality of life (QOL) in patients on a waiting list for percutaneous transluminal coronary angioplasty (PTCA). Variables were selected based on a theoretical model describing psychological correlates of QOL in PTCA patients. This model was based on self-regulation and stress-coping theories. The variables in the model are stress appraisal, coping, coping resources, and general and disease-specific QOL variables. Respondents were 122 patients on a 3-month waiting list for a PTCA. Results indicated that PTCA patients had a poorer QOL than matched healthy controls. Using a path analysis approach to regression analysis, it appeared that goal disturbance, avoidant coping, approach coping, and chest pain were related to QOL. More specifically, chest pain and goal disturbance were only related to health-related QOL and negative affect. Both approach and avoidant coping were related to QOL variables. Results could be explained adequately using self-regulation theory. Recommendations for future research and for form and content of rehabilitation programmes were made.

  15. Comparison of TIMI and Gensini score in patients admitted to the emergency department with chest pain, who underwent coronary angiography.

    Science.gov (United States)

    İşcanlı, Murat Doğan; Metin Aksu, Nalan; Evranos, Banu; Aytemir, Kudret; Özmen, Mehmet Mahir

    2014-03-01

    In patients admitted to the emergency department with complaints of chest pain and unstable angina pectoris, ST-elevation MI scoring is done according to risk factors used to calculate risks of urgent revascularization, MI, and death within 14 days. For this calculation, the most widely used scoring system is TIMI risk score. In this prospective, cross-sectional descriptive study, we evaluated and compared the effectiveness of TIMI and Gensini scores of patients with chest pain who were admitted to Hacettepe University Hospitals Emergency Department between March 2011 and September 2011 and who underwent coronary angiography. The mean (range) age of 165 patients was 62 (31-88) years. Moderate correlation between TIMI and Gensini scores was detected (mean values of Gensini score for TIMI 1 is 53.50, for TIMI 2 it is 52.09, for TIMI 3 it is 102.77, for TIMI 4 it is 113.70, and for TIMI 5 it is 115.43). There was also a positive correlation between TIMI score and the results. TIMI risk stratification score is safe and easy to use for rapid assessment of mortality and MI risk, despite its low possibility of predicting the outcome.

  16. MR-proANP and MR-proADM for risk stratification of patients with acute chest pain.

    Science.gov (United States)

    Tzikas, Stergios; Keller, Till; Ojeda, Francisco M; Zeller, Tanja; Wild, Philipp S; Lubos, Edith; Kunde, Jan; Baldus, Stephan; Bickel, Christoph; Lackner, Karl J; Münzel, Thomas F; Blankenberg, Stefan

    2013-03-01

    To evaluate mid-regional pro-adrenomedullin (MR-proADM) and mid-regional pro-atrial natriuretic peptide (MR-proANP) as prognostic biomarkers in a representative 'real world' cohort of patients with suspected acute coronary syndrome (ACS). Prospective observational multicentre cohort study. Chest pain units of three major hospitals in Germany from 2007 to 2008. Patients presenting with signs and symptoms suggestive of an ACS. Primary end point was death or non-fatal myocardial infarction (MI), and secondary end point was death, non-fatal MI, stroke, need for coronary revascularisation, and hospital admission for cardiovascular cause or acute heart failure within 6 months after enrolment. 1386 patients (male/female = 920/466) were enrolled. Follow-up information was available for 97.8% of patients (median follow-up time 183 days). Forty-three patients reached the primary end point, and 132 the secondary end point. Patients who reached a primary end point had significantly higher MR-proANP (271 vs 101 pmol/l, p Acute Coronary Events risk score, with an overall net reclassification improvement of 41.2% for MR-proADM and 35.7% for MR-proANP. MR-proADM and MR-proANP are predictors of future cardiovascular events in patients presenting with acute chest pain and might facilitate the choice of treatment in those patients complementary to established risk scores.

  17. Prior blunt chest trauma may be a cause of single vessel coronary disease; hypothesis and review

    DEFF Research Database (Denmark)

    Bartels, Mette Damkjær; Nielsen, PE; Sleight, P

    2006-01-01

    Prompted by a case where a patient (with no risk factors, and single vessel disease) developed angina pectoris after previous blunt chest trauma, we searched Medline for blunt chest trauma and myocardial ischaemia. We found 77 cases describing AMI after blunt chest trauma, but only one reporting...... angina pectoris. We focused on the age and sex distribution, type of trauma, the angiography findings and the time interval between the trauma and the angiography. The age distribution was atypical, compared to AMI in general; 82% of the patients with AMI after blunt chest trauma were less than 45 years......, which strongly suggested a causal relation between the trauma and subsequent occlusion. AMI should therefore be considered in patients suffering from chest pain after blunt chest trauma. Because traumatic AMI might often be the result of an intimal tear or dissection, thrombolytic therapy might worsen...

  18. The effects of topical heat therapy on chest pain in patients with acute coronary syndrome: a randomised double-blind placebo-controlled clinical trial.

    Science.gov (United States)

    Mohammadpour, Ali; Mohammadian, Batol; Basiri Moghadam, Mehdi; Nematollahi, Mahmoud Reza

    2014-12-01

    To investigate the effects of local heat therapy on chest pain in patients with acute coronary syndrome. Chest pain is a very common complaint in patients with acute coronary syndrome. It is managed both pharmacologically and nonpharmacologically. Pharmacological pain management is associated with different side effects. This was a randomised double-blind placebo-controlled clinical trial conducted in 2013. A convenience sample of 66 patients with acute coronary syndrome was selected from a coronary care unit of a local teaching hospital affiliated to Gonabad University of Medical Sciences, Gonabad, Iran. Patients were randomly assigned to either the experimental or the placebo group. Patients in the experimental and the placebo groups received local heat therapy using a hot pack warmed to 50 and 37 °C, respectively. We assessed chest pain intensity, duration and frequency as well as the need for opioid analgesic therapy both before and after the study. The study instrument consisted of a demographic questionnaire, the McGill Pain Questionnaire, and a data sheet for documenting pain frequency and duration as well as the need for analgesic therapy. The placebo heat therapy did not significantly decrease the intensity, the duration and the frequency of pain episodes. However, pain intensity, duration and frequency in the experimental group decreased significantly after the study. Moreover, the groups differed significantly in terms of the need for opioid analgesic therapy neither before nor after the intervention. Local heat therapy is an effective intervention for preventing and relieving chest pain in patients with acute coronary syndrome. Effective pain management using local heat therapy could help nurses play an important role in providing effective care to patients with acute coronary syndrome and in minimising adverse effects associated with pain medications. © 2014 John Wiley & Sons Ltd.

  19. Clinical features and prognosis of patients with acute non-specific chest pain in emergency and cardiology departments after the introduction of high-sensitivity troponins

    DEFF Research Database (Denmark)

    Ilangkovan, Nivethitha; Mickley, Hans; Diederichsen, Axel

    2017-01-01

    OBJECTIVES: To determine the incidence of clinical, cardiac-related endpoints and mortality among patients presenting to an emergency or cardiology department with non-specific chest pain (NSCP), and who receive testing with a high-sensitivity troponin. A second objective was to identify risk...... factors for the above-noted endpoints during 12 months of follow-up. DESIGN: A prospective multicentre study. SETTING: Emergency and cardiology departments in Southern Denmark. SUBJECTS: The study enrolled 1027 patients who were assessed for acute chest pain in an emergency or cardiology department......, and in whom a myocardial infarction or another obvious reason for chest pain had been ruled out. Patients were enrolled from September 2014 to June 2015 and followed for 1 year. MAIN OUTCOME MEASURES: Clinical, cardiac-related endpoints (cardiac-related death, acute myocardial infarction, unstable angina...

  20. Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population.

    Science.gov (United States)

    Pollack, Charles V; Sites, Frank D; Shofer, Frances S; Sease, Keara L; Hollander, Judd E

    2006-01-01

    Patients presenting with chest pain or related symptoms suggestive of myocardial ischemia, without ST-segment elevation (NSTE) on their presenting electrocardiograms, often present a diagnostic challenge in the emergency department (ED). Prompt and accurate risk stratification to identify those patients with NSTE chest pain who are at highest risk for adverse events is essential, however, to optimal management. Although validated and used frequently in patients already enrolled in acute coronary syndrome trials, the Thrombolysis in Myocardial Infarction (TIMI) risk score never has been examined for its value in risk stratification in an all-comers, non-trial-based ED chest pain population. An analysis of an ED-based prospective observational cohort study was conducted in 3,929 adult patients presenting with chest pain syndrome and warranting evaluation with an electrocardiogram. These patients had TIMI risk scores determined at ED presentation. The main outcome was the composite of death, acute myocardial infarction (MI), and revascularization within 30 days. The TIMI risk score at ED presentation successfully risk-stratified this unselected cohort of chest pain patients with respect to 30-day adverse outcome, with a range from 2.1%, with a score of 0, to 100%, with a score of 7. The highest correlation of an individual TIMI risk indicator to adverse outcome was for elevated cardiac biomarker at admission. Overall, the score had similar performance characteristics to that seen when applied to other databases of patients enrolled in clinical trials and registries using a 14-day end point. The TIMI risk score may be a useful tool for risk stratification of ED patients with chest pain syndrome.

  1. The occurrences of chest pains and frequent coughing among residents living within the Selebi Phikwe Ni-Cu mine area, Botswana.

    Science.gov (United States)

    Ekosse, Georges; de Jager, Linda; van den Heever, Dawid J

    2005-01-01

    This study aimed at establishing occurrences of chest pains and frequent coughing among different classes of residents within Selebi Phikwe, Botswana where there are on going nickel-copper (Ni-Cu) mining and smelting activities. Through the administration of questionnaires and structured questions to 600 individuals, 7 health service providers, 200 business enterprises, and 30 educational institutions, attempts were made to establish and verify the existing human health status at Selebi Phikwe by focusing on chest pains and frequent coughing which are considered to be some of the respiratory tract related symptoms of sicknesses and diseases. With the aid of statistical package for social sciences (SPSS), interpreted results from respondents indicated that 33 % of the individuals complained of persistent chest pains; and 27 % of educational institutions, 45 % business enterprises, and all health service providers had learners, workers, and patients who complained of chest pains. Furthermore, 49 % of the individuals complained of persistent frequent coughing; and 70 % of educational institutions, 45 % business enterprises, and all health service providers had learners, workers, and patients who complained of frequent coughing. According to study sites, respondents living in sites closest to the mine and smelter / concentrator plant reported a higher incidence of chest pains and frequent coughing, compared to those living in other parts of the study area. Residents associate fumes and dust from mining activities to the frequent coughing and persistent chest pains, which could be symptoms of respiratory tract diseases. This baseline investigation calls for further studies to establish relations of mining activities to human health at Selebi Phikwe.

  2. Multi-detector computerized tomography angiography for evaluation of acute chest pain--a meta analysis and systematic review of literature.

    Science.gov (United States)

    Athappan, Ganesh; Habib, Muzzmal; Ponniah, Thirumalaikolundusubramanian; Jeyaseelan, Lakshmanan

    2010-05-28

    Evaluation of pain localized to the chest in the emergency room is, challenging, time-consuming, costly, and often inconclusive. Available research, though limited, suggests a role for MDCTA in the evaluation of patients with acute chest pain of low to intermediate risk, for identifying and excluding ACSs during the initial emergency department evaluation. Accordingly, our aim was to conduct a meta-analysis to assess the diagnostic accuracy of MDCTA in this setting. We included all studies that compared MDCTA with either coronary angiography or standard of care for early and accurate triage of patients presenting with acute chest pain. Published studies were identified by searches of the Pubmed, Ovid and Google scholar databases as well as hand searches of selected references. Data were extracted independently by two reviewers. Included studies were evaluated for heterogeneity. Meta-analysis was performed at patient level using a random-effects model. 16 studies totaling 1119 patients were included in the current meta-analysis: one randomized trial, one retrospective analysis and fourteen prospective cohort studies. Pooled DOR was 190.80 (95%CI, 102.94-353.65). The pooled sensitivity and specificity were 0.96 (95%CI, 0.93-0.98) and 0.92(95%CI, 0.89-0.94) respectively. The pooled NLR and PLR were 0.09 (95%CI, 0.06-0.14) and 10.12 (95%CI, 6.73-15.22). MDCTA has an excellent diagnostic accuracy in detection of significant coronary artery stenosis in patients with acute chest pain. This diagnostic accuracy of MDCTA has a potential for rapid triage of patients in the ED, with acute chest pain of low to intermediate risk of acute coronary syndrome, to rule out significant epicardial stenosis as the etiology of chest pain. Copyright 2008 Elsevier Ireland Ltd. All rights reserved.

  3. Predictive Value of a 4-Hour Accelerated Diagnostic Protocol in Patients with Suspected Ischemic Chest Pain Presenting to an Emergency Department

    Directory of Open Access Journals (Sweden)

    Mamatha P.R. Rao

    2012-05-01

    Full Text Available Objectives: Currently recommended risk stratification protocols for suspected ischemic chest pain in the emergency department (ED includes point-of-care availability of exercise treadmill/nuclear tests or CT coronary angiograms. These tests are not widely available for most of the ED’s. This study aims to prospectively validate the safety of a predefined 4-hour accelerated diagnostic protocol (ADP using chest pain, ECG, and troponin T among suspected ischemic chest pain patients presenting to an ED of a tertiary care hospital in Oman.Methods: One hundred and thirty-two patients aged over 18 years with suspected ischemic chest pain presenting within 12 hours of onset along with normal or non-diagnostic first ECG and negative first troponin T (<0.010 μg/l were recruited from September 2008 to February 2009. Low-probability acute coronary syndrome (ACS patients at 4-hours defined as absent chest pain and negative ECG or troponin tests were discharged home and observed for 30-days for major adverse cardiac events (MACE (Group I: negative ADP. High-probability ACS patients at 4-hours were defined by recurrent or persistent chest pain, positive ECG or troponin tests and were admitted and observed for in-hospital MACE (Group II: positive ADP.Results: One hundred and thirty-two patients were recruited and 110 patients completed the study. The overall 30-day MACE in this cohort was 15% with a mortality of less than 1%. 30-days MACE occurred in 8/95 of group I patients (8.4% and 9/15 of the in-hospital MACE patients in group II. The ADP had a sensitivity of 52% (95% CI: 0.28-0.76, specificity of 93% (0.85-0.97, a negative predictive value of 91% (0.83-0.96, a positive predictive value of 60% (0.32-0.82, negative likelihood ratio of 0.5 (0.30-0.83 and a positive likelihood ratio of 8.2 (3.3-20 in predicting MACE.Conclusion: A 4-hour ADP using chest pain, ECG, and troponin T had high specificity and negative predictive value in predicting 30-day MACE

  4. Depression is associated with recurrent chest pain with or without coronary artery disease: A prospective cohort study in the emergency department.

    Science.gov (United States)

    Kim, Yeunjung; Soffler, Morgan; Paradise, Summer; Jelani, Qurat-Ul-Ain; Dziura, James; Sinha, Rajita; Safdar, Basmah

    2017-09-01

    Only a small fraction of acute chest pain in the emergency department (ED) is due to obstructive coronary artery disease (CAD). ED chest pain remains associated with high rates of recidivism, often in the presence of nonobstructive CAD. Psychological states such as depression, anxiety, and elevation of perceived stress may account for this finding. The objective of the study was to determine whether psychological states predict recurrent chest pain (RCP). We conducted a prospective cohort study of low- to moderate-cardiac risk ED patients admitted to the Yale Chest Pain Center with acute chest pain. Depression, anxiety, and perceived stress were assessed in each patient using multistudy-validated screening scales: Patient Health Questionnaire (PHQ8), Clinical Anxiety Scale (CAS), and Perceived Stress Scale (PSS), respectively. All patients ruled out for infarction underwent appropriate cardiac stress testing. Primary outcome was RCP at 30 days evaluated by phone follow-up and medical record. The relationship between each psychological scale and RCP was evaluated using ordinal logistic regressions, controlling for known sociodemographic and cardiac risk factors. Depression (PHQ8≥10), anxiety (CAS≥30), and perceived stress (PSS≥15) were considered positive. Between August 2013 and May 2015, 985 patients were screened at the Yale Chest Pain Center. Of 500 enrolled patients, 483 patients had complete data and 365 (76%) patients completed follow-up. Thirty-six percent (n=131) had RCP within 1 month. On multivariable regression models, depression (odds ratio [OR]=2.11, 95% CI 1.18-3.79) was a significant independent predictor of 30-day chest pain recurrence after adjustment, whereas PSS (OR=0.96, 95% CI 0.60-1.53) and anxiety (OR=1.59, 95% CI 0.80-3.20) were not. Similarly, there was a direct relationship between psychometric evaluation of depression (via PHQ8) and the frequency of chest pain. Depression is independently associated with RCP regardless of

  5. Possibilities for exposure reduction in computed tomography examination of acute chest pain; Moeglichkeiten der Dosisreduktion bei CT-Untersuchungen des akuten Thoraxschmerzes

    Energy Technology Data Exchange (ETDEWEB)

    Becker, H.C. [Klinikum der Ludwig-Maximilians-Universitaet Muenchen, Campus Grosshadern, Institut fuer Klinische Radiologie, Muenchen (Germany)

    2012-10-15

    Electrocardiogram-gated (ECG) computed tomography (CT) investigations can be accompanied by high amounts of radiation exposure. This is particularly true for the investigation of patients with unclear and acute chest pain. The common approach in patients with acute chest pain is standard spiral CT of the chest. The chest pain or triple-rule-out CT protocol is a relatively new ECG-gated protocol of the entire chest. This article reviews and discusses different techniques for the CT investigation of patients with acute chest pain. By applying the appropriate scan technique, the radiation exposure for an ECG-gated protocol must not necessarily be higher than a standard chest CT scan Aortic pathologies are far better depicted by ECG-gated scan protocols and depending on the heart rate coronary artery disease can also be detected at the same time. The use of ECG-triggered scans will not support the diagnostics of the pulmonary arteries. However, in unspecific chest pain an ECG-triggered scan protocol can provide information on the differential diagnosis. (orig.) [German] EKG-getriggerte CT-Untersuchungen koennen mit einer relativ hohen Strahlenexposition einhergehen. Dies gilt im besonderen Masse fuer die Untersuchung des gesamten Thorax bei Patienten mit unklarem akutem Thoraxschmerz. Bisher wurden Untersuchungen bei Patienten mit akutem Thoraxschmerz in Spiraltechnik ohne EKG-Triggerung durchgefuehrt. Das ''Chest-pain-'' oder ''Triple-rule-out''-Protokoll ist ein neues EKG-getriggertes Untersuchungsprotokoll des gesamten Thorax. Im vorliegenden Artikel werden verschiedene Techniken zur CT-Untersuchung von Patienten mit akutem Thoraxschmerz vorgestellt und besprochen. Mit der richtigen Untersuchungstechnik muss die Strahlenexposition fuer ein EKG-getriggertes Untersuchungsprotokoll nicht hoeher sein als eine Standarduntersuchung ohne EKG. Mit einem EKG-getriggerten Untersuchungsprotokoll laesst sich die Aorta in Hinblick auf

  6. Predictors of image quality of coronary computed tomography in the acute care setting of patients with chest pain

    Energy Technology Data Exchange (ETDEWEB)

    Bamberg, Fabian; Abbara, Suhny; Schlett, Christopher L.; Cury, Ricardo C.; Truong, Quynh A.; Rogers, Ian S. [Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA (United States); Nagurney, John T. [Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA (United States); Brady, Thomas J. [Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA (United States); Hoffmann, Udo [Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA (United States)], E-mail: uhoffmann@partners.org

    2010-04-15

    Objective: We aimed to determine predictors of image quality in consecutive patients who underwent coronary computed tomography (CT) for the evaluation of acute chest pain. Method and materials: We prospectively enrolled patients who presented with chest pain to the emergency department. All subjects underwent contrast-enhanced 64-slice coronary multi-detector CT. Two experienced readers determined overall image quality on a per-patient basis and the prevalence and characteristics of non-evaluable coronary segments on a per-segment basis. Results: Among 378 subjects (143 women, age: 52.9 {+-} 11.8 years), 345 (91%) had acceptable overall image quality, while 33 (9%) had poor image quality or were unreadable. In adjusted analysis, patients with diabetes, hypertension and a higher heart rate during the scan were more likely to have exams graded as poor or unreadable (odds ratio [OR]: 2.94, p = 0.02; OR: 2.62, p = 0.03; OR: 1.43, p = 0.02; respectively). Of 6253 coronary segments, 257 (4%) were non-evaluable, most due to severe calcification in combination with motion (35%). The presence of non-evaluable coronary segments was associated with age (OR: 1.08 annually, 95%-confidence interval [CI]: 1.05-1.12, p < 0.001), baseline heart rate (OR: 1.35 per 10 beats/min, 95%-CI: 1.11-1.67, p = 0.003), diabetes, hypertension, and history of coronary artery disease (OR: 4.43, 95%-CI: 1.93-10.17, p < 0.001; OR: 2.27, 95-CI: 1.01-4.73, p = 0.03; OR: 5.12, 95%-CI: 2.0-13.06, p < 0.001; respectively). Conclusion: Coronary CT permits acceptable image quality in more than 90% of patients with chest pain. Patients with multiple risk factors are more likely to have impaired image quality or non-evaluable coronary segments. These patients may require careful patient preparation and optimization of CT scanning protocols.

  7. Knee pain and swelling: An atypical presentation of metastatic colon cancer to the patella

    Directory of Open Access Journals (Sweden)

    Bethany Gasagranda, DO

    2014-01-01

    Full Text Available Knee pain is a common reason for a patient to seek medical evaluation. Of the many causes of knee pain, malignancy is one of the least common. When malignancy is the etiology of the pain, it is usually due to a primary tumor of the osseous structures or soft tissues of the knee joint. Metastatic disease involving the knee joint is uncommon, with few cases reported in the literature. Of these reported cases, metastatic colon cancer is exceedingly rare. However, in a patient with new onset knee pain and the proper clinical history, metastatic disease should be considered as a potential explanation of symptoms. We report a case of knee pain and swelling due to metastatic colon cancer to the patella.

  8. [Prevalence and determinants of atypical presentation of acute coronary syndrome].

    Science.gov (United States)

    Pinto, David; Lunet, Nuno; Azevedo, Ana

    2011-12-01

    Knowledge of the characteristics of patients with atypical presentation of acute coronary syndromes may contribute to increased sensitivity in diagnosis in a given population. The purpose of this study is to quantify the prevalence of atypical presentation, to identify its determinants, and to describe the presenting symptoms in cases of acute coronary syndrome at the emergency department of Hospital São João, Porto. Systematic sample of 288 emergency admissions with a confirmed diagnosis of acute coronary syndrome in 2007. Atypical presentation was defined as absence of chest pain and/or syncope. The prevalence of atypical presentation was 20.5% [95% confidence interval (CI): 16.0 to 25.5], with no important variation by gender. It increased with age and was more frequent in cases of ST-segment elevation myocardial infarction. In multivariate analysis, atypical presentation was associated with age [>70 versus ≤ 50 years, odds ratio (OR)=3.45; 95%CI: 1.03-11.61] and it was about four times less likely in the presence of history of ischemic heart disease, hypertension, dyslipidemia and smoking. A history of heart failure was independently associated with a higher likelihood of acute coronary syndrome with atypical presentation (OR = 4.15, 95%CI 1.50-11.46). Among the 223 cases who had chest pain or discomfort, a growing, oppressive, prolonged (longer than 30 minutes), recurrent and episodic pain prevailed. Among other symptoms, dyspnea was the most frequently reported, either as the main symptom in cases of atypical presentation or concurrently with typical symptoms. Factors associated with atypical presentation are consistent with those described in other populations. Using routine clinical data allowed access to a large data base on a representative sample of patients admitted to the emergency department of a third-level hospital that serves a large part of the local urban population. In medical records, data are unstandardized and heterogeneous in validity

  9. Acute Chest Pain and Broad Complex Tachycardia. A Non-typical Case of Pre-excited Atrial Fibrillation

    Science.gov (United States)

    Arias, Ramon Suarez; Villanueva, Nuria Perez; Cubero, Gustavo Iglesias; Lopez, Jose Rubin

    2011-01-01

    Wolff-Parkinson-White syndrome is a common condition in the emergency department. A case is presented of a 76-year-old patient with acute chest pain and broad complex tachycardia. Despite the fact that previous and post cardioversion ECG tracings in sinus rhythm showed no signs of pre-excitation, the characteristic pattern of pre-excited atrial fibrillation (AF) is recognized and after successful DC cardioversion the patient is referred for catheter ablation of the accessory pathway. This case illustrates a non-typical presentation of the WPW syndrome, with an older patient than usual with slight signs of pre-excitation. We highlight the need for high grades of suspicion for the early recognition of pre-excited AF when attending patients with tachycardia and the obligation to know the distinctive aspects of its management for this potentially life-threatening arrhythmia. PMID:28352389

  10. Acute chest pain while exercising: a case report of Bochdalek hernia in an adolescent.

    Science.gov (United States)

    Kurniawan, N; Verheyen, L; Ceulemans, J

    2013-01-01

    We present the case of a 17-year old male patient with a symptomatic congenital posterolateral diaphragmatic hernia with acute onset of symptoms. He was admitted to our emergency department a few days after the onset of symptoms. A large thoracic herniation on the left side was seen on chest X-ray. Further investigation by computed tomography showed the presence of stomach, spleen and colon in the herniation. Semi-urgent surgery was performed by a laparoscopic approach. The diaphragmatic defect was closed with interrupted sutures. The operation and postoperative recovery were uneventful.

  11. Outcomes and radiation exposure of emergency department patients with chest pain and shortness of breath and ultralow pretest probability: a multicenter study.

    Science.gov (United States)

    Kline, Jeffrey A; Shapiro, Nathan I; Jones, Alan E; Hernandez, Jackeline; Hogg, Melanie M; Troyer, Jennifer; Nelson, R Darrell

    2014-03-01

    Excessive radiation exposure remains a concern for patients with symptoms suggesting acute coronary syndrome and pulmonary embolism but must be judged in the perspective of pretest probability and outcomes. We quantify and qualify the pretest probability, outcomes, and radiation exposure of adults with both chest pain and dyspnea. This was a prospective, 4-center, outcomes study. Patients were adults with dyspnea and chest pain, nondiagnostic ECGs, and no obvious diagnosis. Pretest probability for both acute coronary syndrome and pulmonary embolism was assessed with a validated method; ultralow risk was defined as pretest probability less than 2.5% for both acute coronary syndrome and pulmonary embolism. Patients were followed for diagnosis and total medical radiation exposure for 90 days. Eight hundred forty patients had complete data; 23 (3%) had acute coronary syndrome and 15 (2%) had pulmonary embolism. The cohort received an average of 4.9 mSv radiation to the chest, 48% from computed tomography pulmonary angiography. The pretest probability estimates for acute coronary syndrome and pulmonary embolism were less than 2.5% in 227 patients (27%), of whom 0 of 277 (0%; 95% confidence interval 0% to 1.7%) had acute coronary syndrome or pulmonary embolism and 7 of 227 (3%) had any significant cardiopulmonary diagnosis. The estimated chest radiation exposure per patient in this ultralow-risk group was 3.5 mSv, including 26 (3%) with greater than 5 mSv radiation to the chest and no significant cardiopulmonary diagnosis. One quarter of patients with chest pain and dyspnea had ultralow risk and no acute coronary syndrome or pulmonary embolism but were exposed to an average of 3.5 mSv radiation to the chest. These data can be used in a clinical guideline to reduce radiation exposure. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

  12. Spinal cord stimulation to abort painful spasms of atypical stiff limb syndrome.

    Science.gov (United States)

    Ughratdar, I; Sivakumar, G; Basu, S

    2010-01-01

    Stiff limb syndrome (SLS) is a rare chronic condition which can result in significant debility. We report the case of a 44-year-old man suffering from severe painful spasms in his right leg with a diagnosis of SLS. He had been initially treated for his pain with a spinal cord stimulator but presented with exacerbation of pain secondary to a lead fracture for which he underwent revision of the stimulator. Postoperative programming unexpectedly resulted in not only control of his pain but also an ability to abort his spasmodic episodes related to SLS. To our knowledge, spinal cord stimulation has not been previously used for SLS and our report opens up another avenue for this rare condition. We provide a brief overview of SLS and propose an underlying mechanism for the observed phenomenon.

  13. Modification of the Thrombolysis in Myocardial Infarction risk score for patients presenting with chest pain to the emergency department.

    Science.gov (United States)

    Greenslade, Jaimi H; Chung, Kimberly; Parsonage, William A; Hawkins, Tracey; Than, Martin; Pickering, John W; Cullen, Louise

    2017-12-12

    To develop a modified Thrombolysis in Myocardial Infarction (TIMI) score to effectively risk stratify patients presenting to the ED with chest pain. A prospective observational study was conducted at two metropolitan EDs. Data were obtained during patient interview. The primary outcome was major adverse cardiovascular events (MACE) within 30 days of presentation. Two separate modifications of the TIMI score were developed. These scores were compared to the original TIMI in terms of the area under the receiver operating characteristic curve and diagnostic accuracy statistics (sensitivity, specificity, positive and negative predictive values). Of 1760 patients, 364 (20.7%) experienced 30 day MACE. The first modified TIMI score was a simplified TIMI (s-TIMI) including four variables: age ≥65 years, three or more risk factors, high-sensitivity troponin (hs-cTnI) and electrocardiogram changes. The second score included the same four variables plus two Global Registry of Acute Coronary Events (GRACE) variables (systolic blood pressure and estimated glomerular filtration rate). This score was termed the GRACE TIMI (g-TIMI). s-TIMI had a lower sensitivity compared to the original TIMI score (93.41 and 96.98%), but higher specificity (45.49 and 24.50%). The g-TIMI had a sensitivity of 98.90% and specificity of 14.90%. Attempts to modify the TIMI score yielded two scores with added predictive utility in comparison to the original TIMI model. The addition of GRACE variables (g-TIMI) increased sensitivity for MACE, but decreased the specificity of the model. The s-TIMI score yielded good specificity but had sensitivity that would not be acceptable by emergency physicians. The s-TIMI may be useful as part of an accelerated chest pain protocol. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

  14. Variation in the use of 12-lead electrocardiography for patients with chest pain by emergency medical services in North Carolina.

    Science.gov (United States)

    Bush, Montika; Glickman, Lawrence T; Fernandez, Antonio R; Garvey, J L; Glickman, Seth W

    2013-08-06

    Prehospital 12-lead electrocardiography (ECG) is critical to timely STEMI care although its use remains inconsistent. Previous studies to identify reasons for failure to obtain a prehospital ECG have generally only focused on individual emergency medical service (EMS) systems in urban areas. Our study objective was to identify patient, geographic, and EMS agency-related factors associated with failure to perform a prehospital ECG across a statewide geography. We analyzed data from the Prehospital Medical Information System (PreMIS) in North Carolina from January 2008 to November 2010 for patients >30 years of age who used EMS and had a prehospital chief complaint of chest pain. Among 3.1 million EMS encounters, 134 350 patients met study criteria. From 2008-2010, 82 311 (61%) persons with chest pain received a prehospital ECG; utilization increased from 55% in 2008 to 65% in 2010 (trend P<0.001). Utilization by health referral region ranged from 22.9% to 74.2% and was lowest in rural areas. Men were more likely than women to have an ECG performed (63.0% vs 61.3%, adjusted RR 1.02, 95% CI 1.01 to 1.04). The certification-level of the EMS provider (paramedic vsbasic/intermediate) and system-level ECG equipment availability were the strongest predictors of ECG utilization. Persons in an ambulance with a certified paramedic were significantly more likely to receive a prehospital ECG than nonparamedics (RR 2.15, 95% CI 1.55, 2.99). Across a large geographic area prehospital ECG use increased significantly, although important quality improvement opportunities remain. Increasing ECG availability and improving EMS certification and training levels are needed to improve overall care and reduce rural-urban treatment differences.

  15. Prognostic value of CT-derived left atrial and left ventricular measures in patients with acute chest pain.

    Science.gov (United States)

    Takx, Richard A P; Vliegenthart, Rozemarijn; Schoepf, U Joseph; Nance, John W; Bamberg, Fabian; Abro, Joseph A; Carr, Christine M; Litwin, Sheldon E; Apfaltrer, Paul

    2017-01-01

    To determine which left atrial (LA) and left ventricular (LV) parameters are associated with future major adverse cardiac event (MACE) and whether these measurements have independent prognostic value beyond risk factors and computed tomography (CT)-derived coronary artery disease measures. This retrospective analysis was performed under an IRB waiver and in HIPAA compliance. Subjects underwent coronary CT angiography (CCTA) using a dual-source CT system for acute chest pain evaluation. LV mass, LV ejection fraction (EF), LV end-systolic volume (ESV) and LV end-diastolic volume (EDV), LA ESV and LA diameter, septal wall thickness and cardiac chamber diameters were measured. MACE was defined as cardiac death, non-fatal myocardial infarction, unstable angina, or late revascularization. The association between cardiac CT measures and the occurrence of MACE was quantified using Cox proportional hazard analysis. 225 subjects (age, 56.2±11.2; 140 males) were analyzed, of whom 42 (18.7%) experienced a MACE during a median follow-up of 13 months. LA diameter (HR:1.07, 95%CI:1.01-1.13permm) and LV mass (HR:1.05, 95%CI:1.00-1.10perg) remained significant prognostic factor of MACE after controlling for Framingham risk score. LA diameter and LV mass were also found to have prognostic value independent of each other. The other morphologic and functional cardiac measures were no significant prognostic factors for MACE. CT-derived LA diameter and LV mass are associated with future MACE in patients undergoing evaluation for chest pain, and portend independent prognostic value beyond traditional risk factors, coronary calcium score, and obstructive coronary artery disease. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  16. The incremental value of stress testing in patients with acute chest pain beyond serial cardiac troponin testing.

    Science.gov (United States)

    Aldous, Sally; Richards, A Mark; Cullen, Louise; Pickering, John W; Than, Martin

    2016-05-01

    In patients with acute chest pain and normal range cardiac troponin (cTn), accurate risk stratification for acute coronary syndrome is challenging. This study assesses the incremental value of stress testing to identify patients for angiography with a view to revascularisation. A single-centre observational study recruited patients with acute chest pain in whom serial cTn tests were negative and stress testing (exercise tolerance testing/dobutamine stress echocardiography) was performed. Stress tests were reported as negative, non-diagnostic or positive. The primary outcomes were revascularisation on index admission, or cardiac death and myocardial infarction over 1 year follow-up. Of 749 patients recruited, 709 underwent exercise tolerance testing and 40 dobutamine stress echo of which 548 (73.2%) were negative, 169 (22.6%) were non-diagnostic and 32 (4.3%) were positive. Patients with positive tests (n=19 (59.4%)) were more likely to undergo index admission revascularisation than patients with non-diagnostic (n=15 (8.9%)) (pacute myocardial infarction were low and were similar across stress test outcomes. The incremental value of stress testing was the identification of an additional 34 (4.5% (95% CI 3.0% to 6.0%)) patients who underwent index admission revascularisation with a view to preventing future adverse events. Uncertainty in whether revascularisation prevents adverse events in patients with negative cTn means the choice to undertake stress testing depends on whether clinicians perceive value in identifying 4.5% of these patients for revascularisation. ACTRN1260900028327, ACTRN12611001069943. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

  17. Performance of the EDACS-accelerated Diagnostic Pathway in a Cohort of US Patients with Acute Chest Pain.

    Science.gov (United States)

    Stopyra, Jason P; Miller, Chadwick D; Hiestand, Brian C; Lefebvre, Cedric W; Nicks, Bret A; Cline, David M; Askew, Kim L; Riley, Robert F; Russell, Gregory B; Hoekstra, James W; Mahler, Simon A

    2015-12-01

    The Emergency Department Assessment of Chest pain Score-Accelerated Diagnostic Protocol (EDACS-ADP) is a decision aid designed to safely identify emergency department (ED) patients with chest pain for early discharge. Derivation and validation studies in Australasia have demonstrated high sensitivity (99%-100%) for major adverse cardiac events (MACE). To validate the EDACS-ADP in a cohort of US ED patients with symptoms suspicious for acute coronary syndrome (ACS). A secondary analysis of participants enrolled in the HEART Pathway Randomized Controlled Trial was conducted. This single-site trial enrolled 282 ED patients≥21 years old with symptoms concerning for ACS, inclusive of all cardiac risk levels. Each patient was classified as low risk or at risk by the EDACS-ADP based on EDACS, electrocardiogram, and serial troponins. Potential early discharge rate and sensitivity for MACE at 30 days, defined as cardiac death, myocardial infarction (MI), or coronary revascularization were calculated. MACE occurred in 17/282 (6.0%) participants, including no deaths, 16/282 (5.6%) with MI, and 1/282 (0.4%) with coronary revascularization without MI. The EDACS-ADP identified 188/282 patients [66.7%, 95% confidence interval (CI): 60.8%-72.1%] as low risk. Of these, 2/188 (1.1%, 95% CI: 0.1%-3.9%) had MACE at 30 days. EDACS-ADP was 88.2% (95% CI: 63.6%-98.5%) sensitive for MACE, identifying 15/17 patients. Of the 2 patients identified as low risk with MACE, 1 had MI and 1 had coronary revascularization without MI. Within a US cohort of ED patients with symptoms concerning for ACS, sensitivity for MACE was 88.2%. We are unable to validate the EDACS-ADP as sufficiently sensitive for clinical use.

  18. Depression masquerading as chest pain in a patient with Wolff Parkinson White syndrome

    OpenAIRE

    Madabushi, Rajashree; Agarwal, Anil; Tewari, Saipriya; Gautam, Sujeet K S; Khuba, Sandeep

    2016-01-01

    Wolff Parkinson White (WPW) syndrome is a condition in which there is an aberrant conduction pathway between the atria and ventricles, resulting in tachycardia. A 42-year-old patient, who was treated for WPW syndrome previously, presented with chronic somatic pain. With her cardiac condition in mind, she was thoroughly worked up for a recurrence of disease. As part of routine screening of all patients at our pain clinic, she was found to have severe depression as per the Patient Health Questi...

  19. GRACE and TIMI risk scores but not stress imaging predict long-term cardiovascular follow-up in patients with chest pain after a rule-out protocol

    NARCIS (Netherlands)

    van der Zee, P. M.; Verberne, H. J.; Cornel, J. H.; Kamp, O.; van der Zant, F. M.; Bholasingh, R.; de Winter, R. J.

    2011-01-01

    Objective To determine the long-term prognostic value of stress imaging and clinical risk scoring for cardiovascular mortality in chest pain patients after ruling out acute coronary syndrome (ACS). Methods A standard rule-out protocol was performed in emergency room patients with a normal or

  20. A brief cognitive-behavioral intervention for treating depression and panic disorder in patients with noncardiac chest pain : a 24-week randomized controlled trial

    NARCIS (Netherlands)

    van Beek, M. H. C. T.; Voshaar, R. C. Oude; Beek, A. M.; van Zijderveld, G. A.; Visser, S.; Speckens, A. E. M.; Batelaan, N.; van Balkom, A. J. L. M.

    BACKGROUND: Most patients with noncardiac chest pain experience anxiety and depressive symptoms. Commonly they are reassured and referred back to primary care, leaving them undiagnosed and untreated. Some small studies have suggested efficacy of 12 cognitive behavioral therapy (CBT) sessions. Our

  1. A brief cognitive-behavioral intervention for treating depression and panic disorder in patients with noncardiac chest pain: a 24-week randomized controlled trial

    NARCIS (Netherlands)

    Beek, M.H.C.T. van; Oude Voshaar, R.C.; Beek, A.M.; Zijderveld, G.A. van; Visser, S.; Speckens, A.E.M.; Batelaan, N.; Balkom, A.J.L.M. van

    2013-01-01

    BACKGROUND: Most patients with noncardiac chest pain experience anxiety and depressive symptoms. Commonly they are reassured and referred back to primary care, leaving them undiagnosed and untreated. Some small studies have suggested efficacy of 12 cognitive behavioral therapy (CBT) sessions. Our

  2. A brief cognitive-behavioural intervention for treating depression and panic disorder in patients with noncardiac chest pain: a 24-week randomized controlled trial

    NARCIS (Netherlands)

    van Beek, M.H.C.T.; Oude Voshaar, R.C.; Beek, A.M.; van Zijderveld, G.A.; Visser, S.; Speckens, A.E.M.; Batelaan, N.; van Balkom, A.J.L.M.

    2013-01-01

    Background: Most patients with noncardiac chest pain experience anxiety and depressive symptoms. Commonly they are reassured and referred back to primary care, leaving them undiagnosed and untreated. Some small studies have suggested efficacy of 12 cognitive behavioral therapy (CBT) sessions. Our

  3. Efficiency and safety of coronary CT angiography compared to standard care in the evaluation of patients with acute chest pain: a Canadian study.

    Science.gov (United States)

    Peña, Elena; Rubens, Fraser; Stiell, Ian; Peterson, Rebecca; Inacio, Joao; Dennie, Carole

    2016-08-01

    The optimal assessment of patients with chest pain and possible acute coronary syndrome (ACS) remains a diagnostic dilemma for emergency physicians. Cardiac computed tomographic angiography (CCTA) may identify patients who can be safely discharged home from the emergency department (ED). The objective of the study was to compare the efficiency and safety of CCTA to standard care in patients presenting to the ED with low- to intermediate-risk chest pain. This was a single-center before-after study enrolling ED patients with chest pain and low to intermediate risk of ACS, before and after implementing a cardiac CT-based management protocol. The primary outcome was efficiency (time to diagnosis). Secondary outcomes included safety (30-day incidence of major adverse cardiovascular events (MACE)) and length of stay in the ED. We enrolled 258 patients: 130 in the standard care group and 128 in the cardiac CT-based management group. The cardiac CT group had a shorter time to diagnosis of 7.1 h (IQR 5.8-14.0) compared to 532.9 h (IQR 312.8-960.5) for the standard care group (p patients with low- to intermediate-risk chest pain was safe and led to a shorter time to diagnosis but increased length of stay in the ED.

  4. Non-obstructive coronary artery disease upon multi-detector computed tomography in patients presenting with acute chest pain--results of an intermediate term follow-up.

    Science.gov (United States)

    Segev, Amit; Beigel, Roy; Goitein, Orly; Brosh, Sella; Oiero, Dan; Konen, Eli; Hod, Hanoch; Matetzky, Shlomi

    2012-02-01

    Multi-detector computed tomography (MDCT) has emerged as an efficient tool for detection of obstructive coronary artery disease (CAD) and assessment of patients with acute chest pain. MDCT may detect premature, non-obstructive atherosclerotic lesions which otherwise would have not been detected upon functional cardiac imaging tests. Currently, there is scarce data regarding the clinical significance of these lesions. The purpose of this study was to prospectively analyse the intermediate term outcome of patients admitted to chest pain unit (CPU) with findings of non-obstructive CAD upon MDCT. Method and results The study comprised 444 patients admitted to the CPU at Sheba Medical Center and underwent evaluation by MDCT for complaints of acute chest pain. Studies were classified as: normal; non-obstructive CAD (defined as any narrowing Patients were followed up for a minimum of 1 year and outcomes were compared between the non-obstructive (n = 115) and the normal (n = 266) MDCT groups in regard to MACE [coronary revascularization, acute coronary syndrome (ACS), and death]. Comparing the groups, those with non-obstructive CAD were older, more likely to be males, and dyslipidaemic. During an intermediate term follow-up (2.5 ± 0.4 years) MACE was equally low between the two groups (1% for both groups; P = 0.9). Among patients evaluated by MDCT for acute chest pain, during an intermediate term follow-up, those with non-obstructive CAD had a benign clinical outcome compared with those with normal coronary arteries.

  5. Myocardial deformation by strain echocardiography identifies patients with acute coronary syndrome and non-diagnostic ECG presenting in a chest pain unit: a prospective study of diagnostic accuracy.

    Science.gov (United States)

    Schroeder, Joerg; Hamada, Sandra; Gründlinger, Nina; Rubeau, Tanja; Altiok, Ertunc; Ulbrich, Katrin; Keszei, Andras; Marx, Nikolaus; Becker, Michael

    2016-03-01

    Clinical assessment often cannot risk stratify patients hospitalized with chest pain and non-diagnostic electrocardiography (ECG) or myocardial enzymes. An inappropriate admission of patients with non-cardiac chest pain is an enormous cost factor. 2315 patients who presented in the chest pain unit (CPU) with symptoms suggestive of acute coronary syndrome (ACS) were screened. All patients with relevant changes in ECG or myocardial enzymes were excluded. 268 consecutive patients (mean 58 ± 7 years, 88 men) were prospectively included and underwent echocardiography for left ventricular ejection fraction (LVEF), wall motion score index (WMSI) and strain parameter and a coronary angiography (CA) within 2 ± 1 days after admission. Anatomically obstructive coronary artery disease (CAD) (≥70 % diameter stenosis) was present in 110 patients (41 %). The incremental value of LVEF, WMSI, and strain parameters to relevant clinical variables was determined in nested Cox models. Baseline clinical data associated with relevant CAD were age [hazard ratio (HR) 1.31, p = 0.03], arterial hypertension (HR 1.39, p = 0.03) and diabetes (HR 1.46, p = 0.001). The addition of endocardial global circumferential strain (GCS) (HR 1.57, p chest pain or prompt cardiological allocation of patients with CAD. NCT 02357641.

  6. Efficacy of multi-detector coronary computed tomography angiography in comparison with exercise electrocardiogram in the triage of patients of low risk acute chest pain.

    Science.gov (United States)

    Nagori, M; Narain, V S; Saran, R K; Dwivedi, S K; Sethi, R

    2014-01-01

    To compare the safety and diagnostic efficacy of coronary computed tomography angiography (CTA) with exercise electrocardiography (XECG) in triaging patients of low risk acute chest pain. Noninvasive assessment of coronary stenosis by CTA may improve early and accurate triage of patients presenting with acute chest pain to the emergency department (ED). Low risk patients of possible acute coronary syndrome (ACS) were included in the study. The patients in CTA arm with significant stenosis (≥ 50%) underwent catheterization, while those with no or intermediate stenosis (chest pain presenting to the ED, with a PPV of 94.7% and an NPV of 100%.The overall diagnostic efficacy was 97.6%. XECG was observed to be 72.7% sensitive and 96.6% specific in diagnosing MACE with a PPV of 88.9% and NPV of 90.3% in low risk chest pain patients presenting to the ED. The overall diagnostic accuracy was 90%. CTA is an excellent diagnostic tool in ED patients with low risk of ACS, with minimum time delay as compared to XECG, and also is safe for triaging such patients. Copyright © 2014 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

  7. Inaccuracy of Thrombolysis in Myocardial Infarction and Global Registry in Acute Coronary Events scores in predicting outcome in ED patients with potential ischemic chest pain.

    Science.gov (United States)

    Boubaker, Hamdi; Beltaief, Kaouther; Grissa, Mohamed Habib; Kerkeni, Wièm; Dridi, Zohra; Msolli, Mohamed Amine; Chouchène, Hamdène; Belaïd, Alia; Chouchène, Hamadi; Sassi, Mohamed; Bouida, Wahid; Boukef, Riadh; Methemmem, Mehdi; Marghli, Soudani; Nouira, Semir

    2015-09-01

    The Thrombolysis in Myocardial Infarction (TIMI) and the Global Registry in Acute Coronary Events (GRACE) scores were largely evaluated and validated in stratifying risk of cardiovascular events in patients with chest pain and acute coronary syndrome. Our objective was to compare these 2 scores in predicting outcome in emergency department (ED) patients with undifferentiated chest pain. This was a prospective cohort study including patients presenting to 4 EDs with chest pain with nondiagnostic or normal ECG. For all included patients (n = 3125), TIMI and GRACE scores were calculated. Follow-up was conducted at 30-day and 1-year post-ED index admission to identify major adverse events. Main outcome included all cause mortality, acute coronary syndrome, and coronary non-ED planned revascularization. Prognostic performance of the scores was assessed by the receiver operating characteristic (ROC) curves. We reported 285 (9.1%) major adverse events at 30 days and 436 (13.9%) at 1 year. In patients with low TIMI (≤2) and GRACE (chest pain patients. Copyright © 2015 Elsevier Inc. All rights reserved.

  8. A brief cognitive-behavioral intervention for treating depression and panic disorder in patients with noncardiac chest pain: a 24-week randomized controlled trial

    NARCIS (Netherlands)

    van Beek, M.H.C.T.; Oude Voshaar, R.C.; Beek, A.M.; van Zijderveld, G.A.; Visser, S.; Speckens, A.E.M.; Batelaan, N.M.; van Balkom, A.J.L.M.

    2013-01-01

    Background Most patients with noncardiac chest pain experience anxiety and depressive symptoms. Commonly they are reassured and referred back to primary care, leaving them undiagnosed and untreated. Some small studies have suggested efficacy of 12 cognitive behavioral therapy (CBT) sessions. Our aim

  9. Long-Term Clinical Impact of Coronary CT Angiography in Patients With Recent Acute-Onset Chest Pain: The Randomized Controlled CATCH Trial.

    Science.gov (United States)

    Linde, Jesper J; Hove, Jens D; Sørgaard, Mathias; Kelbæk, Henning; Jensen, Gorm B; Kühl, Jørgen T; Hindsø, Louise; Køber, Lars; Nielsen, Walter B; Kofoed, Klaus F

    2015-12-01

    The aim of the CATCH (CArdiac cT in the treatment of acute CHest pain) trial was to investigate the long-term clinical impact of a coronary computed tomographic angiography (CTA)-guided treatment strategy in patients with recent acute-onset chest pain compared to standard care. The prognostic implications of a coronary CTA-guided treatment strategy have not been compared in a randomized fashion to standard care in patients referred for acute-onset chest pain. Patients with acute chest pain but normal electrocardiograms and troponin values were randomized to treatment guided by either coronary CTA or standard care (bicycle exercise electrocardiogram or myocardial perfusion imaging). In the coronary CTA-guided group, a functional test was included in cases of nondiagnostic coronary CTA images or coronary stenoses of borderline severity. The primary endpoint was a composite of cardiac death, myocardial infarction (MI), hospitalization for unstable angina pectoris (UAP), late symptom-driven revascularizations, and readmission for chest pain. We randomized 299 patients to coronary CTA-guided strategy and 301 to standard care. After inclusion, 24 patients withdrew their consent. The median (interquartile range) follow-up duration was 18.7 (range 16.8 to 20.1) months. In the coronary CTA-guided group, 30 patients (11%) had a primary endpoint versus 47 patients (16%) in the standard care group (p = 0.04; hazard ratio [HR]: 0.62 [95% confidence interval: 0.40 to 0.98]). A major adverse cardiac event (cardiac death, MI, hospitalization for UAP, and late symptom-driven revascularization) was observed in 5 patients (2 MIs, 3 UAPs) in the coronary CTA-guided group versus 14 patients (1 cardiac death, 7 MIs, 5 UAPs, 1 late symptom-driven revascularization) in the standard care group (p = 0.04; HR: 0.36 [95% CI: 0.16 to 0.95]). Differences in cardiac death and MI (8 vs. 2) were insignificant (p = 0.06). A coronary CTA-guided treatment strategy appears to improve clinical outcome

  10. Multi-modal intervention for the inpatient management of sickle cell pain significantly decreases the rate of acute chest syndrome.

    Science.gov (United States)

    Reagan, Mary M; DeBaun, Michael R; Frei-Jones, Melissa J

    2011-02-01

    Pain in children with sickle cell disease (SCD) is the leading cause of acute care visits and hospitalizations. Pain episodes are a risk factor for the development of acute chest syndrome (ACS), contributing to morbidity and mortality in SCD. Few strategies exist to prevent this complication. We performed a before-and-after prospective multi-modal intervention. All children with SCD admitted for pain during the 2-year study period were eligible. The multi-modal intervention included standardized admission orders, monthly house staff education, and one-on-one patient and caregiver education. A total of 332 admissions for pain occurred during the study period; 159 before the intervention and 173 during the intervention. The ACS rate declined by 50% during the intervention period 25% (39 of 159) to 12% (21 of 173); P = 0.003. Time to ACS development increased from 0.8 days (0.03-5.2) to 1.7 days (0.03-5.8); P = 0.047. No significant difference was found in patient demographics, intravenous fluid amount administered, frequency of normal saline bolus administration, or cumulative opioid amount delivered in the first 24 hr. Patient controlled analgesia-use was more common after the intervention 52% (82 of 159) versus 73% (126 of 173; P = 0.0001) and fewer patients required changes in analgesic dosing within the first 24 hr after admission (26%, 42 of 159 vs. 16%, 28 of 173; P = 0.015). A multi-modal intervention to educate and subsequently change physician's behavior likely decreased the rate of ACS in the setting of a single teaching hospital. Copyright © 2010 Wiley-Liss, Inc.

  11. Chest pain unit (CPU) in the management of low to intermediate risk acute coronary syndrome: a tertiary hospital experience from New Zealand.

    Science.gov (United States)

    Mazhar, J; Killion, B; Liang, M; Lee, M; Devlin, G

    2013-02-01

    A chest pain unit (CPU) for management of patients with chest pain at low to intermediate risk for acute coronary syndrome (ACS) appears safe and cost-effective. We report our experience with a CPU from March 2005 to July 2009. Prospective audit of patients presenting with chest pain suggestive of ACS but no high risk features and managed using a CPU, which included; serial cardiac troponins and electrocardiography and exercise tolerance test (ETT) if indicated. Outcomes assessed included three-month readmission rate and one year mortality. 2358 patients were managed according to the CPU. Mean age 56 years (17-96 years), 59% men and median stay of 22h (IQR 17-26h). 1933 (82%) were diagnosed as non-cardiac chest pain. 1741 (74%) patients had an ETT. Median time from triage to ETT was 21h (IQR 16-24h). 64 (2.7%) were readmitted within three months. The majority of readmissions, 39 (61%) were for a non-cardiac cause. Twenty patients (1%) were readmitted with ACS. There was no cardiac death after one year of being discharged as non-cardiac chest pain. This study confirms that a CPU with high usage of predischarge ETT is a safe and effective way of excluding ACS in patients without high risk features in a New Zealand setting. Copyright © 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

  12. A brief cognitive-behavioral intervention for treating depression and panic disorder in patients with noncardiac chest pain: a 24-week randomized controlled trial.

    Science.gov (United States)

    van Beek, M H C T; Oude Voshaar, R C; Beek, A M; van Zijderveld, G A; Visser, S; Speckens, A E M; Batelaan, N; van Balkom, A J L M

    2013-07-01

    Most patients with noncardiac chest pain experience anxiety and depressive symptoms. Commonly they are reassured and referred back to primary care, leaving them undiagnosed and untreated. Some small studies have suggested efficacy of 12 cognitive behavioral therapy (CBT) sessions. Our aim was to examine efficacy of brief CBT in reducing anxiety and depressive symptoms in patients with noncardiac chest pain and comorbid panic and/or depressive disorders. In this 24-week randomized controlled trial comparing CBT (n = 60) versus treatment as usual (TAU, n = 53), we included all adults who presented at the cardiac emergency unit of a university hospital with noncardiac chest pain, scored ≥8 on the hospital anxiety and depression scale (HADS) and were diagnosed with a comorbid panic and/or depressive disorder with the Mini International Neuropsychiatric Interview. CBT consisted of six individual sessions. Main outcome was disease severity assessed with the clinical global inventory (CGI) by a blinded independent rater. ANCOVA in the intention-to-treat and completer sample showed that CBT was superior to TAU after 24 weeks in reducing disease severity assessed with CGI (P depressive symptoms (Hamilton depression rating scale) were in line with these results except for HADS-depression (P = .10), fear questionnaire (P = .13), and STAI-state (P = .11). Brief CBT significantly reduces anxiety and depressive symptoms in patients with noncardiac chest pain who are diagnosed with panic and/or depressive disorders. Patients presenting with noncardiac chest pain should be screened for psychopathology and if positive, CBT should be considered. © 2013 Wiley Periodicals, Inc.

  13. Clinical utility of the HEART score in patients admitted with chest pain to an inner-city hospital in the USA.

    Science.gov (United States)

    Patnaik, Soumya; Shah, Mahek; Alhamshari, Yaser; Ram, Pradhum; Puri, Ritika; Lu, Marvin; Balderia, Percy; Imms, John B; Maludum, Obiora; Figueredo, Vincent M

    2017-06-01

    Chest pain is one of the most common presentations to a hospital, and appropriate triaging of these patients can be challenging. The HEART score has been used for such purposes in some countries and only a few validation studies from the USA are available. We aim to determine the utility of the HEART score in patients presenting with chest pain to an inner-city hospital in the USA. We retrospectively screened 417 consecutive patients admitted with chest pain to the observation/telemetry units at Einstein Medical Center Philadelphia. After applying inclusion and exclusion criteria, 299 patients were included in the analysis. Patients were divided into low-risk (0-3) and intermediate-high (≥4)-risk HEART score groups. Baseline characteristics, thrombolysis in myocardial infarction score, need for revascularization during index hospitalization, and major adverse cardiovascular events (MACE) at 6 weeks and 12 months were recorded. There were 98 and 201 patients in the low-score group and intermediate-high-score group, respectively. Compared with the low-score group, patients in the intermediate-high-risk group had a higher incidence of revascularization during the index hospital stay (16.4 vs. 0%; P=0.001), longer hospital stay, higher MACE at 6 weeks (9.5 vs. 0%) and 12 months (20.4 vs. 3.1%), and higher cardiac readmissions. HEART score of at least 4 independently predicted MACE at 12 months (odds ratio 7.456, 95% confidence interval: 2.175-25.56; P=0.001) after adjusting for other risk factors in regression analysis. HEART score of at least 4 was predictive of worse outcomes in patients with chest pain in an inner-city USA hospital. If validated in multicenter prospective studies, the HEART score could potentially be useful in risk-stratifying patients presenting with chest pain in the USA and could impact clinical decision-making.

  14. Evaluation of non-ST segment elevation acute chest pain syndromes with a novel low-profile continuous imaging ultrasound transducer.

    Science.gov (United States)

    Chandraratna, P Anthony N; Mohar, Dilbahar S; Sidarous, Peter F; Brar, Prabhjyot; Miller, Jeffrey; Shah, Nissar; Kadis, John; Ali, Ashgar; Mohar, Prabhsimran

    2012-09-01

    This investigation was designed to test the hypothesis that continuous cardiac imaging using an ultrasound transducer developed in our laboratory (ContiScan) is superior to electrocardiogram (ECG) monitoring in the diagnosis of coronary artery disease (CAD) in patients with acute non-ST segment elevation chest pain syndromes. Seventy patients with intermediate to high probability of CAD who presented with typical anginal chest pain and no evidence of ST segment elevation on the ECG were studied. The 2.5-MHz transducer is spherical in its distal part mounted in an external housing to permit steering in 360 degrees. The transducer was placed at the left sternal border to image the left ventricular short-axis view and recorded on video tape at baseline, during and after episodes of chest pain. Two ECG leads were continuously monitored. The presence of CAD was confirmed by coronary arteriography or nuclear or echocardiographic stress testing. Twenty-four patients had regional wall motion abnormalities (RWMA) on their initial echo which were unchanged during the period of monitoring. All had evidence of CAD. Twenty-eight patients had transient RWMA. All had evidence of CAD. Eighteen patients had normal wall motion throughout the monitoring period, 14 of these had no evidence of CAD, and four had evidence of CAD. These four patients did not have chest pain during monitoring. The sensitivity, specificity, and accuracy of echocardiographic monitoring for diagnosing non-ST elevation myocardial infarction was 88%, 100%, and 91% respectively. The sensitivity, specificity, and accuracy of the ECG for diagnosis of CAD were 31%, 100%, and 52%, respectively. Echocardiography was superior to ECG (P patients presenting with acute non-ST segment elevation chest pain syndromes. This technique could be a useful adjunct to ECG monitoring for myocardial ischemia in the acute care setting. © 2012, Wiley Periodicals, Inc.

  15. Variation in chest pain emergency department admission rates and acute myocardial infarction and death within 30 days in the Medicare population.

    Science.gov (United States)

    Cotterill, Philip G; Deb, Partha; Shrank, William H; Pines, Jesse M

    2015-08-01

    The objective was to assess the relationship between emergency department (ED) admission rates for Medicare beneficiaries with chest pain and outcomes, specifically 30-day rates of acute myocardial infarction (AMI) and mortality. Using a 20% random sample of Medicare beneficiaries in 2009, 158,295 beneficiaries with a primary diagnosis of chest pain at the conclusion of their ED visits were selected to assess outcomes based on the decision to hospitalize or discharge home. The proportions of these patients admitted to inpatient or observation status at 2,219 U.S. hospitals were calculated, adjusting for differences in patient and hospital characteristics. Both bivariate analysis and multivariable logistic regression were used to estimate the effect of the adjusted admission rates (designed to be a measure of care intensity) on patient outcomes. Other covariates in the multivariable model included patient demographics, medical conditions, and hospital utilization in the 30 days prior to the ED visits. Results from the bivariate and multivariable analyses were compared for consistency. The adjusted Medicare admission rate for ED patients with chest pain averaged 63% for the middle quintile of the patient sample and ranged from 38% to 81% in the lowest and highest quintiles. The multivariable model yielded estimates of 3.6 fewer cases of AMI (95% confidence interval [CI] = 1.5 to 5.1 cases) and 2.8 fewer deaths (95% CI = 0.6 to 4.1 deaths) per 1,000 chest pain patients associated with an admission rate of 81% versus 38%. The estimates from the bivariate analysis were of similar magnitude. Considerable variation exists across U.S. hospitals in ED admission rates for Medicare patients with chest pain. Hospitals that approach admissions more conservatively (i.e., higher admission rates) in this population have lower rates of AMI and mortality. © 2015 by the Society for Academic Emergency Medicine.

  16. Low levels of high-density lipoproteins cholesterol are independently associated with acute coronary heart disease in patients hospitalized for chest pain.

    Science.gov (United States)

    Cordero, Alberto; Moreno-Arribas, José; Bertomeu-González, Vicente; Agudo, Pilar; Miralles, Beatriz; Masiá, M Dolores; López-Palop, Ramón; Bertomeu-Martínez, Vicente

    2012-04-01

    The role of high-density lipoproteins in the context of acute chest pain has not been well characterized. The objective of this study was to determine the relative contribution of lipid profile to the risk of acute coronary syndrome in patients admitted to a cardiology ward for chest pain. We included all consecutive admissions in a single cardiology department over a period of 10 months and 1-year follow-up was performed. In total, 959 patients were included: 457 (47.7%) were diagnosed with non-ischemic chest pain, 355 (37%) with non-ST-elevation acute coronary syndrome, and 147 (15.3%) with ST-elevation acute coronary syndrome. Prevalence of high-density lipoproteins acute coronary syndrome (69.4% vs 30.6%; Pacute coronary syndrome increased with reductions in mean high-density lipoproteins. Age, active smoking, diabetes, fasting glucose >100 mg/dL, and high-density lipoproteins acute coronary syndrome, and low high-density lipoproteins was the main associated factor (odds ratio, 4.11; 95% confidence interval, 2.87-5.96). Survival analysis determined that, compared with non-ischemic chest pain, the presence of acute coronary syndrome was associated with significantly greater risk of all-cause and cardiovascular mortality. Low levels of high-density lipoproteins cholesterol (≤40 mg/dL) were independently associated with a diagnosis of acute coronary syndrome in patients hospitalized for chest pain, with an inverse relationship between lower levels of high-density lipoproteins and prevalence of acute coronary syndrome. Copyright © 2011 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.

  17. [Pindborg tumor in the maxillary sinus. An unusual case of atypical facial pain].

    Science.gov (United States)

    Larsen, P O; Poulsen, P

    1989-01-02

    A woman aged 40 years had experienced left-sided facial pain for some months. Dental treatment did not result in any improvement. X-ray of the maxillary sinus revealed a tooth in the left maxillary sinus. At operation, this was shown to be a calcified epithelial odontogenic tumour (Pindborg tumour).

  18. New risk score for patients with acute chest pain, non-ST-segment deviation, and normal troponin concentrations: a comparison with the TIMI risk score.

    Science.gov (United States)

    Sanchis, Juan; Bodí, Vicent; Núñez, Julio; Bertomeu-González, Vicente; Gómez, Cristina; Bosch, María José; Consuegra, Luciano; Bosch, Xavier; Chorro, Francisco J; Llàcer, Angel

    2005-08-02

    The purpose of this research was to develop a risk score for patients with chest pain, non-ST-segment deviation electrocardiogram (ECG), and normal troponin levels. Prognosis assessment in this population remains a challenge. A total of 646 consecutive patients were evaluated by clinical history (risk factors and chest pain score according to pain characteristics), ECG, and early exercise testing. ST-segment deviation and troponin elevation were exclusion criteria. The primary end point was mortality or myocardial infarction at one year. The secondary end point was mortality, myocardial infarction, or urgent revascularization at 14 days (similar to the Thrombolysis In Myocardial Infarction [TIMI] risk score). Primary and secondary end point rates were 6.7% and 5.4%. A risk score was constructed using the variables related to the primary end point: chest pain score > or =10 points (hazard ratio [HR] = 2.5; 1 point), > or =2 pain episodes in last 24 h (HR = 2.2; 1 point), age > or =67 years (HR = 2.3; 1 point), insulin-dependent diabetes mellitus (HR = 4.2; 2 points), and prior percutaneous transluminal coronary angioplasty (HR = 2.2; 1 point). Patients were classified into five categories of risk (p = 0.0001): 0 points, 0% event rate; 1 point, 3.1%; 2 points, 5.4%; 3 points, 17.6%; > or =4 points, 29.6%. The accuracy of the score was greater than that of the TIMI risk score for the primary (C index of 0.78 vs. 0.66, p = 0.0002) and secondary (C index of 0.70 vs. 0.66, p = 0.1) end points. Patients presenting with chest pain despite no ST-segment deviation or troponin elevation show a non-negligible rate of events at one year. A risk score derived from this specific population allows more accurate stratification than when using the TIMI risk score.

  19. Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain.

    Science.gov (United States)

    Scheuermeyer, Frank Xavier; Wong, Hubert; Yu, Eugenia; Boychuk, Barb; Innes, Grant; Grafstein, Eric; Gin, Kenneth; Christenson, Jim

    2014-03-01

    Current guidelines emphasize that emergency department (ED) patients at low risk for potential ischemic chest pain cannot be discharged without extensive investigations or hospitalization to minimize the risk of missing acute coronary syndrome (ACS). We sought to derive and validate a prediction rule that permitted 20 to 30% of ED patients without ACS safely to be discharged within 2 hours without further provocative cardiac testing. This prospective cohort study enrolled 1,669 chest pain patients in two blocks in 2000-2003 (development cohort) and 2006 (validation cohort). The primary outcome was 30-day ACS diagnosis. A recursive partitioning model incorporated reliable and predictive cardiac risk factors, pain characteristics, electrocardiographic findings, and cardiac biomarker results. In the derivation cohort, 165 of 763 patients (21.6%) had a 30-day ACS diagnosis. The derived prediction rule was 100.0% sensitive and 18.6% specific. In the validation cohort, 119 of 906 patients (13.1%) had ACS, and the prediction rule was 99.2% sensitive (95% CI 95.4-100.0) and 23.4% specific (95% CI 20.6-26.5). Patients have a very low ACS risk if arrival and 2-hour troponin levels are normal, the initial electrocardiogram is nonischemic, there is no history of ACS or nitrate use, age is pain characteristics are met. The validation of the rule was limited by the lack of consistency in data capture, incomplete follow-up, and lack of evaluation of the accuracy, comfort, and clinical sensibility of this clinical decision rule. The Vancouver Chest Pain Rule may identify a cohort of ED chest pain patients who can be safely discharged within 2 hours without provocative cardiac testing. Further validation across other centres with consistent application and comprehensive and uniform follow-up of all eligible and enrolled patients, in addition to measuring and reporting the accuracy of and comfort level with applying the rule and the clinical sensibility, should be completed prior to

  20. Pain processing in atypical Parkinsonisms and Parkinson disease: A comparative neurophysiological study.

    Science.gov (United States)

    Avenali, Micol; Tassorelli, Cristina; De Icco, Roberto; Perrotta, Armando; Serrao, Mariano; Fresia, Mauro; Pacchetti, Claudio; Sandrini, Giorgio

    2017-10-01

    Pain is a frequent non-motor feature in Parkinsonism but mechanistic data on the alteration of pain processing are insufficient to understand the possible causes and to define specifically-targeted treatments. we investigated spinal nociception through the neurophysiological measure of the threshold (TR) of nociceptive withdrawal reflex (NWR) and its temporal summation threshold (TST) comparatively in 12 Progressive Supranuclear Palsy (PSP) subjects, 11 Multiple System Atrophy (MSA) patients, 15 Parkinson's disease (PD) subjects and 24 healthy controls (HC). We also investigated the modulatory effect of L-Dopa in these three parkinsonian groups. We found a significant reduction in the TR of NWR and in the TST of NWR in PSP, MSA and PD patients compared with HC. L-Dopa induced an increase in the TR of NWR in the PSP group while TST of NWR increased in both PSP and PD. Our neurophysiological findings identify a facilitation of nociceptive processing in PSP that is broadly similar to that observed in MSA and PD. Specific peculiarities have emerged for PSP. Our data advance the knowledge of the neurophysiology of nociception in the advanced phases of parkinsonian syndromes and on the role of dopaminergic pathways in the control on pain processing. Copyright © 2017 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.

  1. Non-Hodgkin's lymphoma and atypical neck pain: A case report.

    Science.gov (United States)

    Rojas, Natividad; Fernandes, Carlos; Conde, Montse; Montala, Nuria; Fornos, Xavier; Rosselló, Lluís; Pallisó, Francésc

    2017-06-14

    Neck pain is a common reason for seeking medical attention. It affects at least 15% of the labor force and up to 40% of individuals whose occupation is hazardous. On the other hand, primary bone lymphoma is a very rare disease (less than 1% of all malignant bone tumors), and the relationship between the 2 has rarely been mentioned. We report the case of a patient who had a 1-month history of neck pain. The main symptom was pain on palpation of C2-C6 cervical spinous processes and contracture of the trapezius muscle that did not cease with conventional treatment. Imaging studies indicated an abnormality. He underwent surgery and the results of vertebral biopsy were compatible with diffuse large B-cell lymphoma. He was treated with radiotherapy with a good outcome. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.

  2. 29. Triple rule out versus standard coronary computed tomography angiography in evaluation of acute chest pain syndrome.

    Directory of Open Access Journals (Sweden)

    O. smettei

    2016-07-01

    Full Text Available Acute chest pain (ACP in emergency department represents a health care challenge. Triple-rule-out (TRO Computed Tomography Angiography (CTA can provide an evaluation of the coronary arteries, aorta,Pulmonary arteries, and chest structures in one scan. The aim of our work was to evaluate the diagnostic yield of TRO versus cardiac CTA in patients with ACP, In addition to compare the image quality, contrast material and radiation doses of TRO with standard CTA.We hypothesized that TRO CTA has a comparable diagnostic yield to standard coronary CTA, in addition to its ability to add extra diagnostic information. Prospective analysis of 134 TRO CTA data, to assess the presence of coronary artery disease(CAD, Aortic dissection, pulmonary embolism and other chest pathology. Then retrospectively to compare the results with 132 standard CTA. Normal coronaries or non-significant CAD was seen in 97 (72.9% patients, 19 (14.2% had moderate or significant CAD, two (1.5% had aortic dissection, three (2.2% had a pulmonary embolism, 61% had other findings. The image quality score and noise were comparable between the standard and TRO CTA (2.8 ± 0.6 vs 2.96 ± 0.6, P = 0.28 and (30.5 ± 10.6 vs 28.4 ± 1, P = 0.1 respectively. The effective radiation dose was significantly lower in the standard compared to the TRO CTA using prospective (4.4 ± 1.7 vs. 5.1 ± 0.5 mSv = 0.008 and (11.9 vs. 18.3 ± 5 msv, P = 0.0001 for retrospective gating protocols. The contrast dose was lower with standard protocol (83 ± 5 vs 102 ± 9 ml. p = 0.001. TRO CTA is a valid tool for diagnosis of CAD and can provide accurate detection of non-coronary pathology, but it was associated with higher radiation and contrast doses compared to the standard CTA.

  3. Impact of non-chest pain complaint as a presenting symptom on door-to-balloon time and clinical outcomes in patients with acute ST-elevation myocardial infarction.

    Science.gov (United States)

    Park, Jin Sup; Cha, Kwang Soo; Shin, Donghun; Lee, Dae Sung; Lee, Hye Won; Oh, Jun-Hyok; Choi, Jung Hyun; Lee, Han Cheol; Hong, Taek Jong; Jeong, Myung Ho; Ahn, Youngkeun; Chae, Shung Chull; Kim, Young Jo

    2014-12-15

    Many patients with ST-elevation myocardial infarctions (STEMIs) have non-chest pain complaints and are given low priority during triage. This prospective, multicenter, observational, registry-based study investigated the impact of non-chest pain complaints on door-to-balloon (DTB) time and clinical outcomes. Patients with STEMI who had undergone primary percutaneous coronary intervention were compared with respect to the presence of chest pain or non-chest pain complaints as presenting symptoms. To eliminate biased estimates, a propensity score model was built, and 2 cohorts of 1:1 matched patients were obtained. Propensity matching identified 2 cohorts of 976 patients each. After comparing patients with chest pain and those with non-chest pain complaints, significant delays in the median DTB time were noted (74 vs 84 minutes, respectively; p chest pain complaints were independent predictors of DTB time in the multivariate linear regression models. In-hospital mortality (adjusted hazard ratio [HR] 1.402, 95% confidence interval [CI] 0.727 to 2.705, p = 0.313), all-cause mortality (adjusted HR 1.175, 95% CI 0.453 to 3.853, p = 0.642), and major adverse cardiac events at follow-up (adjusted HR 0.139, 95% CI 0.876 to 1.48, p = 0.331) did not differ between the 2 groups of patients. In conclusion, short- and long-term clinical outcomes in patients with STEMI with non-chest pain complaints do not differ from those of patients with chest pain as the presenting symptom, despite having delayed diagnosis and reperfusion. Copyright © 2014 Elsevier Inc. All rights reserved.

  4. Evaluation of the Effectiveness of a Phone Based Care Coordination Pilot on Hospital Utilisation and Costs for Patients With Chest Pain.

    Science.gov (United States)

    Price, Peita; Vincent, Ruth; Tacey, Mark; Gilchrist, Jane; Liew, Danny; Grigg, Leeanne; Naccarella, Lucio

    2017-04-20

    A small percentage of the population represents a disproportionate number of attendances at emergency departments (ED). "Frequent presenters" to ED with chest pain do not always fit into established pathways for acute myocardial events. With accelerated "rule out" protocols, patients are often discharged from the Emergency Department (ED) after short lengths of stay. This research will evaluate the effectiveness of a phone based care-coordination pilot designed to meet the needs of patients attending ED with cardiac and non-cardiac chest pain. A longitudinal, single-arm interventional study with retrospectively recruited control group. Ninety-five patients were enrolled as the intervention group; 97 patients were retrospectively identified as controls. These patients had re-presented with chest pain within 6 months of a cardiac event, or attended hospital within 12 months two or more times with chest pain and/or complex needs. Intervention group patients were holistically assessed then phone-coached to support self-management of chest pain over 6 months. Following descriptive and univariate analysis, multivariate analysis was conducted to adjust for noted differences between the intervention and control groups. Thirty-day representation to ED was significantly less for the intervention group (14.1%) compared to controls (27.7%). After adjusting for baseline differences, intervention patients were more than two-fold less likely to re-present compared to controls (OR=0.42, 95%CI: 0.19-0.96). After adjustment for baseline differences, the savings in subsequent inpatient costs was $1588 per person, as a result of intervention, patients were less likely to have inpatient readmissions (16.3%) compared to controls (20.2%), although this was not statistically significant (p=0.588). A phone based care-coordination pilot with targeted interventions has the potential to reduce ED presentations and hospital readmissions among patients representing with chest pain. Copyright

  5. Evaluating Diagnostic and Prognostic Value of Plasma miRNA133a in Acute Chest Pain Patients Undergoing Coronary Angiography.

    Science.gov (United States)

    Ke-Gang, Jia; Zhi-Wei, Li; Xin, Zhang; Jing, Wang; Ping, Shi; Xue-Jing, Han; Hong-Xia, Tang; Xin, Tang; Xiao-Cheng, Liu

    2016-04-01

    Circulating microRNA has recently emerged as a promising biomarker for cardiovascular disease. This study sought to evaluate the diagnostic and prognostic value of circulating miR-133a as a marker of acute myocardial infarction in acute chest pain patients undergoing coronary angiography.Plasma was collected from 312 patients with chest pain on admission in the emergency department and 67 healthy controls. MiR-133a was detected using real-time quantitative PCR and enhanced accu-TnI, creatinine kinase-MB mass, and myoglobin were measured by immunoassay. End-point events (serious adverse cardiovascular events which require hospitalization or cardiovascular death) were examined in the AMI (acute myocardical infarction) group within 1, 6, 12, and 24 months.The miR-133a level was higher in AMI patients than in non-AMI patients (P < 0.001). In the ROC analysis, the sensitivity of miR-133a in diagnosis of AMI is 0.61 and the specificity is 0.68. In the prognostic analysis, only 1 endpoint event was observed in the non-AMI group; the amount of cases with end-point events in the AMI group at 1,6,12, and 24 months were 8, 19, 28, and 35, respectively. The cutoff value of miR-133a was determined using the median value of the AMI group and separated the patients into a positive group and a negative group. The Kaplan-Meier survival curve showed no significant difference in survival was detected in AMI patients between the miR-133a positive group and negative group after follow-up (12-month: x2 = 1.353, P = 0.245; 24-month: x2 = 3.722, P = 0.054). After adjusting for age, gender, Killip classes, prior myocardiac infarction history, myoglobin, LVEF (left ventricular ejection fraction), diabetes, hypertension, smoking and systolic blood pressure, miR133a had a significant association with the risk of events at 12 months (HR = 2.869, P = 0.024) and 24 months (HR = 3.936, P = 0.001).In patients undergoing coronary angiography, circulating miR-133a

  6. Computed Tomography-Derived Parameters of Myocardial Morphology and Function in Black and White Patients With Acute Chest Pain.

    Science.gov (United States)

    Takx, Richard A P; Vliegenthart, Rozemarijn; Schoepf, U Joseph; Abro, Joseph A; Nance, John W; Ebersberger, Ullrich; Bamberg, Fabian; Carr, Christine M; Apfaltrer, Paul

    2016-02-01

    Blacks have higher mortality and hospitalization rates because of congestive heart failure compared with white counterparts. Differences in cardiac structure and function may contribute to the racial disparity in cardiovascular outcomes. Our aim was to compare computed tomography (CT)-derived cardiac measurements between black patients with acute chest pain and age- and gender-matched white patients. We performed a retrospective analysis under an institutional review board waiver and in Health Insurance Portability and Accountability Act compliance. We investigated patients who underwent cardiac dual-source CT for acute chest pain. Myocardial mass, left ventricular (LV) ejection fraction, LV end-systolic volume, and LV end-diastolic volume were quantified using an automated analysis algorithm. Septal wall thickness and cardiac chamber diameters were manually measured. Measurements were compared by independent t test and linear regression. The study population consisted of 300 patients (150 black-mean age 54 ± 12 years; 46% men; 150 white-mean age 55 ± 11 years; 46% men). Myocardial mass was larger for blacks compared with white (176.1 ± 58.4 vs 155.9 ± 51.7 g, p = 0.002), which remained significant after adjusting for age, gender, body mass index, and hypertension. Septal wall thickness was slightly greater (11.9 ± 2.7 vs 11.2 ± 3.1 mm, p = 0.036). The LV inner diameter was moderately larger in black patients in systole (32.3 ± 9.0 vs 30.1 ± 5.4 ml, p = 0.010) and in diastole (50.1 ± 7.8 vs 48.9 ± 5.2 ml, p = 0.137), as well as LV end-diastolic volume (134.5 ± 42.7 vs 128.2 ± 30.6 ml, p = 0.143). Ejection fraction was nonsignificantly lower in blacks (67.1 ± 13.5% vs 69.0 ± 9.6%, p = 0.169). In conclusion, CT-derived myocardial mass was larger in blacks compared with whites, whereas LV functional parameters were generally not statistically different, suggesting that LV mass might be a possible contributing factor to the higher rate of cardiac events

  7. Association between use of pre-hospital ECG and 30-day mortality: A large cohort study of patients experiencing chest pain.

    Science.gov (United States)

    Rawshani, Nina; Rawshani, Araz; Gelang, Carita; Herlitz, Johan; Bång, Angela; Andersson, Jan-Otto; Gellerstedt, Martin

    2017-12-01

    In the assessment of patients with chest pain, there is support for the use of pre-hospital ECG in the literature and in the care guidelines. Using propensity score methods, we aim to examine whether the mere acquisition of a pre-hospital ECG among patients with chest pain affects the outcome (30-day mortality). The association between pre-hospital ECG and 30-day mortality was studied in the overall cohort (n=13151), as well as in the one-to-one matched cohort with 2524 patients not examined with pre-hospital ECG and 2524 patients examined with pre-hospital ECG. In the overall cohort, 21% (n=2809) did not undergo an ECG tracing in the pre-hospital setting. Among those who had pain during transport, 14% (n=1159) did not undergo a pre-hospital ECG while 32% (n=1135) of those who did not have pain underwent an ECG tracing. In the overall cohort, the OR for 30-day mortality in patients who had a pre-hospital ECG, as compared with those who did not, was 0.63 (95% CI 0.05-0.79; ppre-hospital ECG was used. The PH-ECG is underused among patients with chest discomfort and the mere acquisition of a pre-hospital ECG may reduce mortality. Copyright © 2017 Elsevier B.V. All rights reserved.

  8. MRI of the Chest

    Medline Plus

    Full Text Available ... for lung abnormalities where Chest CT is a preferred imaging test. MR imaging can assess blood flow ... If you are anxious, confused or in severe pain, you may find it difficult to lie still ...

  9. Residents' performance in the interpretation of on-call "triple-rule-out" CT studies in patients with acute chest pain.

    Science.gov (United States)

    Garrett, K Gabriel; De Cecco, Carlo N; Schoepf, U Joseph; Silverman, Justin R; Krazinski, Aleksander W; Geyer, Lucas L; Lewis, Alex J; Headden, Gary F; Ravenel, James G; Suranyi, Pal; Meinel, Felix G

    2014-07-01

    To evaluate the performance of radiology residents in the interpretation of on-call, emergency "triple-rule-out" (TRO) computed tomographic (CT) studies in patients with acute chest pain. The study was institutional review board-approved and Health Insurance Portability and Accountability Act compliant. Data from 617 on-call TRO studies were analyzed. Dedicated software enables subspecialty attendings to grade discrepancies in interpretation between preliminary trainee reports and their final interpretation as "unlikely to be significant" (minor discrepancies) or "likely to be significant" for patient management (major discrepancies). The frequency of minor, major and all discrepancies in resident's TRO interpretations was compared to 609 emergent non-electrocardiography (ECG)-synchronized chest CT studies using Pearson χ(2) test. Minor discrepancies occurred more often in the TRO group (9.1% vs. 3.9%, P patient outcomes. On-call resident interpretation of TRO CT studies in patients with acute chest pain is congruent with final subspecialty attending interpretation in the overwhelming majority of cases. The rate of discrepancies likely to affect patient management in this domain is not different from emergent non-ECG-synchronized chest CT. Copyright © 2014 AUR. Published by Elsevier Inc. All rights reserved.

  10. A Systematic Review of Atypical Antipsychotics in Chronic Pain Management: Olanzapine Demonstrates Potential in Central Sensitization, Fibromyalgia, and Headache/Migraine.

    Science.gov (United States)

    Jimenez, Xavier F; Sundararajan, Tharani; Covington, Edward C

    2017-10-26

    Many psychopharmacologic agents are used as primary or adjunct agents in pain management. Atypical antipsychotics (AAs) have also been used as adjuncts in pain management regimens in a variety of manners; however, their efficacy in this capacity is unclear. A systematic review of all studies examining AA use for pain was conducted. Three literature databases were utilized to search for word combinations of "pain" and a variety of commonly-prescribed AAs (olanzapine, quetiapine, risperidone, aripiprazole, ziprasidone, clozapine, paliperidone, iloperidone, lurasidone). Articles chosen for review included retrospective analyses, randomized control trials, and case series/reports. A PRISMA diagram illustrates the study selection process. Olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone are the only AAs with published studies in pain syndromes. Of these, olanzapine and quetiapine have the most combined studies (11 and 6, respectively). Olanzapine shows preliminary and consistent efficacy in fibromyalgia and headache/migraine, although only one study was a randomized controlled trial with Level I evidence of efficacy. Other AAs (quetiapine included) fail to demonstrate efficacy in pain syndromes and/or lack robust study designs. Few studies have been conducted to evaluate the analgesic effects of AAs. The collective findings of multiple studies evaluating olanzapine in pain syndromes suggest a high yet preliminary level of evidence of efficacy, warranting prospective studies in various pain syndrome contexts. Pharmacological mechanisms of AA action are elaborated, and the findings of this review are discussed. Risk and benefits of using AAs in chronic pain are elaborated, and investigational implications and future directions are explored.

  11. Considerations for early acute myocardial infarction rule-out for emergency department chest pain patients: the case of copeptin.

    Science.gov (United States)

    Lippi, Giuseppe; Plebani, Mario; Di Somma, Salvatore; Monzani, Valter; Tubaro, Marco; Volpe, Massimo; Moscatelli, Paolo; Vernocchi, Arialdo; Cavazza, Mario; Galvani, Marcello; Cappelletti, Piero; Marenzi, Giancarlo; Ferraro, Simona; Lombardi, Alberto; Peracino, Andrea

    2012-01-06

    The evaluation of patients admitted at the emergency department (ED) for chest pain is challenging and involves many different clinical specialists including emergency physicians, laboratory professionals and cardiologists. The preferable approach to deal with this issue is to develop joint protocols that will assist the clinical decision-making to quickly and accurately rule-out patients with non life-threatening conditions that can be considered for early and safe discharge or further outpatient follow-up, rule-in patients with acute coronary syndrome and raise the degree of alert of the emergency physicians on non-cardiac life-threatening emergencies. The introduction of novel biomarkers alongside the well-established troponins might support this process and also provide prognostic information about acute short-term or chronic long-term risk and severity. Among the various biomarkers, copeptin measurement holds appealing perspectives. The utility of combining troponin with copeptin might be cost-effective due to the high negative predictive value of the latter biomarker in the rule-out of an acute coronary syndrome. Moreover, in the presence of a remarkably increased concentration (e.g., more than 10 times the upper limit of the reference range), to reveal the presence of acute life-threatening conditions that may not necessarily be identified with the use of troponin alone. The aim of this article is to review current evidence about the clinical significance of copeptin testing in the ED as well as its appropriate placing within diagnostic protocols.

  12. Coronary artery disease in association with depression or anxiety among patients undergoing angiography to investigate chest pain.

    Science.gov (United States)

    Vural, Mutlu; Satiroglu, Omer; Akbas, Berfu; Goksel, Isin; Karabay, Ocal

    2009-01-01

    In search of associations between coronary artery disease and symptoms of depression and anxiety, we conducted a prospective cross-sectional study of 314 patients (age range, 19-79 yr) who had presented with chest pain. Coronary angiographic findings were classified into 5 categories (0-4), in which higher numbers indicated more severe disease. Symptoms of depression and anxiety were evaluated by the Beck depression and anxiety inventories, in which higher scores indicated more severe symptoms.Older age, male sex, diabetes mellitus, hypercholesterolemia, and high income were found in association with coronary artery disease. Woman patients exhibited significantly higher depression and anxiety scores (P coronary artery disease infrequently (P = 0.003). At first, no significant correlation was found between coronary artery disease levels 0, 1, 2, 3, or 4 and scores of depression or anxiety. After controlling for sex differences and other confounding variables, however, we found that every 1-point increase in the depression score was associated with an average 5% to 6% increase in abnormal coronary angiographic findings or definitive coronary artery disease, respectively (P = 0.01 and P = 0.002). Although there was no such association between anxiety score and coronary artery disease, the highest anxiety scores were encountered in patients with slow coronary flow.

  13. Clinician gestalt estimate of pretest probability for acute coronary syndrome and pulmonary embolism in patients with chest pain and dyspnea.

    Science.gov (United States)

    Kline, Jeffrey A; Stubblefield, William B

    2014-03-01

    Pretest probability helps guide diagnostic testing for patients with suspected acute coronary syndrome and pulmonary embolism. Pretest probability derived from the clinician's unstructured gestalt estimate is easier and more readily available than methods that require computation. We compare the diagnostic accuracy of physician gestalt estimate for the pretest probability of acute coronary syndrome and pulmonary embolism with a validated, computerized method. This was a secondary analysis of a prospectively collected, multicenter study. Patients (N=840) had chest pain, dyspnea, nondiagnostic ECGs, and no obvious diagnosis. Clinician gestalt pretest probability for both acute coronary syndrome and pulmonary embolism was assessed by visual analog scale and from the method of attribute matching using a Web-based computer program. Patients were followed for outcomes at 90 days. Clinicians had significantly higher estimates than attribute matching for both acute coronary syndrome (17% versus 4%; Pprobability but on receiver operating curve analysis were as accurate for pulmonary embolism but not acute coronary syndrome. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

  14. The German CPU Registry: Dyspnea independently predicts negative short-term outcome in patients admitted to German Chest Pain Units.

    Science.gov (United States)

    Hellenkamp, Kristian; Darius, Harald; Giannitsis, Evangelos; Erbel, Raimund; Haude, Michael; Hamm, Christian; Hasenfuss, Gerd; Heusch, Gerd; Mudra, Harald; Münzel, Thomas; Schmitt, Claus; Schumacher, Burghard; Senges, Jochen; Voigtländer, Thomas; Maier, Lars S

    2015-02-15

    While dyspnea is a common symptom in patients admitted to Chest Pain Units (CPUs) little is known about the impact of dyspnea on their outcome. The purpose of this study was to evaluate the impact of dyspnea on the short-term outcome of CPU patients. We analyzed data from a total of 9169 patients admitted to one of the 38 participating CPUs in this registry between December 2008 and January 2013. Only patients who underwent coronary angiography for suspected ACS were included. 2601 patients (28.4%) presented with dyspnea. Patients with dyspnea at admission were older and frequently had a wide range of comorbidities compared to patients without dyspnea. Heart failure symptoms in particular were more common in patients with dyspnea (21.0% vs. 5.3%, pCPU patients. Our data show that dyspnea is associated with a fourfold higher 3month mortality which is underestimated by the established ACS risk scores. To improve their predictive value we therefore propose to add dyspnea as an item to common risk scores. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

  15. Comparison of epicardial fat volume by computed tomography in black versus white patients with acute chest pain.

    Science.gov (United States)

    Apfaltrer, Paul; Schindler, Andreas; Schoepf, U Joseph; Nance, John W; Tricarico, Francesco; Ebersberger, Ullrich; McQuiston, Andrew D; Meyer, Mathias; Henzler, Thomas; Schoenberg, Stefan O; Bamberg, Fabian; Vliegenthart, Rozemarijn

    2014-02-01

    Disparities in the risk of coronary artery disease (CAD) between races may be influenced by differences in the thoracic adipose tissue. We compared computed tomography (CT)-derived volumes of epicardial adipose tissue (EAT), mediastinal adipose tissue (MAT), and pericoronary fat thickness (PFT) and correlations with CAD between black and white patients. This institutional review board-approved Health Insurance Portability and Accountability Act-compliant study included 372 age- and gender-matched black versus white patients (186 black, 54 ± 11 years, 50% men; 186 white, 54 ± 11 years, 50% men) who underwent CT for chest pain evaluation. EAT, MAT, and PFT were measured. The amount of coronary calcium was quantified as calcium score. CAD was defined as ≥50% coronary artery narrowing. EAT and MAT volumes were significantly lower in black than white patients (59 [twenty-fifth to seventy-fifth percentile 39 to 84] vs 97 [67 to 132] cm(3) and 44 [27 to 77] vs 87 [52 to 157] cm(3), for both p patients was slightly lower than white patients (17.2 ± 3.2 vs 18.1 ± 3.4 mm, p patients (r = 0.19 to 0.26, p patients. In conclusion, CT-derived measurements of thoracic fat differ between symptomatic black and white patients, suggesting a differential relation between thoracic adipose tissue and CAD pathophysiology by race. Copyright © 2014 Elsevier Inc. All rights reserved.

  16. Atypical Depression

    Science.gov (United States)

    Atypical depression Overview Any type of depression can make you feel sad and keep you from enjoying life. However, atypical depression — also called depression with atypical features — means that ...

  17. Comparing HEART, TIMI, and GRACE scores for prediction of 30-day major adverse cardiac events in high acuity chest pain patients in the emergency department.

    Science.gov (United States)

    Sakamoto, Jeffrey Tadashi; Liu, Nan; Koh, Zhi Xiong; Fung, Nicholas Xue Jin; Heldeweg, Micah Liam Arthur; Ng, Janson Cheng Ji; Ong, Marcus Eng Hock

    2016-10-15

    The HEART, TIMI, and GRACE scores have been applied in the Emergency Department (ED) to risk stratify patients with undifferentiated chest pain. This study aims to compare the accuracy of HEART, TIMI, and GRACE for the prediction of major adverse cardiac events (MACE) in high acuity chest pain patients. Adult patients who presented with chest pain suggestive of cardiac origin in the most acute triage category at an academic ED from September 2010 to October 2015 were included. The HEART, TIMI, and GRACE scores were calculated retrospectively from prospectively collected data. The primary outcome was occurrence of MACE (mortality, AMI, PCI, CABG) within 30-days of initial presentation. 604 patients were included in the study. Patient demographics include an average age of 61years, 69% male, and 48% with history of ischemic heart disease. 36% of patients met the primary outcome. The c-statistics of HEART, TIMI, and GRACE were 0.78 (95% CI: 0.74-0.81), 0.65 (95% CI: 0.60-0.69), and 0.62 (95% CI: 0.58-0.67), respectively. For the purpose of accurately ruling out patients for 30-day MACE, a HEART score of ≤3 had a sensitivity and NPV of 99% and 98%, respectively, compared to 97% and 91%, respectively, for TIMI=0, and 94% and 85%, respectively, for GRACE ≤75. The percent of patients with 30-day MACE with HEART scores between 0 and 3, 4-6, and 7-10 was 2%, 28%, and 63%, respectively. In high acuity chest pain patients, the HEART score is superior to the TIMI and GRACE scores in predicting 30-day MACE. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  18. Coronary computed tomography and triple rule out CT in patients with acute chest pain and an intermediate cardiac risk profile. Part 1: Impact on patient management

    Energy Technology Data Exchange (ETDEWEB)

    Gruettner, Joachim, E-mail: joachim.gruettner@umm.de [Emergency Department, University Medical Center, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim (Germany); Fink, Christian, E-mail: Christian.Fink@umm.de [Institute of Clinical Radiology and Nuclear Medicine, University Medical Center, Medical Faculty Mannheim, Heidelberg University, Mannheim (Germany); Walter, Thomas, E-mail: thomas.walter@umm.de [Emergency Department, University Medical Center, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim (Germany); Meyer, Mathias, E-mail: mr.meyer.mathias@gmail.com [Institute of Clinical Radiology and Nuclear Medicine, University Medical Center, Medical Faculty Mannheim, Heidelberg University, Mannheim (Germany); Apfaltrer, Paul, E-mail: Paul.Apfaltrer@umm.de [Institute of Clinical Radiology and Nuclear Medicine, University Medical Center, Medical Faculty Mannheim, Heidelberg University, Mannheim (Germany); Schoepf, U. Joseph, E-mail: schoepf@musc.edu [Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, Ashley River Tower, 25 Courtenay Drive, Charleston, SC 29425-2260 (United States); Saur, Joachim, E-mail: joachim.saur@umm.de [1st Department of Medicine (Cardiology), University Medical Center, Medical Faculty Mannheim, Heidelberg University, Mannheim (Germany); Sueselbeck, Tim, E-mail: tim.sueselbeck@umm.de [1st Department of Medicine (Cardiology), University Medical Center, Medical Faculty Mannheim, Heidelberg University, Mannheim (Germany); Traunwieser, Dominik, E-mail: dominik.traunwieser@umm.de [1st Department of Medicine (Cardiology), University Medical Center, Medical Faculty Mannheim, Heidelberg University, Mannheim (Germany); Takx, Richard, E-mail: richard.takx@gmail.com [Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, Ashley River Tower, 25 Courtenay Drive, Charleston, SC 29425-2260 (United States); and others

    2013-01-15

    Objective: To evaluate the impact of coronary CT angiography (coronary CTA) or “triple-rule-out” CT angiography (TRO-CTA) on patient management in the work-up of patients with acute chest pain and an intermediate cardiac risk profile. Materials and methods: 100 patients with acute chest pain and an intermediate cardiac risk for acute coronary syndrome (ACS) underwent coronary CTA or TRO-CTA for the evaluation of chest pain. Patients with a high and low cardiac risk profile were not included in this study. All patients with significant coronary stenosis >50% on coronary CTA underwent invasive coronary catheterization (ICC). Important other pathological findings were recorded. All patients had a 90-day follow-up period for major adverse cardiac events (MACE). Results: Based on a negative coronary CTA 60 of 100 patients were discharged on the same day. None of the discharged patients showed MACE during the 90-day follow-up. Coronary CTA revealed a coronary stenosis >50% in 19 of 100 patients. ICC confirmed significant coronary stenosis in 17/19 patients. Among the 17 true positive patients, 9 underwent percutaneous coronary intervention with stent implantation, 7 were received intensified medical therapy, and 1 patient underwent coronary artery bypass surgery. A TRO-CTA protocol was performed in 36/100 patients due to elevated D-dimer levels. Pulmonary embolism was present in 5 patients, pleural effusion of unknown etiology in 3 patients, severe right ventricular dysfunction with pericardial effusion in 1 patient, and an incidental bronchial carcinoma was diagnosed in 1 patient. Conclusion: Coronary CTA and TRO-CTA allow a rapid and safe discharge in the majority of patients presenting with acute chest pain and an intermediate risk for ACS while at the same time identifies those with significant coronary artery stenosis.

  19. HEART score and clinical gestalt have similar diagnostic accuracy for diagnosing ACS in an unselected population of patients with chest pain presenting in the ED.

    Science.gov (United States)

    Visser, Anniek; Wolthuis, Albert; Breedveld, Rob; ter Avest, Ewoud

    2015-08-01

    Acute coronary syndrome (ACS) can be a diagnostic challenge in the emergency department (ED). Recently, the HEART score was developed, a simple bedside scoring system that quantifies risk of ischaemic events in patients with undifferentiated chest pain presenting in the ED. In this prospective cohort study, we compared the diagnostic accuracy of HEART score and clinical gestalt (clinical judgement) for diagnosing ACS in an unselected population of patients with chest pain presenting to the ED. HEART score (0-10) and clinical gestalt (low risk, intermediate risk or high risk of ACS) were prospectively determined in the ED in 255 patients presenting with chest pain by the treating physician. The reference standard was the presence of ACS, which was defined as either acute myocardial infarction (AMI) or the occurrence of a major adverse cardiac event within 6 weeks after presentation in the ED. 75 out of 255 patients (29%) had an ACS. A HEART score ≤3 had a lower negative likelihood ratio (0.15 (0.06-0.36)) for ACS than a low risk based on clinical gestalt (0.35 (0.19-0.64)), whereas a high HEART score ≥7 had a higher positive likelihood ratio (5.2 (3.2-8.5) vs 3.1 (2.2-4.4)). However, c-statistic of HEART score was not significantly different from clinical gestalt (0.81 (0.76-0.86) vs 0.79 (0.73-0.84), p=0.13). Our study demonstrates that HEART score and clinical gestalt have similar diagnostic accuracy for diagnosing ACS in an unselected population of patients with chest pain presenting in the ED. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

  20. Role of strain values using automated function imaging on transthoracic echocardiography for the assessment of acute chest pain in emergency department.

    Science.gov (United States)

    Lee, Mirae; Chang, Sung-A; Cho, Eun Jeong; Park, Sung-Ji; Choi, Jin-Oh; Lee, Sang-Chol; Oh, Jae K; Park, Seung Woo

    2015-03-01

    Left ventricular strain echocardiography is reported to be more sensitive in detecting myocardial ischemia than conventional transthoracic echocardiography (TTE). We evaluated the usefulness of 2D strain analysis for the assessment of acute chest pain in emergency department (ED). Patients presenting to ED with acute chest pain were recruited. Patients with ST-elevation myocardial infarction, known coronary artery disease (CAD), non-ischemic cardiomyopathy, or non-cardiac chest pain were excluded. The pretest probability of CAD and TTEs were evaluated in all patients. TTEs included visual assessments of regional wall motion abnormality (RWMA) and analysis of global and regional longitudinal strain (GLS and RLS). The diagnosis of CAD and the occurrence of cardiac events during 1 month after ED visit were reviewed. Cardiac events were observed in 25% of total 104 patients, and CAD was detected in 36% of 69 patients with coronary imaging tests. Compared to RWMA, RLS showed higher sensitivity (sensitivity/specificity = 64/89 vs. 92/77%) with similar diagnostic accuracy (79.7 vs. 82.6%, p = 0.791) for CAD. RLS also demonstrated better diagnostic performance than either GLS (sensitivity/specificity = 92/57%) or pretest probability (sensitivity/specificity = 72/64 %). Similarly, RLS had the higher predictive value for 1-month cardiac events. In multivariable analyses including pretest probability, LVEF, RWMA, cardiac enzyme, GLS, and RLS; only pretest probability (OR 1.91, 95% CI 1.22-2.99, p = 0.005) and RLS (OR 25.42, 95 % CI 1.84-342.04, p = 0.016) independently predicted CAD. Strain echocardiography appears to be effective in diagnosing CAD and predicting future events with high sensitivity and negative predictive value in acute chest pain patients visiting ED.

  1. Coronary computed tomography and triple rule out CT in patients with acute chest pain and an intermediate cardiac risk profile. Part 1: impact on patient management.

    Science.gov (United States)

    Gruettner, Joachim; Fink, Christian; Walter, Thomas; Meyer, Mathias; Apfaltrer, Paul; Schoepf, U Joseph; Saur, Joachim; Sueselbeck, Tim; Traunwieser, Dominik; Takx, Richard; Kralev, Stefan; Borggrefe, Martin; Schoenberg, Stefan O; Henzler, Thomas

    2013-01-01

    To evaluate the impact of coronary CT angiography (coronary CTA) or "triple-rule-out" CT angiography (TRO-CTA) on patient management in the work-up of patients with acute chest pain and an intermediate cardiac risk profile. 100 patients with acute chest pain and an intermediate cardiac risk for acute coronary syndrome (ACS) underwent coronary CTA or TRO-CTA for the evaluation of chest pain. Patients with a high and low cardiac risk profile were not included in this study. All patients with significant coronary stenosis >50% on coronary CTA underwent invasive coronary catheterization (ICC). Important other pathological findings were recorded. All patients had a 90-day follow-up period for major adverse cardiac events (MACE). Based on a negative coronary CTA 60 of 100 patients were discharged on the same day. None of the discharged patients showed MACE during the 90-day follow-up. Coronary CTA revealed a coronary stenosis >50% in 19 of 100 patients. ICC confirmed significant coronary stenosis in 17/19 patients. Among the 17 true positive patients, 9 underwent percutaneous coronary intervention with stent implantation, 7 were received intensified medical therapy, and 1 patient underwent coronary artery bypass surgery. A TRO-CTA protocol was performed in 36/100 patients due to elevated d-dimer levels. Pulmonary embolism was present in 5 patients, pleural effusion of unknown etiology in 3 patients, severe right ventricular dysfunction with pericardial effusion in 1 patient, and an incidental bronchial carcinoma was diagnosed in 1 patient. Coronary CTA and TRO-CTA allow a rapid and safe discharge in the majority of patients presenting with acute chest pain and an intermediate risk for ACS while at the same time identifies those with significant coronary artery stenosis. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

  2. Do immature platelet levels in chest pain patients presenting to the emergency department aid in the diagnosis of acute coronary syndrome?

    Science.gov (United States)

    Berny-Lang, M A; Darling, C E; Frelinger, A L; Barnard, M R; Smith, C S; Michelson, A D

    2015-02-01

    Early and accurate identification of acute coronary syndrome (ACS) vs. noncardiac chest pain in patients presenting to the emergency department (ED) is problematic and new diagnostic markers are needed. Previous studies reported that elevated mean platelet volume (MPV) is associated with ACS and predictive of cardiovascular risk. MPV is closely related to the immature platelet fraction (IPF), and recent studies have suggested that IPF may be a more sensitive marker of ACS than MPV. The objective of the present study was to determine whether the measurement of IPF assists in the diagnosis of ACS in patients presenting to the ED with chest pain. In this single-center, prospective, cross-sectional study, adult patients presenting to the ED with chest pain and/or suspected ACS were considered for enrollment. Blood samples from 236 ACS-negative and 44 ACS-positive patients were analyzed in a Sysmex XE-2100 for platelet count, MPV, IPF, and the absolute count of immature platelets (IPC). Total platelet counts, MPV, IPF, and IPC were not statistically different between ACS-negative and ACS-positive patients. The IPF was 4.6 ± 2.7% and 5.0 ± 2.8% (mean ± SD, P = 0.24), and the IPC was 10.0 ± 4.6 and 11.5 ± 7.5 × 10(3) /μL (P = 0.27) for ACS-negative and ACS-positive patients, respectively. In 280 patients presenting to the ED with chest pain and/or suspected ACS, no differences in IPF, IPC or MPV were observed in ACS-negative vs. ACS-positive patients, suggesting that these parameters do not assist in the diagnosis of ACS. © 2014 John Wiley & Sons Ltd.

  3. Use of multislice CT for the evaluation of emergency room patients with chest pain: the so-called "triple rule-out".

    Science.gov (United States)

    Gallagher, Michael J; Raff, Gilbert L

    2008-01-01

    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. Copyright 2008 Wiley-Liss, Inc.

  4. Who gets admitted to the Chest Pain Unit (CPU) and how do we manage them? Improving the use of the CPU in Waikato DHB, New Zealand.

    Science.gov (United States)

    Jade, Judith; Huggan, Paul; Stephenson, Douglas

    2015-01-01

    Chest pain is a commonly encountered presentation in the emergency department (ED). The chest pain unit at Waikato DHB is designed for patients with likely stable angina, who are at low risk of acute coronary syndrome (ACS), with a normal ECG and Troponin T, who have a history which is highly suggestive of coronary artery disease (CAD). Two issues were identified with patient care on the unit (1) the number of inappropriate admissions and (2) the number of inappropriate exercise tolerance tests. A baseline study showed that 73% of admissions did not fulfil the criteria and the majority of patients (72%) had an exercise tolerance test (ETT) irrespective of clinical picture. We delivered educational presentations to key stakeholders and the implementation of a new fast track chest pain pathway for discharging patients directly from the ED. There was an improvement in the number of patients inappropriately admitted, which fell to 61%. However, the number of inappropriate ETTs did not decrease, and were still performed on 76.9% of patients.

  5. Rapid-access cardiology services: can these reduce the burden of acute chest pain on Australian and New Zealand health services?

    Science.gov (United States)

    Klimis, Harry; Thiagalingam, Aravinda; Altman, Mikhail; Atkins, Emily; Figtree, Gemma; Lowe, Harry; Cheung, Ngai Wah; Kovoor, Pramesh; Denniss, Alan Robert; Chow, Clara K

    2017-09-01

    Chest pain is common and places a significant burden on hospital resources. Many patients with undifferentiated low- to intermediate-risk chest pain are admitted to hospital. Rapid-access cardiology (RAC) services are hospital co-located, cardiologist-led outpatient clinics that provide rapid assessment and immediate management but not long-term management. This service model is described as part of chest pain management and the National Service Framework for coronary heart disease in the United Kingdom (UK). We review the evidence on the effectiveness, safety and acceptability of RAC services. Our review finds that early assessment in RAC outpatient services of patients with suspected angina, without high-risk features suspicious of an acute coronary syndrome, is safe, can reduce hospitalisations, is cost effective and has good medical practitioner and patient acceptability. However, the literature is limited in that the evaluation of this model of care has been only in the UK. It is potentially suited to other settings and needs further evaluation in other settings to assess its utility. © 2016 Royal Australasian College of Physicians.

  6. Gated-SPECT myocardial perfusion imaging and coronary calcium score for evaluation of patients with acute chest pain and a normal or nondiagnostic electrocardiogram.

    Science.gov (United States)

    Peix, Amalia; Batista, Elida; Cabrera, Lázaro O; Rodríguez, Lydia; Padrón, Kenia; Saínz, Benito; Mendoza, Vladimir; Carrillo, Regla; Fernández, Yoel; Mena, Erick; Dondi, Maurizio

    2012-11-01

    To assess the ability of rest myocardial perfusion imaging (MPI) to rule out an acute coronary syndrome (ACS) in emergency department patients, as well as to investigate whether there exists a concordance between MPI and coronary calcium. Fifty-five patients with chest pain and a normal or nondiagnostic ECG were included. Clinical follow-up was carried out within 1 year. Sixteen patients (29%) showed an abnormal rest MPI, and in 11 (20%) the MPI was equivocal. There was a weak concordance between MPI and coronary arteries calcium score (CACS) (κ: 0.25). Coronary angiogram driven by a positive MPI was performed in 12 patients (23%), resulting in percutaneous coronary intervention in nine cases (75%). A positive MPI (abnormal or equivocal results) was associated with the occurrence of events in the follow-up (χ(2)=19.961, Ppatient presenting to the emergency department with acute chest pain and a normal or nondiagnostic ECG, with a positive MPI, the relative risk of having events during the first year was 7.5 (95% confidence interval: 2.8-19.2), Ppatients were free of events. Patients presenting with acute chest pain and a low-to-intermediate likelihood of coronary artery disease with a normal rest MPI have a very low probability of cardiac events during the first year. Coronary calcium score was not helpful in risk-stratifying these patients. © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.

  7. Performance and efficacy of 320-row computed tomography coronary angiography in patients presenting with acute chest pain: results from a clinical registry.

    Science.gov (United States)

    van Velzen, J E; de Graaf, F R; Kroft, L J; de Roos, A; Reiber, J H C; Bax, J J; Jukema, J W; Schuijf, J D; Schalij, M J; van der Wall, E E

    2012-04-01

    The purpose of this study was to evaluate the performance of 320-row computed tomography angiography (CTA) in the identification of significant coronary artery disease (CAD) in patients presenting with acute chest pain and to examine the relation to outcome during follow-up. A total of 106 patients with acute chest pain underwent CTA to evaluate presence of CAD. Each CTA was classified as: normal, non-significant CAD (patients, 23 patients (22%) had a normal CTA, 19 patients (18%) had non-significant CAD on CTA, 59 patients (55%) had significant CAD on CTA, and 5 patients (5%) had non-diagnostic image quality. In total, 16 patients (15%) were immediately discharged after normal CTA and 90 patients (85%) underwent invasive coronary angiography. Sensitivity, specificity, and positive and negative predictive values to detect significant CAD on CTA were 100, 87, 93, and 100%, respectively. During mean follow-up of 13.7 months, no cardiovascular events occurred in patients with a normal CTA examination. In patients with non-significant CAD on CTA, no cardiac death or myocardial infarctions occurred and only 1 patient underwent revascularization due to unstable angina. In patients presenting with acute chest pain, an excellent clinical performance for the non-invasive assessment of significant CAD was demonstrated using CTA. Importantly, normal or non-significant CAD on CTA predicted a low rate of adverse cardiovascular events and favorable outcome during follow-up.

  8. High-risk plaque detected on coronary CT angiography predicts acute coronary syndromes independent of significant stenosis in acute chest pain: results from the ROMICAT-II trial.

    Science.gov (United States)

    Puchner, Stefan B; Liu, Ting; Mayrhofer, Thomas; Truong, Quynh A; Lee, Hang; Fleg, Jerome L; Nagurney, John T; Udelson, James E; Hoffmann, Udo; Ferencik, Maros

    2014-08-19

    It is not known whether high-risk plaque, as detected by coronary computed tomography angiography (CTA), permits improved early diagnosis of acute coronary syndromes (ACS) independently to the presence of significant coronary artery disease (CAD) in patients with acute chest pain. The primary aim of this study was to determine whether high-risk plaque features, as detected by CTA in the emergency department (ED), may improve diagnostic certainty of ACS independently and incrementally to the presence of significant CAD and clinical risk assessment in patients with acute chest pain but without objective evidence of myocardial ischemia or myocardial infarction (MI). We included patients randomized to the coronary CTA arm of the ROMICAT-II (Rule Out Myocardial Infarction/Ischemia Using Computer-Assisted Tomography II) trial. Readers assessed coronary CTA qualitatively for the presence of nonobstructive CAD (1% to 49% stenosis), significant CAD (≥50% or ≥70% stenosis), and the presence of at least 1 of the high-risk plaque features (positive remodeling, low acute chest pain but negative initial electrocardiogram and troponin, presence of high-risk plaques on coronary CTA increased the likelihood of ACS independent of significant CAD and clinical risk assessment (age, sex, and number of cardiovascular risk factors). (Multicenter Study to Rule Out Myocardial Infarction by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239). Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

  9. A Multivariate Model for Prediction of Obstructive Coronary Disease in Patients with Acute Chest Pain: Development and Validation.

    Science.gov (United States)

    Correia, Luis Cláudio Lemos; Cerqueira, Maurício; Carvalhal, Manuela; Ferreira, Felipe; Garcia, Guilherme; Silva, André Barcelos da; Sá, Nicole de; Lopes, Fernanda; Barcelos, Ana Clara; Noya-Rabelo, Márcia

    2017-04-01

    Currently, there is no validated multivariate model to predict probability of obstructive coronary disease in patients with acute chest pain. To develop and validate a multivariate model to predict coronary artery disease (CAD) based on variables assessed at admission to the coronary care unit (CCU) due to acute chest pain. A total of 470 patients were studied, 370 utilized as the derivation sample and the subsequent 100 patients as the validation sample. As the reference standard, angiography was required to rule in CAD (stenosis ≥ 70%), while either angiography or a negative noninvasive test could be used to rule it out. As predictors, 13 baseline variables related to medical history, 14 characteristics of chest discomfort, and eight variables from physical examination or laboratory tests were tested. The prevalence of CAD was 48%. By logistic regression, six variables remained independent predictors of CAD: age, male gender, relief with nitrate, signs of heart failure, positive electrocardiogram, and troponin. The area under the curve (AUC) of this final model was 0.80 (95% confidence interval [95%CI] = 0.75 - 0.84) in the derivation sample and 0.86 (95%CI = 0.79 - 0.93) in the validation sample. Hosmer-Lemeshow's test indicated good calibration in both samples (p = 0.98 and p = 0.23, respectively). Compared with a basic model containing electrocardiogram and troponin, the full model provided an AUC increment of 0.07 in both derivation (p = 0.0002) and validation (p = 0.039) samples. Integrated discrimination improvement was 0.09 in both derivation (p acute chest pain. Atualmente, não existe um modelo multivariado validado para predizer a probabilidade de doença coronariana obstrutiva em pacientes com dor torácica aguda. Desenvolver e validar um modelo multivariado para predizer doença arterial coronariana (DAC) com base em variáveis avaliadas à admissão na unidade coronariana (UC) devido a dor torácica aguda. Foram estudados um total de 470 pacientes

  10. Impact of Fractionation and Dose in a Multivariate Model for Radiation-Induced Chest Wall Pain

    Energy Technology Data Exchange (ETDEWEB)

    Din, Shaun U. [Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York (United States); Williams, Eric L.; Jackson, Andrew [Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York (United States); Rosenzweig, Kenneth E. [Department of Radiation Oncology, Mount Sinai Medical Center, New York, New York (United States); Wu, Abraham J.; Foster, Amanda [Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York (United States); Yorke, Ellen D. [Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York (United States); Rimner, Andreas, E-mail: rimnera@mskcc.org [Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York (United States)

    2015-10-01

    Purpose: To determine the role of patient/tumor characteristics, radiation dose, and fractionation using the linear-quadratic (LQ) model to predict stereotactic body radiation therapy–induced grade ≥2 chest wall pain (CWP2) in a larger series and develop clinically useful constraints for patients treated with different fraction numbers. Methods and Materials: A total of 316 lung tumors in 295 patients were treated with stereotactic body radiation therapy in 3 to 5 fractions to 39 to 60 Gy. Absolute dose–absolute volume chest wall (CW) histograms were acquired. The raw dose-volume histograms (α/β = ∞ Gy) were converted via the LQ model to equivalent doses in 2-Gy fractions (normalized total dose, NTD) with α/β from 0 to 25 Gy in 0.1-Gy steps. The Cox proportional hazards (CPH) model was used in univariate and multivariate models to identify and assess CWP2 exposed to a given physical and NTD. Results: The median follow-up was 15.4 months, and the median time to development of CWP2 was 7.4 months. On a univariate CPH model, prescription dose, prescription dose per fraction, number of fractions, D83cc, distance of tumor to CW, and body mass index were all statistically significant for the development of CWP2. Linear-quadratic correction improved the CPH model significance over the physical dose. The best-fit α/β was 2.1 Gy, and the physical dose (α/β = ∞ Gy) was outside the upper 95% confidence limit. With α/β = 2.1 Gy, V{sub NTD99Gy} was most significant, with median V{sub NTD99Gy} = 31.5 cm{sup 3} (hazard ratio 3.87, P<.001). Conclusion: There were several predictive factors for the development of CWP2. The LQ-adjusted doses using the best-fit α/β = 2.1 Gy is a better predictor of CWP2 than the physical dose. To aid dosimetrists, we have calculated the physical dose equivalent corresponding to V{sub NTD99Gy} = 31.5 cm{sup 3} for the 3- to 5-fraction groups.

  11. Comparison of traditional cardiovascular risk models and coronary atherosclerotic plaque as detected by computed tomography for prediction of acute coronary syndrome in patients with acute chest pain.

    Science.gov (United States)

    Ferencik, Maros; Schlett, Christopher L; Bamberg, Fabian; Truong, Quynh A; Nichols, John H; Pena, Antonio J; Shapiro, Michael D; Rogers, Ian S; Seneviratne, Sujith; Parry, Blair Alden; Cury, Ricardo C; Brady, Thomas J; Brown, David F; Nagurney, John T; Hoffmann, Udo

    2012-08-01

    The objective was to determine the association of four clinical risk scores and coronary plaque burden as detected by computed tomography (CT) with the outcome of acute coronary syndrome (ACS) in patients with acute chest pain. The hypothesis was that the combination of risk scores and plaque burden improved the discriminatory capacity for the diagnosis of ACS. The study was a subanalysis of the Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) trial-a prospective observational cohort study. The authors enrolled patients presenting to the emergency department (ED) with a chief complaint of acute chest pain, inconclusive initial evaluation (negative biomarkers, nondiagnostic electrocardiogram [ECG]), and no history of coronary artery disease (CAD). Patients underwent contrast-enhanced 64-multidetector-row cardiac CT and received standard clinical care (serial ECG, cardiac biomarkers, and subsequent diagnostic testing, such as exercise treadmill testing, nuclear stress perfusion imaging, and/or invasive coronary angiography), as deemed clinically appropriate. The clinical providers were blinded to CT results. The chest pain score was calculated and the results were dichotomized to ≥10 (high-risk) and patient was assigned to a low-, intermediate-, or high-risk category. Because of the low number of subjects in the high-risk group, the intermediate- and high-risk groups were combined into one. CT images were evaluated for the presence of plaque in 17 coronary segments. Plaque burden was stratified into none, intermediate, and high (zero, one to four, and more than four segments with plaque). An outcome panel of two physicians (blinded to CT findings) established the primary outcome of ACS (defined as either an acute myocardial infarction or unstable angina) during the index hospitalization (from the presentation to the ED to the discharge from the hospital). Logistic regression modeling was performed to examine the association of risk scores

  12. Impact of an Abbreviated Cardiac Enzyme Protocol to Aid Rapid Discharge of Patients with Cocaine-associated Chest Pain in the Clinical Decision Unit

    Directory of Open Access Journals (Sweden)

    Faheem W. Guirgis

    2014-03-01

    Full Text Available Introduction: In 2007 there were 64,000 visits to the emergency department (ED for possible myocardial infarction (MI related to cocaine use. Prior studies have demonstrated that low- to intermediate-risk patients with cocaine-associated chest pain can be safely discharged after 9-12 hours of observation. The goal of this study was to determine the safety of an 8-hour protocol for ruling out MI in patients who presented with cocaine-associated chest pain. Methods: We conducted a retrospective review of patients treated with an 8-hour cocaine chest pain protocol between May 1, 2011 and November 30, 2012 who were sent to the clinical decision unit (CDU for observation. The protocol included serial cardiac biomarker testing with Troponin-T, CK-MB (including delta CK-MB, and total CK at 0, 2, 4, and 8 hours after presentation with cardiac monitoring for the observation period. Patients were followed up for adverse cardiac events or death within 30 days of discharge. Results: There were 111 admissions to the CDU for cocaine chest pain during the study period. One patient had a delta CK-MB of 1.6 ng/ml, but had negative Troponin-T at all time points. No patient had a positive Troponin-T or CK-MB at 0, 2, 4 or 8 hours, and there were no MIs or deaths within 30 days of discharge. Most patients were discharged home (103 and there were 8 inpatient admissions from the CDU. Of the admitted patients, 2 had additional stress tests that were negative, 1 had additional cardiac biomarkers that were negative, and all 8 patients were discharged home. The estimated risk of missing MI using our protocol is, with 99% confidence, less than 5.1% and with 95% confidence, less than 3.6% (99% CI, 0-5.1%; 95% CI, 0-3.6%. Conclusion: Application of an abbreviated cardiac enzyme protocol resulted in the safe and rapid discharge of patients presenting to the ED with cocaine-associated chest pain. [West J Emerg Med. 2014;15(2:180–183.

  13. Chest MRI

    Science.gov (United States)

    Nuclear magnetic resonance - chest; Magnetic resonance imaging - chest; NMR - chest; MRI of the thorax; Thoracic MRI ... healthy enough to filter the contrast. During the MRI, the person who operates the machine will watch ...

  14. Zero Calcium Score as a Filter for Further Testing in Patients Admitted to the Coronary Care Unit with Chest Pain.

    Science.gov (United States)

    Correia, Luis Cláudio Lemos; Esteves, Fábio P; Carvalhal, Manuela; Souza, Thiago Menezes Barbosa de; Sá, Nicole de; Correia, Vitor Calixto de Almeida; Alexandre, Felipe Kalil Beirão; Lopes, Fernanda; Ferreira, Felipe; Noya-Rabelo, Márcia

    2017-06-12

    The accuracy of zero coronary calcium score as a filter in patients with chest pain has been demonstrated at the emergency room and outpatient clinics, populations with low prevalence of coronary artery disease (CAD). To test the gatekeeping role of zero calcium score in patients with chest pain admitted to the coronary care unit (CCU), where the pretest probability of CAD is higher than that of other populations. Patients underwent computed tomography for calcium scoring, and obstructive CAD was defined by a minimum 70% stenosis on invasive angiography. In 146 patients studied, the prevalence of CAD was 41%. A zero calcium score was present in 35% of the patients. The sensitivity and specificity of zero calcium score yielded a negative likelihood ratio of 0.16. After logistic regression adjustment for pretest probability, zero calcium score was independently associated with lower odds of CAD (OR = 0.12, 95%CI = 0.04-0.36), increasing the area under the ROC curve of the clinical model from 0.76 to 0.82 (p = 0.006). Zero calcium score provided a net reclassification improvement of 0.20 (p = 0.0018) over the clinical model when using a pretest probability threshold of 10% for discharging without further testing. In patients with pretest probability papel do escore de cálcio zero como filtro nos pacientes com dor torácica admitidos numa unidade coronariana intensiva (UCI), na qual a probabilidade pré-teste de DAC é maior do que em outras populações. Pacientes foram submetidos a tomografia computadorizada para quantificar o escore de cálcio, DAC obstrutiva foi definida por uma estenose mínima de 70% na cineangiocoronariografia invasiva. Um escore clínico para estimar a probabilidade pré-teste de DAC obstrutiva foi criado em amostra de 370 pacientes, usado para definir subgrupos na definição de valores preditivos negativos do escore zero. Em 146 pacientes estudados, a prevalência de DAC foi 41% e o escore de cálcio zero foi demonstrado em 35% deles. A

  15. Chest pain with ST segment elevation in a patient with prosthetic aortic valve infective endocarditis: a case report

    Directory of Open Access Journals (Sweden)

    Gamma Reto

    2011-08-01

    Full Text Available Abstract Introduction Acute ST-segment elevation myocardial infarction secondary to atherosclerotic plaque rupture is a common medical emergency. This condition is effectively managed with percutaneous coronary intervention or thrombolysis. We report a rare case of acute myocardial infarction secondary to coronary embolisation of valvular vegetation in a patient with infective endocarditis, and we highlight how the management of this phenomenon may not be the same. Case presentation A 73-year-old British Caucasian man with previous tissue aortic valve replacement was diagnosed with and treated for infective endocarditis of his native mitral valve. His condition deteriorated in hospital and repeat echocardiography revealed migration of vegetation to his aortic valve. Whilst waiting for surgery, our patient developed severe central crushing chest pain with associated anterior ST segment elevation on his electrocardiogram. Our patient had no history or risk factors for ischaemic heart disease. It was likely that coronary embolisation of part of the vegetation had occurred. Thrombolysis or percutaneous coronary intervention treatments were not performed in this setting and a plan was made for urgent surgical intervention. However, our patient deteriorated rapidly and unfortunately died. Conclusion Clinicians need to be aware that atherosclerotic plaque rupture is not the only cause of acute myocardial infarction. In the case of septic vegetation embolisation, case report evidence reveals that adopting the current strategies used in the treatment of myocardial infarction can be dangerous. Thrombolysis risks intra-cerebral hemorrhage from mycotic aneurysm rupture. Percutaneous coronary intervention risks coronary mycotic aneurysm formation, stent infections as well as distal septic embolisation. As yet, there remains no defined treatment modality and we feel all cases should be referred to specialist cardiac centers to consider how best to proceed.

  16. Which clinical scoring system should we use for the evaluation of chest pain in the Emergency Department? A review

    Directory of Open Access Journals (Sweden)

    Nicola Parenti

    2016-12-01

    Full Text Available Many clinical prediction rules and scoring systems have been developed to predict Acute Coronary Syndrome in-patient with chest pain (CP in Emergency Department. In this review we check and compare the level of validity and reliability of the TIMI (thrombolysis in myocardial infarction; HEART (history, ECG, age, risk factors, troponin; GRACE (global registry of acute coronary events. We used as eligibility criteria: all studies, reviews and meta-analysis on validity and reliability of clinical score systems for CP conducted on all ages of patients in all languages. The selection of articles included in the review was performed according to PRISMA guidelines. We collected one systematic review, one meta-analysis and eleven studies. The HEART score showed the best validity in predicting the outcomes tested with a mean AUROC value of 0.86 (range 0.83- 0.88; the GRACE score showed a good validity: mean AUROC value=0.78 (range 0.70-0.82; the TIMI a moderate validity: mean AUROC=0.67 (range 0.42-0.79. The only included study on the reliability showed that the TIMI score had a poor to moderate reliability: weighted kappa range=k= 0.30-0.43. In conclusion, in this review the HEART and GRACE scores showed the best validity in predicting acute coronary syndromes and major cardiac events. To our knowledge there is only one study on the reliability of TIMI score that showed a poor to moderate inter-rater reliability. There are no studies on the reliability of other score systems.

  17. Use of Coronary Computed Tomographic Angiography Findings to Modify Statin and Aspirin Prescription in Patients With Acute Chest Pain.

    Science.gov (United States)

    Pursnani, Amit; Celeng, Csilla; Schlett, Christopher L; Mayrhofer, Thomas; Zakroysky, Pearl; Lee, Hang; Ferencik, Maros; Fleg, Jerome L; Bamberg, Fabian; Wiviott, Stephen D; Truong, Quynh A; Udelson, James E; Nagurney, John T; Hoffmann, Udo

    2016-02-01

    Coronary CT angiography (CCTA) is used in patients with low-intermediate chest pain presenting to the emergency department for its reliability in excluding acute coronary syndrome (ACS). However, its influence on medication modification in this setting is unclear. We sought to determine whether knowledge of CCTA-based coronary artery disease (CAD) was associated with change in statin and aspirin prescription. We used the CCTA arm of the Rule Out Myocardial Infarction using Computed Angiographic Tomography II multicenter, randomized control trial (R-II) and comparison cohort from the observational Rule Out Myocardial Infarction using Computed Angiographic Tomography I cohort (R-I). In R-II, subjects were randomly assigned to CCTA to guide decision making, whereas in R-I patients underwent CCTA with results blinded to caregivers and managed according to standard care. Our final cohort consisted of 277 subjects from R-I and 370 from R-II. ACS rate was similar (6.9% vs 6.2% respectively, p = 0.75). For subjects with CCTA-detected obstructive CAD without ACS, initiation of statin was significantly greater after disclosure of CCTA results (0% in R-I vs 20% in R-II, p = 0.009). Conversely, for subjects without CCTA-detected CAD, aspirin prescription was lower with disclosure of CCTA results (16% in R-I vs 4.8% in R-II, p = 0.001). However, only 68% of subjects in R-II with obstructive CAD were discharged on statin and 65% on aspirin. In conclusion, physician knowledge of CCTA results leads to improved alignment of aspirin and statin with the presence and severity of CAD although still many patients with CCTA-detected CAD are not discharged on aspirin or statin. Our findings suggest opportunity for practice improvement when CCTA is performed in the emergency department. Copyright © 2016 Elsevier Inc. All rights reserved.

  18. Coronary CT angiography for acute chest pain triage: Techniques for radiation exposure reduction; 128 vs. 64 multidetector CT

    Energy Technology Data Exchange (ETDEWEB)

    Goitein, Orly; Eshet, Yael; Konen, Eli (Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, and the Sackler Faculty of Medicine, Tel Aviv Univ., Tel Aviv (Israel)), email: orly.goitein@sheba.health.gov.il; Matetzky, Shlomi (Heart Inst., Sheba Medical Center, Tel Hashomer, and the Sackler Faculty of Medicine, Tel Aviv Univ., Tel Aviv (Israel)); Goitein, David (Surgery C, Sheba Medical Center, Tel Hashomer, and the Sackler Faculty of Medicine, Tel Aviv Univ., Tel Aviv (Israel)); Hamdan, Ashraf; Di Segni, Elio (Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, and the Sackler Faculty of Medicine, Tel Aviv Univ., Tel Aviv (Israel); Heart Inst., Sheba Medical Center, Tel Hashomer, and the Sackler Faculty of Medicine, Tel Aviv Univ., Tel Aviv (Israel))

    2011-10-15

    Background. Coronary CT angiography (CCTA) is used daily in acute chest pain triage, although exposing patients to significant radiation dosage. CCTA using prospective ECG gating (PG CCTA) enables significant radiation reduction Purpose. To determine whether the routine use of 128 vs. 64 multidetector CT (MDCT) can increase the proportion of patients scanned using PG CCTA technique, lowering radiat