Abstract 115: Predictors Of A Positive Stress Test Among Patient Presenting To The Emergency Department With Chest Pain

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Taraka V Gadiraju ◽  
Jahnavi Sagi ◽  
Dev Basu ◽  
Srikanth Penumetsa ◽  
Michael Rothberg
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Stress Test ◽  
Tertiary Care ◽  
Face Validity ◽  
Pseudorandom Number Generator ◽  
Multivariable Model ◽  
Final Multivariable Model ◽  
Significant Difference ◽  
History Of

Objectives: Patients frequently present to the hospital with chest pain. Once myocardial infarction is ruled out based on EKG and cardiac enzymes, most patients undergo stress testing, but only few patients have a positive test. In ambulatory practice, age, sex and symptomatology can establish pretest probability of the coronary disease. However, there are no studies evaluating the predictors of a positive stress test in the emergency department (ED). We assessed predictors for a positive stress test in patients presenting to our hospital with chest pain. Methods: This is a case-control study conducted on a subset of patients admitted to our tertiary care center with chest pain between 2007 and 2009, and who had an inpatient stress test (n=1474). Using chart review, we identified 87 patients, whose stress tests were positive (abnormals), defined as presence of ischemia on EKG and/or imaging modalities. We then used a pseudorandom number generator to select 194 patients whose stress test results were normal (normals) for comparison. Clinical features of chest pain and CAD risk factors were abstracted from the medical record for comparison. A bivariable screening process was used to identify characteristics for inclusion in a multivariable predictive model. Sex and age were maintained in the model for face validity, and remaining covariates were removed in ascending order of their z-statistics until only those with a two-sided p-value of <0.10 remained. Stata 12.1 (Copyright 2011, StataCorp LP) was used for all analyses. Results: Patients with an abnormal stress test were older and more likely to be male and to have a history of vascular disease. Although patients with abnormal stress test were more likely to have history of hypertension, hyperlipidemia and current or ex-smoking, this difference was not statistically significant. Over half of the patients presented with non-cardiac chest pain and there was no significant difference in the chest pain characteristics between patients who had a normal and an abnormal stress test result. In the final multivariable model, when compared to the normals, abnormals were four times as likely to have a history of revascularization (OR 4.13, 95% CI 2.11, 8.09) and twice as likely to have a history of hyperlipidemia (OR 2.1, 95% CI 1.18, 3.79). They were also more likely to have an EKG suggestive of ischemia at presentation (OR 1.90, 95% CI 1.03, 3.53). Specificity of the model was 89%; sensitivity was 43%, and the c-statistic for the final multivariable model was 0.76, suggesting fair to good discrimination. Conclusions: Among patients presenting to the ED with chest pain, a past history of revascularization and hyperlipidemia and an EKG suggestive of ischemia may independently predict the likelihood of an abnormal stress test. Further validation of this model on an external dataset is necessary.

Abstract 359: Lack Of Blood Pressure Augmentation During Stress Testing Is Associated With Increased Mortality.

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Geoffrey D’Cruz ◽  
Ashish Rastogi ◽  
Neil Yager ◽  
Amarinder Bindra ◽  
Steven A Fein ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Chest Pain ◽  
Stress Echocardiography ◽  
Stress Testing ◽  
Systolic Function ◽  
Stress Test ◽  
Care Center ◽  
Tertiary Care ◽  
History Of ◽  
Response To Exercise

Objective: We investigated long-term outcomes associated with hypertensive response to exercise in patients with chest pain referred for stress echocardiography. Methods: Records of 404 patients with normal baseline LV systolic function (45% females, mean age 60+/-11 years, baseline SBP 136+/-20 mmHg, 26% with CAD, 4% with CHF, 39% with hypertension, 13% with diabetes mellitus, 5% with peripheral vascular disease, 21% with history of smoking or active smoking, 43% on beta-blockers, 23% on ACE-inhibitors/ARBs) referred for chest pain evaluation with stress echocardiography at a single tertiary care center were reviewed. Demographics, clinical data, and outcomes were collected. Median length of followup was 35+/-0.3 months. Patients were divided into four groups depending on their maximum blood pressure during exercise (greater or less than 180mmHg) and whether they achieved their age-adjusted target heart rate. Results: Contrary to the expectations, hypertensive response to exercise was not associated with the increased mortality (Table). Instead, lack of blood pressure augmentation during exercise and low double product were predictive of increased mortality. History of CHF (p=0.0003) and/or PVD (p=0.001) were the strongest predictors of failure to augment blood pressure during stress testing. Conclusions: Failure to augment systolic blood pressure during exercise appears to be associated with increased mortality. Although ischemia on echocardiography and reduced exercise capacity are the stress test outcomes traditionally associated with poor prognosis, failure to augment blood pressure during exercise may be an important predictor of mortality as well. Additional studies of this subject are needed.

Comparative Morbidity Profile of Elective vs Therapeutic Neck Dissection

2021 ◽  
pp. 019459982110089
Author(s):  
Quinn Dunlap ◽  
James Reed Gardner ◽  
Amanda Ederle ◽  
Deanne King ◽  
Maya Merriweather ◽  
...  
Keyword(s):  
Neck Dissection ◽  
Surgical Complications ◽  
Chart Review ◽  
Care Center ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Neck Surgery ◽  
Continuous Variables ◽  
Significant Difference ◽  
History Of

Objective Neck dissection (ND) is one of the most commonly performed procedures in head and neck surgery. We sought to compare the morbidity of elective ND (END) versus therapeutic ND (TND). Study Design Retrospective chart review. Setting Academic tertiary care center. Methods Retrospective chart review of 373 NDs performed from January 2015 to December 2018. Patients with radical ND or inadequate chart documentation were excluded. Demographics, clinicopathologic data, complications, and sacrificed structures during ND were retrieved. Statistical analysis was performed with χ2 and analysis of variance for comparison of categorical and continuous variables, respectively, with statistical alpha set a 0.05. Results Patients examined consisted of 224 males (60%) with a mean age of 60 years. TND accounted for 79% (n = 296) as compared with 21% (n = 77) for END. Other than a significantly higher history of radiation (37% vs 7%, P < .001) and endocrine pathology (34% vs 2.6%, P < .001) in the TND group, no significant differences in demographics were found between the therapeutic and elective groups. A significantly higher rate of structure sacrifice and extranodal extension within the TND group was noted to hold in overall and subgroup comparisons. No significant difference in rate of surgical complications was appreciated between groups in overall or subgroup analysis. Conclusion While the significantly higher rate of structure sacrifice among the TND population represents an increased morbidity profile in these patients, no significant difference was found in the rate of surgical complications between groups. The significant difference seen between groups regarding history of radiation and endocrine pathology likely represents selection bias.

scholarly journals Clinical judgement in chest pain: a case report 

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Mishita Goel ◽  
Shubhkarman Dhillon ◽  
Sarwan Kumar ◽  
Vesna Tegeltija
Keyword(s):  
Chest Pain ◽  
Coronary Artery ◽  
Tobacco Use ◽  
Stress Test ◽  
Artery Bypass ◽  
Pretest Probability ◽  
Clinical Judgement ◽  
Test Results ◽  
Cardiac Stress ◽  
History Of

Abstract Background Cardiac stress testing is a validated diagnostic tool to assess symptomatic patients with intermediate pretest probability of coronary artery disease (CAD). However, in some cases, the cardiac stress test may provide inconclusive results and the decision for further workup typically depends on the clinical judgement of the physician. These decisions can greatly affect patient outcomes. Case presentation We present an interesting case of a 54-year-old Caucasian male with history of tobacco use and gastroesophageal reflux disease (GERD) who presented with atypical chest pain. He had an asymptomatic electrocardiogram (EKG) stress test with intermediate probability of ischemia. Further workup with coronary computed tomography angiography (CCTA) and cardiac catheterization revealed multivessel CAD requiring a bypass surgery. In this case, the patient only had a history of tobacco use but no other significant comorbidities. He was clinically stable during his hospital stay and his testing was anticipated to be negative. However to complete workup, cardiology recommended anatomical testing with CCTA given the indeterminate EKG stress test results but the results of significant stenosis were surprising with the patient eventually requiring coronary artery bypass grafting (CABG). Conclusion As a result of the availability of multiple noninvasive diagnostic tests with almost similar sensitivities for CAD, physicians often face this dilemma of choosing the right test for optimal evaluation of chest pain in patients with intermediate pretest probability of CAD. Optimal test selection requires an individualized patient approach. Our experience with this case emphasizes the role of history taking, clinical judgement, and the risk/benefit ratio in deciding further workup when faced with inconclusive stress test results. Physicians should have a lower threshold for further workup of patients with inconclusive or even negative stress test results because of the diagnostic limitations of the test. Instead, utilizing a different, anatomical test may be more valuable. Specifically, the case established the usefulness of CCTA in cases such as this where other CAD diagnostic testing is indeterminate.

Abstract 14721: Impact of Covid-19 on Cardiology Consultation in Tertiary Care Hospital of a Developing Country

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
ghufran adnan ◽  
Osman Faheem ◽  
Maria Khan ◽  
Pirbhat Shams ◽  
Jamshed Ali
Keyword(s):  
Emergency Department ◽  
Tertiary Care ◽  
Reduction Rate ◽  
Care Hospital ◽  
Chi Square ◽  
Coronary Syndrome ◽  
Significant Difference ◽  
Drastic Increase ◽  
Chi Square Test ◽  
The Difference

Introduction: COVID-19 pandemic has overwhelmed the healthcare system of Pakistan. There has been observation regarding changes in pattern of patient presentation to emergency department (ED) for all diseases particularly cardiovascular. The aim of the study is to investigate these changes in cardiology consultations and compare pre-COVID-19 and COVID-19 era. Hypothesis: There is a significant difference in cardiology consultations during COVID era as compared to non-COVID era. Method: We collected data retrospectively of consecutive patients who visited emergency department (ED) during March-April 2019 (non-COVID era) and March-April 2020 (COVID era). Comparison has been made to quantify the differences in clinical characteristics, locality, admission, type, number, and reason of Cardiology consults generated. Results: We calculated the difference of 1351 patients between COVID and non-COVID era in terms of cardiology consults generated from Emergency department, using Chi-square test. Out of which 880 (59%) are male with mean age of 61(SD=15). Analysis shows pronounced augmentation in number of comorbidities [Hypertension(6%), Chronic kidney disease (6%), Diabetes (5%)] but there was 36% drop in total cardiology consultations and 43% reduction rate in patient’s ED visit from other cities during COVID era. There was 60% decrease in acute coronary syndrome presentation in COVID era, but fortuitously drastic increase (30%) in type II myocardial injury has been noted. Conclusion: There is a remarkable decline observed in patients presenting with cardiac manifestations during COVID era. Lack in timely care could have a pernicious impact on outcomes, global health care organizations should issue directions to adopt telemedicine services in underprivileged areas to provide timely care to cardiac patients.

Oral paracetamol versus zolmitriptan to treat acute migraine attack in the emergency department

2021 ◽  
Keyword(s):  
Emergency Department ◽  
Rating Scale ◽  
Rescue Therapy ◽  
Tertiary Care ◽  
Numeric Rating Scale ◽  
Controlled Study ◽  
Care Hospital ◽  
Acute Migraine ◽  
Pain Scores ◽  
Significant Difference

Background: Treatment provided in an emergency department is aimed at alleviating pain immediately with minimized adverse effects as well as warding off further migraine attacks. The primary aim of this article is to compare the effectiveness of oral paracetamol versus zolmitriptan in treating acute migraine attacks. Methods: This prospective, randomized, and controlled study was carried out at a tertiary care hospital visited by 95,000 patients annually. The study recruited 200 participants who were randomized into two groups. One group received 1000 mg paracetamol while the other group received 2.5 mg zolmitriptan orally. Baseline pain scores were recorded using the Visual Analogue Scale (VAS) and Numeric Rating Scale (NRS) at 15, 30 and at 60 min following administration of the study drugs. Patients requiring further treatment were provided fentanyl at a dosage of 1 µg/kg as a rescue therapy. Results: A significant decrease was evident in VAS and NRS scores following the administration of the study drugs in both groups (P < 0.001). The change in VAS pain scores after 15, 30 and 60 min was calculated as 17.0 ± 13.9, 41.2 ± 16.3 and 61.2 ± 17.5 mm, respectively, in the paracetamol group and 14.2 ± 11.7, 39.2 ± 17.9 and 59.2± 19.3 mm, respectively, in the zolmitriptan group, which did not indicate significant differences (P = 0.103, P = 0.425, P = 0.483, respectively). Likewise, NRS pain scores showed a downward trend in line with VAS pain scores and did not yield a significant difference (P = 0.422). No significant difference concerning rescue therapy was noted between the two groups (P = 0.596). Conclusion: Oral paracetamol and zolmitriptan prove to be similarly effective and have low incidence of acute side effects in treating acute migraine cases without aura.

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 ◽  
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.

scholarly journals Chest Pain and Exercise Induced Ischemia with Angiographically Insignificant Coronary Arterial Disease: Clinical Presentation and Follow-Up

1970 ◽  
Vol 6 (1) ◽  
pp. 27-31
Author(s):  
Md Khurshed Ahmed ◽  
Mohammad Salman ◽  
Md Ashraf Uddin Sultan ◽  
Md Abu Siddique ◽  
KMHS Sirajul Haque ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cardiovascular Risk ◽  
Chest Pain ◽  
Stress Test ◽  
Exercise Stress Test ◽  
Exercise Stress ◽  
Coronary Angiogram ◽  
Ecg Changes ◽  
History Of

Angiography of patients with typical chest pain reveals normal epicardial coronary arteries in about 15-20%. ECG changes suggestive of myocardial ischemia during exercise also can be demonstrated in this subset of the patients. Total 58 patients (42 females) with mean age 42±7 years who were undergoing coronary angiogram in the Department of Cardiology, University Cardiac Center, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from January 2005 to December 2009 were evaluated. The patients were recruited on the basis of presence of history of chest pain, with normal resting ECG and ischemia like ECG changes during exercise stress test. 32.8% patients had hypertension and 15.5% were diabetics, 19.0% had dyslipidemia and 6.9% had family history of ischemic heart disease. All the patients were having positive exercise stress test. Angiographic findings showed luminal irregularities in 29.3% patients, 15.5% patients had luminal stenosis less than 30% and rest had normal coronary angiogram. Follow up of the patients after one and six months of angiogram was done. After one month 63.8% patients remained symptomatic and after six months 63.3% patients remained symptomatic despite maximum medical management. The pathophysiology and appropriate management of this subset of the patients still remained a challenge for physicians. Optimum management of cardiovascular risk factors is very important issue in this group of patients.Key words: Angiography; Epicardial coronary arteries; Exercise stress test; Cardiovascular risk factors. DOI: 10.3329/uhj.v6i1.7187University Heart Journal Vol.6(1) 2010 pp.27-31

scholarly journals Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome

CJEM ◽  
2010 ◽  
Vol 12 (02) ◽  
pp. 128-134 ◽  
Author(s):  
Erik P. Hess ◽  
Jeffrey J. Perry ◽  
Pam Ladouceur ◽  
George A. Wells ◽  
Ian G. Stiell
Keyword(s):  
Heart Failure ◽  
Emergency Department ◽  
Congestive Heart Failure ◽  
Chest Pain ◽  
Chest Radiography ◽  
Clinical Decision ◽  
Chest Radiographs ◽  
Clinical Decision Rule ◽  
Coronary Syndrome ◽  
History Of

ABSTRACTObjective:We derived a clinical decision rule to determine which emergency department (ED) patients with chest pain and possible acute coronary syndrome (ACS) require chest radiography.Methods:We prospectively enrolled patients over 24 years of age with a primary complaint of chest pain and possible ACS over a 6-month period. Emergency physicians completed standardized clinical assessments and ordered chest radiographs as appropriate. Two blinded investigators independently classified chest radiographs as “normal,” “abnormal not requiring intervention” and “abnormal requiring intervention,” based on review of the radiology report and the medical record. The primary outcome was abnormality of chest radiographs requiring acute intervention. Analyses included interrater reliability assessment (with κ statistics), univariate analyses and recursive partitioning.Results:We enrolled 529 patients during the study period between Jul. 1, 2007, and Dec. 31, 2007. Patients had a mean age of 59.9 years, 60.3% were male, 4.0% had a history of congestive heart failure and 21.9% had a history of acute myocardial infarction. Only 2.1% (95% confidence interval [CI] 1.1%–3.8%) of patients had radiographic abnormality of the chest requiring acute intervention. The κ statistic for chest radiograph classification was 0.81 (95% CI 0.66–0.95). We derived the following rule: patients can forgo chest radiography if they have no history of congestive heart failure, no history of smoking and no abnormalities on lung auscultation. The rule was 100% sensitive (95% CI 32.0%–10.4%) and 36.1% specific (95% CI 32.0%–40.4%).Conclusion:This rule has potential to reduce health care costs and enhance ED patient flow. It requires validation in an independent patient population before introduction into clinical practice.

scholarly journals A study of the prevalence of gestational diabetes mellitus and its maternal and fetal outcomes in a tertiary care hospital

2017 ◽  
Vol 6 (9) ◽  
pp. 4011 ◽  
Author(s):  
Manisha R. Gandhewar ◽  
Binti R. Bhatiyani ◽  
Priyanka Singh ◽  
Pradip R. Gaikwad
Keyword(s):  
Diabetes Mellitus ◽  
Birth Weight ◽  
Gestational Diabetes ◽  
Gestational Diabetes Mellitus ◽  
Tertiary Care ◽  
Significant Risk ◽  
Care Hospital ◽  
Family History Of Diabetes ◽  
Significant Difference ◽  
History Of

Background: The aim of this study was to study the prevalence of gestational diabetes mellitus (GDM) using Diabetes in Pregnancy Study group India (DIPSI) criteria to diagnose patients with GDM and to study the maternal and neonatal outcomes.Methods: 500 patients attending the antenatal clinic between January 2013 to September 2014 with singleton pregnancies between 24 and 28 weeks of gestation were evaluated by administering 75g glucose in a nonfasting state and diagnosing GDM if the 2-hour plasma glucose was more than 140 mg/ dl. Women with multiple pregnancies, pre-existing diabetes mellitus, cardiac or renal disease were excluded from the study.Results: 31 women were diagnosed with GDM (prevalence 6.2%). The prevalence of risk factors such as age more than 25, obesity, family history of Diabetes Mellitus, history of GDM or birth weight more than 4.5kg in previous pregnancy and history of perinatal loss were associated with a statistically significant risk of developing GDM. Though the incidence of Gestational hypertension, polyhydramnios and postpartum haemorrhage was higher in the GDM group, it did not reach statistical significance. More women in the GDM group were delivered by LSCS. There was no significant difference in the incidence of SGA or preterm delivery in the groups. The mean birth weight in GDM group was higher than in the non GDM group.Conclusions: Early detection helps in preventing both maternal and fetal complications. This method of screening is convenient to women as it does not require them to be fasting.

scholarly journals Chest Pain in Emergency Department Patients: If the Pain is Relieved by Nitroglycerin, is it More Likely to be Cardiac Chest Pain?

CJEM ◽  
2006 ◽  
Vol 8 (03) ◽  
pp. 164-169 ◽  
Author(s):  
Robert Steele ◽  
Timothy McNaughton ◽  
Melissa McConahy ◽  
John Lam
Keyword(s):  
Coronary Artery Disease ◽  
Emergency Department ◽  
Chest Pain ◽  
Coronary Artery ◽  
Diagnostic Test ◽  
Tertiary Care ◽  
Positive Likelihood Ratio ◽  
Care Hospital ◽  
Artery Disease

ABSTRACT Introduction: It is often believed that chest pain relieved by nitroglycerin is indicative of coronary artery disease origin. Objective: To determine if relief of chest pain with nitroglycerin can be used as a diagnostic test to help differentiate cardiac chest pain and non-cardiac chest pain. Design: Prospective observational cohort study with a 4-week follow-up of patients enrolled. Setting: Academic tertiary care hospital, with 60 000 visits/year. Inclusion criteria: Adult patients presenting to the emergency department with active chest pain who received nitroglycerin and were admitted for chest pain. Exclusion criteria: Patients with acute myocardial infarction diagnosed after obtaining an ECG, patients whose chest pain could not be quantified, those for whom no cardiac work-up was done, or those who received emergent cardiac catheterization. Results: 270 patients were enrolled. Nitroglycerin relieved chest pain in 66% of the subjects. The diagnostic sensitivity of nitroglycerin to determine cardiac chest pain was 72% (64%–80%), and the specificity was 37% (34%–41%). The positive likelihood ratio for having coronary artery disease if nitroglycerin relieved chest pain was 1.1 (0.96–1.34). Telephone follow-up at 4 weeks was performed, with a 95% follow-up rate. Conclusions: Relief of chest pain with nitroglycerin is not a reliable diagnostic test and does not distinguish between cardiac and non-cardiac chest pain.

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