Research Article: Management of Pulmonary Embolism: Results from the German Chest Pain Unit Registry

Cardiology ◽  
2021 ◽  
pp. 1-7
Author(s):  
Stephan Settelmeier ◽  
Matthias Hochadel ◽  
Evangelos Giannitsis ◽  
Stavros Konstantinides ◽  
Thomas Voigtländer ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Chest Pain ◽  
Public Awareness ◽  
Critical Time ◽  
Acute Chest Pain ◽  
Patient Characteristics ◽  
Left Ventricular ◽  
Diagnostic Workup ◽  
Coronary Syndrome ◽  
Normal Left Ventricular

Introduction: Since 2008, specialized chest pain units (CPUs) were implemented across Germany ensuring structured diagnostics in acute chest pain. This study aims to analyze the management of pulmonary embolism (PE) patients in such certified CPUs. Methods: Data were retrieved from 13,902 patients enrolled in the German CPU registry and analyzed for the diagnosis of PE including patient characteristics, critical time intervals, diagnostic workup, treatment, and prognosis. PE patients were compared to the overall CPU patient cohort. Only patients with a complete 3-month follow-up were included. Results: Overall, 1.1% of all CPU patients were diagnosed with PE. Chest pain and dyspnea were the leading symptoms. Patients with PE were older, presented with higher heart rates, and more frequently exhibited signs of heart failure, despite a normal left ventricular function. PE patients showed significantly longer time delays between symptom onset and the first medical contact, while PE patients with chest pain presented earlier than PE patients with dyspnea only. Whereas more PE patients had to be transferred to the intensive care unit, in-CPU mortality and event rates over 3 months were low. Discussion/Conclusion: This study suggests a certain risk for underdiagnosis and consecutive potential undertreatment of PE patients in German Cardiac Society (GCS)-certified CPUs, which is thought to result from an anticipated focus on patients with acute coronary syndrome (ACS). Public awareness for PE beyond chest pain should be improved. Certified CPUs should be urged to implement strategic pathways for a better simultaneous diagnostic workup of differential diagnosis beyond ACS.

Abstract 16639: Low Yield of Additional Non-invasive Testing in Moderate Worst Stenosis by cCTA in Acute Chest Pain Patients - Results From a Clinical ED cCTA Registry

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Sumbal A Janjua ◽  
Harshna V Vadvala ◽  
Pedro V Staziaki ◽  
Richard A Takx ◽  
Anand M Prabhakar ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Chest Pain ◽  
Unstable Angina ◽  
Acute Chest Pain ◽  
Left Ventricular ◽  
Fractional Flow ◽  
Coronary Syndrome ◽  
Non Invasive ◽  
Lipid Rich Plaque ◽  
Pain Patients

Introduction: Coronary computed tomography angiography (cCTA) allows efficient triage of low-intermediate risk patients with suspected acute coronary syndrome (ACS); appropriate management of patients with moderate stenosis by cCTA is unknown. We evaluated the yield of downstream testing in moderate stenosis patients in a clinical ED cCTA registry. Methods: All consecutive ED patients with acute chest pain undergoing cCTA as part of routine care between October 2012 and July 2014 were screened. Patients with moderate as their worst stenosis (50-69% stenosis) on cCTA were included. Plaque characteristics, resting left ventricular function (by cCTA), results of any functional downstream non-invasive testing, invasive coronary angiography (ICA) and interventions, and discharge diagnosis were reported. ACS was defined as acute myocardial infarction (MI) or unstable angina pectoris (UAP) and adjudicated by an independent committee. Ischemia was defined as clear, territorial abnormality by myocardial perfusion scintigraphy imaging (MPI) or rest or stress echocardiogram, significant dynamic ST-T shift by exercise treadmill test (ETT) and stenosis >70% on ICA or fractional flow reserve (FFR) <0.75. Results: 586 patients underwent cCTA, with 7.2% (n=42) deemed moderate stenosis. Rate of ACS was 14.2% (n=6) with all adjudicated as UAP. Of these, 83% had stenosis caused by lipid-rich plaque; 33% had wall motion abnormalities on cCTA. The majority (n=28; 66%) underwent downstream non-invasive testing. Overall, n=2 (6%) of the non-invasive tests were positive for ischemia while n=3 (42%) of the invasive tests were diagnosed as positive for ischemia (all revascularized) (Figure 1). Conclusions: Unstable angina but not myocardial infarction is frequent among acute chest pain patients with moderate stenosis by cCTA. cCTA findings of lipid-rich plaque and resting functional abnormalities had a relatively higher yield vs. other non-invasive tests to detect ischemia.

scholarly journals Copeptin Does Not Add Diagnostic Information to High-Sensitivity Troponin T in Low- to Intermediate-Risk Patients with Acute Chest Pain: Results from the Rule Out Myocardial Infarction by Computed Tomography (ROMICAT) Study

2011 ◽  
Vol 57 (8) ◽  
pp. 1137-1145 ◽  
Author(s):  
Mahir Karakas ◽  
James L Januzzi ◽  
Julia Meyer ◽  
Hang Lee ◽  
Christopher L Schlett ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Chest Pain ◽  
Predictive Value ◽  
Troponin T ◽  
Cardiac Computed Tomography ◽  
Acute Chest Pain ◽  
High Sensitivity ◽  
Left Ventricular ◽  
Intermediate Risk ◽  
Coronary Syndrome

PURPOSE Copeptin, a stable peptide derived from the AVP precursor, has been linked to presence and severity of myocardial ischemia. We sought to evaluate the predictive value of copeptin and its incremental value beyond that of high-sensitivity cardiac troponin T (hs-cTnT) in patients with acute chest pain and low to intermediate risk for acute coronary syndrome (ACS). METHODS We recruited patients who presented with acute chest pain to the emergency department and had a negative initial conventional troponin T test (&lt;0.03 μg/L). In all patients, hs-cTnT and copeptin measurements were taken. Each patient also underwent cardiac computed tomography (CT) and coronary angiography. RESULTS Baseline copeptin concentrations, in contrast to hs-cTnT, were not significantly higher in patients with ACS than in those without (P = 0.24). hs-cTnT showed an earlier rise in patients with ACS than copeptin, when analyses were stratified by time. A copeptin concentration ≥7.38 pmol/L had a negative predictive value (NPV) of 94% and a sensitivity of 51%, whereas hs-cTnT (≥13.0 pg/mL) had a NPV of 96% and a sensitivity of 63%. The combination of copeptin and hs-cTnT resulted in a lower diagnostic accuracy than hs-cTnT alone. Finally, on cardiac CT, copeptin concentrations were not associated with coronary artery morphology, although they were related to the presence of left ventricular dysfunction (P = 0.02). CONCLUSIONS Among patients with acute chest pain and low to intermediate risk for ACS, copeptin concentrations are not independently predictive of ACS and do not add diagnostic value beyond that of hs-cTnT measurements.

The Use of Echocardiography in Certified Chest Pain Units: Results from the German Chest Pain Unit Registry

Cardiology ◽  
2016 ◽  
Vol 134 (2) ◽  
pp. 75-83 ◽  
Author(s):  
Frank Breuckmann ◽  
Matthias Hochadel ◽  
Thomas Voigtländer ◽  
Michael Haude ◽  
Claus Schmitt ◽  
...  
Keyword(s):  
Chest Pain ◽  
Systolic Function ◽  
Clinical Signs ◽  
Acute Chest Pain ◽  
Final Diagnosis ◽  
Left Ventricular ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
St Segment ◽  
Invasive Management

Objectives: To analyze the current usage of transthoracic echocardiography (TTE) as a rapid, noninvasive tool in the early stratification of acute chest pain in certified German chest pain units (CPUs). Methods: A total of 23,997 patients were enrolled. Analyses comprised TTE evaluation rates in relation to clinical presentation, risk profile, left ventricular impairment, final diagnosis and invasive management. Critical times were assessed. Multivariable analyses for independent determinants for the use of TTE were performed. Results: TTE evaluation was available in CPUs in 70.1% of cases. It was associated with lower rates of invasive management in unstable angina pectoris (UAP) and with higher rates in patients with initially suspected non-cardiac origin of symptoms and/or reduced systolic function (p < 0.05). Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) was an independent determinant favoring TTE evaluation [NSTE-myocardial infarction: odds ratio (OR) 1.62; UAP: OR 1.34; p < 0.001 for both]. Clinical signs of heart failure (OR 1.31; p < 0.001), referral by emergency medical service (OR 1.18; p < 0.001) and kidney failure (OR 1.16; p < 0.05) were independently associated with higher TTE rates. TTE did not delay door-to-balloon times. Conclusions: About two thirds of the patients admitted to certified CPUs received TTE evaluation, with the highest rates being in ACS patients, and thereby providing diagnostic information supporting or refuting further invasive management.

Atypical Takotsubo Cardiomyopathy with Hypokinetic Left Mid-ventricle and Apical Wall Sparing: A Case Report and Literature Review

2020 ◽  
Vol 16 (3) ◽  
pp. 241-246
Author(s):  
Dipesh Ludhwani ◽  
Belaal Sheikh ◽  
Vasu K Patel ◽  
Khushali Jhaveri ◽  
Mohammad Kizilbash ◽  
...  
Keyword(s):  
Case Report ◽  
Takotsubo Cardiomyopathy ◽  
Systolic Dysfunction ◽  
Obstructive Coronary Artery Disease ◽  
Left Ventricular ◽  
Reduced Ejection Fraction ◽  
Coronary Syndrome ◽  
Normal Left Ventricular ◽  
Artery Disease

Background: Takotsubo Cardiomyopathy (TTC) is an uncommon cause of acute reversible ventricular systolic dysfunction in the absence of obstructive Coronary Artery Disease (CAD). Typically manifesting as apical wall ballooning, TTC can rarely present atypically with apical wall sparing. Case report: A 62-year-old female presented with complaints of chest pain and features mimicking acute coronary syndrome. Coronary angiogram revealed no obstructive CAD and left ventriculogram showed reduced ejection fraction, normal left ventricular apex and hypokinetic mid-ventricles consistent with atypical TTC. The patient was discharged home on heart failure medications and a follow-up transthoracic echocardiogram demonstrated improved left ventricular function with no wall motion abnormality. Conclusion: This case report provides an insight into the diagnosis and management of TTC in the absence of pathognomic features.

Abstract 681: Characteristics of Atherosclerotic Plaque Burden in Patients With and Without Acute Coronary Syndrome Presenting With Acute Chest Pain to the Emergency Department

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Fabian Bamberg ◽  
Maros Ferecik ◽  
Quynh Truong ◽  
Ian Rogers ◽  
Michael Shapiro ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Coronary Arteries ◽  
Atherosclerotic Plaque ◽  
Acute Chest Pain ◽  
Coronary Plaque ◽  
Plaque Burden ◽  
Coronary Syndrome ◽  
Coronary Ct ◽  
Calcified Plaque

Background: Coronary computed tomography (CT) may improve the early triage of patients with acute chest pain in the emergency department (ED). The aim of this study was to compare the presence and extent of coronary atherosclerotic plaque as detected by coronary CT in patients with and without acute coronary syndromes (ACS). Methods: The study was designed as a prospective, observational cohort study in patients with acute chest pain but negative cardiac biomarkers and no diagnostic ECG changes, admitted to rule out myocardial ischemia. All patients underwent coronary CT prior to hospital admission. The presence of coronary plaque was treated as a dichotomous outcome, and the extent of CAD was defined as number of (1) coronary segments with plaque, or (2) major coronary arteries with plaque detected by MDCT as assessed by two independent observers. The clinical outcome (ACS) was adjudicated by a review committee using established AHA criteria; subjects with history of CAD (stent placement, bypass) were excluded. Results : Among 368 patients with acute chest pain (mean age 53±12 years, 61% male) 31 patients were determined to have ACS (8%). None of the 183 subjects without plaque (50%) had an ACS. Among the remaining 185 subjects (mean age 58.0±11.5 years, 68% male) in whom coronary plaque was detected, patients with ACS had a significantly more plaque (7.2±3.7 vs. 4.2±3.4, p<0.0001 segments) as compared to subjects without ACS. Similar results were seen for calcified plaque and non-calcified plaque (6.5±3.7 vs. 3.6±3.5 segments, p<0.0001; and 3.6±3.2 vs. 1.8±2.2 segments, p<0.0001, respectively). In addition, the rate of ACS increased with the number of major coronary arteries with plaque (1-vessel: 6.8%, 2-vessels: 10.6%, 3 vessels: 30.8%, and 4-vessels: 25%; p<0.01). In contrast, the ratio of non-calcified to calcified plaque was not different between patients with and without ACS (0.68±0.6 vs. 0.54±0.72, p=0.31). Conclusions: The extent of coronary plaque differs between subjects with and without ACS among patients presenting with acute chest pain. Detailed assessment of the extent and composition of coronary plaque may be helpful to assess risk of ACS among patients with acute chest pain but inconclusive initial ED evaluation.

Abstract 290: Circulating miRNAs as Biomarkers in Acute Coronary Syndrome

2012 ◽  
Vol 111 (suppl_1) ◽  
Author(s):  
Lina Cordeddu ◽  
Anna P Pilbrow ◽  
Vicky A Cameron ◽  
Richard W Troughton ◽  
Mark A Richards ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Left Ventricular Function ◽  
Healthy Volunteers ◽  
Ventricular Function ◽  
Plasma Levels ◽  
Left Ventricular ◽  
Coronary Syndrome ◽  
Normal Left Ventricular ◽  
Unstable Atherosclerotic Plaque ◽  
Plasma Microrna

Introduction Acute coronary syndrome is characterized by the active, inflamed and unstable atherosclerotic plaque that is vulnerable to rupture, predisposing to lumen occlusion and varying extents of myocardial injury. Plasma microRNA have been examined in the hope of identifying an easily accessible biomarker for acute coronary syndrome. But so far studies have taken a candidate approach and screened only for miRNA that are potentially released from the injured myocardium. Even so, data from these studies are inconsistent and a consensus is yet to be reached. Aim We set out to screen for circulating plasma microRNAs to serve as biomarkers for patients with Acute Coronary Syndrome. Methods and results We selected patients who suffered from 2 ends of the severity spectrum of acute coronary syndrome vs age-matched healthy controls. These were 20 μsevere” (STEMI: troponin-positive with subsequent rapid deterioration in left ventricular function or death within 5 years), 20 μmild” (unstable angina: troponin-negative with sustained normal left ventricular function and survival at 5 years), and 20 normal healthy volunteers. Blood samples were obtained from patients within 2 weeks of the acute event. We took a non-constrained approach and screened using an array panel consisting of 379 miRNA. We found 32 miRNA that were significantly upregulated (29/32) or downregulated (3/32) in the comparison between patient vs. control (sum of t-statistic>2). We have made a preliminary analysis of these in relation to a full panel of other classical biomarkers and patient clinical details. We selected 4 candidate microRNAs (miR-27b, -103, -323-3p, -652) and proceeded to test the plasma levels of these in a validation cohort of 100 troponin-positive, 100 troponin-negative patients and 100 normal healthy volunteers. miR 27b, -323-3p, -652 were significantly upregulated in disease and hence robustly validated. Conclusion miR 27b, -323-3p, -652 strongly associates with the event of acute coronary syndrome. Further work will be required to determine the origin and physiological function of these candidate miRNA, and whether their plasma levels can be used for prognostication purposes.

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