Comparison of 64-Slice CT Angiogram With Other Clinical Predictors of Acute Coronary Syndromes in a Low-Risk Chest Pain Observation Unit Population

Abstract Background Traditional coronary artery disease risk factors are well established and help risk stratify most patients presenting with chest pain syndromes. Young patients (under age 30 years) without other risk factors are thought to be at very low risk of coronary artery disease and acute coronary syndromes. Case presentation We highlight the case of a 27-year-old Afro-Caribbean male who presented to hospital with chest pain and was discharged from the emergency room because he was thought to be low risk for ischemic heart disease. Laboratory investigations subsequently confirmed acute coronary syndrome. He was found to have an anomalous right coronary artery with a malignant origin running between the aorta and pulmonary artery eventually requiring surgical correction. Anomalous origins of the coronary arteries are rare causes of acute coronary syndromes, chest pain, and sudden cardiac death. Conclusion Our patient could have easily had an adverse outcome as his diagnosis was missed by the initial treating physician. It is important to consider anomalous coronary artery origin in the evaluation of young symptomatic patients who may be otherwise low risk and not have traditional risk factors for ischemic heart disease.

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Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain

QJM ◽

10.1093/qjmed/hcg152 ◽

2003 ◽

Vol 96 (12) ◽

pp. 893-898 ◽

Cited By ~ 44

Author(s):

S.W. Goodacre ◽

K. Angelini ◽

J. Arnold ◽

S. Revill ◽

F. Morris

Keyword(s):

Chest Pain ◽

Acute Coronary Syndromes ◽

Clinical Predictors ◽

Coronary Syndromes

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Clinical predictors and angiographic features of acute coronary syndromes caused by systemic embolism

European Heart Journal ◽

10.1093/ehjci/ehaa946.1530 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Jeronimo Baza ◽

C Salazar ◽

M.J Perez Vyzcaino ◽

L Nombela ◽

P Jimenez Quevedo ◽

...

Keyword(s):

Atrial Fibrillation ◽

Hospital Mortality ◽

Acute Coronary Syndromes ◽

Tertiary Hospital ◽

Control Group ◽

Systemic Embolism ◽

Clinical Predictors ◽

Coronary Syndrome ◽

Valvular Surgery ◽

Coronary Syndromes

Abstract Introduction Systemic embolism to coronary arteries is one of the mechanisms of acute myocardial infarction (AMI) of non-atherosclerotic cause. However, its clinical profile has not been properly established yet. Purpose To identify clinical predictors and angiographic characteristics of acute coronary syndromes caused by systemic embolism to a principal coronary artery (ACS-E), as well as to describe in-hospital mortality of these patients. Methods 40 patients with ACS-E, admitted between 2003 and 2018 in a tertiary hospital. Epidemiological, clinical and angiographic characteristics of these cases were compared with those from 4989 patients, attended for acute coronary syndrome of atherosclerotic cause (ACS-A) in the same hospital during the same period. Results Patients with ACS-E were younger (28% vs 10% were <45 years old, p<0.001) and had a higher proportion of women (43% vs 22%, p 0.003), atrial fibrillation (40% vs 5%, p<0.001) and neoplasia (18% vs 7%, p 0.009). They had also undergone previous valvular surgery more frequently than patients with ACS-A (13% vs 0.5%, p<0.001) and a higher proportion of them were under treatment with warfarin (15% vs 3%, p<0.001). Variables identified as independent predictors of ACS-E in the multivariate analysis are shown in the table. Regarding clinical presentation, ST elevation AMI was more frequent in ACS-E cases (83% vs 67%, p 0.04). Patients with ACS-E did not present any significative stenosis in other vessels apart from the culprit one (number of other vessels with at least 1 severe stenosis was 0 in the ACS-E group vs 1.33 + 1 in the ACS-A arm, p<0.001). PCI was attempted in 75% of the patients with ACS-E, resulting successful in 80% of the cases. On the other hand, 100% of SCA-A underwent PCI, with a success proportion of 99% (p<0.001). In-hospital mortality in ACS-E group was 15% and 4% in the control group (p<0.001). Conclusions ACS-E and ACS-A have different clinical and angiographic features. Atrial fibrillation, chronic warfarin treatment, previous valvular surgery, presence of any neoplasia and female sex are independent predictors for ACS-E. Funding Acknowledgement Type of funding source: None

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350: Correlation Between Emergency Physician Performed Intimal-Medial Thickness Measurement of the Common Carotid Artery and Stress Echocardiography Results in Low Risk Patients Evaluated for Chest Pain in an ED Observation Unit

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2007.06.411 ◽

2007 ◽

Vol 50 (3) ◽

pp. S109

Author(s):

M. Blaivas ◽

S. Adhikari ◽

M. Lyon ◽

S. Shiver

Keyword(s):

Chest Pain ◽

Carotid Artery ◽

Emergency Physician ◽

Common Carotid Artery ◽

Stress Echocardiography ◽

Thickness Measurement ◽

Low Risk ◽

Observation Unit ◽

Risk Patients ◽

The Common

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Physical fitness cannot be used to predict the likelihood of acute coronary syndromes in ED patients with chest pain

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2010.07.027 ◽

2012 ◽

Vol 30 (1) ◽

pp. 57-60

Author(s):

Taku Taira ◽

Breena R. Taira ◽

Jasmine Chohan ◽

Daniel Dickinson ◽

Regina M. Troxell ◽

...

Keyword(s):

Chest Pain ◽

Physical Fitness ◽

Acute Coronary Syndromes ◽

Coronary Syndromes

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Chronic kidney disease as a risk factor for acute coronary syndromes in patients presenting to the emergency room with chest pain

Translational Research ◽

10.1016/j.trsl.2011.12.006 ◽

2012 ◽

Vol 159 (5) ◽

pp. 391-396 ◽

Cited By ~ 5

Author(s):

Sherezade Khambatta ◽

Michael E. Farkouh ◽

R. Scott Wright ◽

Guy S. Reeder ◽

Peter A. McCullough ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Risk Factor ◽

Chest Pain ◽

Kidney Disease ◽

Emergency Room ◽

Acute Coronary Syndromes ◽

Coronary Syndromes

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Abstract 16592: The Diamond-Forrester Criterion Significantly Overestimates the Risk of Obstructive Coronary Artery Disease in Patients Presenting to the Emergency Department With Low-Risk Chest Pain

Circulation ◽

10.1161/circ.130.suppl_2.16592 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Todd Lecher ◽

William R Davidson ◽

Andrew Foy

Keyword(s):

Risk Factors ◽

Emergency Department ◽

Chest Pain ◽

Stress Echocardiography ◽

Stress Test ◽

Pretest Probability ◽

Low Risk ◽

High Cholesterol ◽

Observation Unit ◽

Diamond Forrester

Introduction: We sought to (1) classify patients who underwent stress echocardiography in an emergency department observation unit based on their pretest probabilities of obstructive CAD using the Diamond-Forrester criterion, (2) to compare observed versus expected frequencies of obstructive CAD based on the Diamond-Forrester risk categories of low (<25%), intermediate (25-75%), and high (>75%) pretest probability of disease, and (3) to test the association of traditional cardiovascular risk factors (age, gender, hypertension, diabetes, high cholesterol, and smoking) with obstructive CAD. METHODS: Retrospective review of the electronic medical record for patients who presented to the emergency department with chest pain and underwent observation followed by stress echocardiography between the period January 1, 2012 to December 31, 2012. Patients were classified as low, intermediate, or high risk for obstructive CAD using the Diamond-Forrester criterion. Main outcome measures were stress echocardiography results as well as receipt of cardiac catheterization and results. RESULTS: A total of 504 patients were included in the final analysis. Overall, 4.8% had a positive stress test and only 1.2% had angiographic evidence of obstructive CAD. In each category of risk, the observed frequency of obstructive CAD was significantly lower than expected. Having a high pretest probability as defined by the Diamond-Forrester criterion was significantly associated with obstructive CAD. Age, gender, diabetes, hypertension, high cholesterol, and smoking were not independently associated with evidence of obstructive CAD; nor were any composites of these risk factors. CONCLUSIONS: The traditional Diamond-Forrester criterion significantly overestimates the probability of obstructive CAD in ED observation unit patients. Reliance on the Diamond-Forrester criterion and other traditional risk factors associated with obstructive CAD in the outpatient setting could lead to faulty Bayesian reasoning, overuse of non-invasive imaging, and improper interpretation of test results in an ED population of low-risk chest pain patients. Further work is required to determine an optimal risk-assessment strategy for this patient population.

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PRe-hospital Evaluation of Sensitive TrOponin (PRESTO) Study: multicentre prospective diagnostic accuracy study protocol

BMJ Open ◽

10.1136/bmjopen-2019-032834 ◽

2019 ◽

Vol 9 (10) ◽

pp. e032834 ◽

Cited By ~ 3

Author(s):

Abdulrhman Alghamdi ◽

Eloïse Cook ◽

Edward Carlton ◽

Aloysius Siriwardena ◽

Mark Hann ◽

...

Keyword(s):

Chest Pain ◽

Hospital Admission ◽

Diagnostic Accuracy ◽

Blood Sample ◽

Acute Coronary Syndromes ◽

Venous Blood ◽

Prehospital Setting ◽

Registration Number ◽

Coronary Syndromes ◽

Rule Out

IntroductionWithin the UK, chest pain is one of the most common reasons for emergency (999) ambulance calls and the most common reason for emergency hospital admission. Diagnosing acute coronary syndromes (ACS) in a patient with chest pain in the prehospital setting by a paramedic is challenging. The Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision rule is a validated tool used in the emergency department (ED) to stratify patients with suspected ACS following a single blood test.We are seeking to evaluate the diagnostic accuracy of the T-MACS decision aid algorithm to ‘rule out’ ACS when used in the prehospital environment with point-of-care troponin assays. If successful, this could allow paramedics to immediately rule out ACS for patients in the ‘very low risk’ group and avoid the need for transport to the ED, while also risk stratifying other patients using a single blood sample taken in the prehospital setting.Methods and analysisWe will recruit patients who call emergency (999) ambulance services where the responding paramedic suspects cardiac chest pain. The data required to apply T-MACS will be prospectively recorded by paramedics who are responding to each patient. Paramedics will be required to draw a venous blood sample at the time of arrival to the patient. Blood samples will later be tested in batches for cardiac troponin, using commercially available troponin assays. The primary outcome will be a diagnosis of acute myocardial infarction, established at the time of initial hospital admission. The secondary outcomes will include any major adverse cardiac events within 30 days of enrolment.Ethics and disseminationThe study obtained approval from the National Research Ethics Service (reference: 18/ES/0101) and the Health Research Authority. We will publish our findings in a high impact general medical journal.Trial registration numberRegistration number: ClinicalTrials.gov, study ID: NCT03561051

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