Abstract 236: Triaging Young Patients With Acs in the Ed - A Case Report

Introduction: Cardiovascular Disease (CVD) is the leading cause of death in the United States. According to the Centers for Disease Control and Prevention (CDC), one person dies every 37 seconds from complications of CVD. One of the main complication of CVD is acute coronary syndrome (ACS) which includes unstable angina as well as an acute myocardial infarction (AMI). 1 More than 790,000 Americans have an AMI annually, of which 73% are first-time AMIs. 2 These events generally affect older people, with an average age of 65.6 years for men and 72 years for women. Furthermore, only 0.3% of men and women under the age of 39 will have an AMI. 3,4 As a result, it is often overlooked among this population in the acute care setting. We present the case of a young man with a delayed diagnosis of ACS despite typical presentation and EKG findings. Case presentation: A 27 year old male presented after three days of progressive substernal chest pain at rest. ECG revealed anterolateral ST elevations, but “No STEMI” was noted on the EKG and a troponin was not drawn for 4 hours. While the ED did not have a specific diagnosis in mind, they did not believe such a young person likely had ACS and originally ‘misread’ the EKG. Triage to PCI did not occur until troponin returned positive later that afternoon, more than 8 hours after initial presentation. Cardiac angiography showed a complete occlusion of the mid LAD requiring a single DES. Post-procedure ECG showed persistent anterolateral ST elevation raising concern for future complications in part due to delayed triage. Discussion: The delayed presentation and triage of this patient warrants discussion. While there is a lack of data on door to balloon time based on age for ACS patients, it appears extremely likely that this diagnosis was missed, despite EKG findings and typical chest pain, in part due to age related bias. This case raises concern that providers are hesitant to diagnosis ACS in young patients due to its low prevalence in this population and warrants further study on steps that can be taken to decrease missed ACS diagnoses and the resultant suboptimal medical outcomes that may follow.

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Chest pain and chest pain units

10.1093/med/9780199687039.003.0008_update_001 ◽

2018 ◽

Author(s):

Eric Durand ◽

Aurès Chaib ◽

Etienne Puymirat ◽

Nicolas Danchin

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Acute Coronary Syndromes ◽

Acute Chest Pain ◽

The United States ◽

Cardiac Biomarkers ◽

Coronary Syndrome ◽

Cardiology Department ◽

Coronary Syndromes ◽

Rule Out

Patients presenting at the emergency department with acute chest pain and suspected to represent an acute coronary syndrome were classically admitted as routine to the cardiology department, resulting in expensive and time-consuming evaluations. However, 2-5% of patients with acute coronary syndromes were discharged home inappropriately, resulting in increased mortality. To address the inability to exclude the diagnosis of acute coronary syndrome, chest pain units were developed, particularly in the United States. These provide an environment where serial electrocardiograms, cardiac biomarkers, and provocative testing can be performed to confirm or rule out an acute coronary syndrome. Eligible candidates include the majority of patients with non-diagnostic electrocardiograms. The results have been impressive; chest pain units have markedly reduced adverse events, while simultaneously increasing the rate of safe discharge by 36%. Despite evidence to suggest that care in chest pain units is more effective for such patients, the percentage of emergency or cardiology departments setting up chest pain units remains low in Europe.

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Chest pain and chest pain units

10.1093/med/9780199687039.003.0008 ◽

2015 ◽

Author(s):

Eric Durand ◽

Aures Chaib ◽

Nicolas Danchin

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Acute Coronary Syndromes ◽

Acute Chest Pain ◽

The United States ◽

Cardiac Biomarkers ◽

Coronary Syndrome ◽

Cardiology Department ◽

Coronary Syndromes ◽

Rule Out

Patients presenting at the emergency department with acute chest pain and suspected to represent an acute coronary syndrome were classically admitted as routine to the cardiology department, resulting in expensive and time-consuming evaluations. However, 2-5% of patients with acute coronary syndromes were discharged home inappropriately, resulting in increased mortality. To address the inability to exclude the diagnosis of acute coronary syndrome, chest pain units were developed, particularly in the United States. These provided an environment where serial electrocardiograms, cardiac biomarkers, and provocative testing could be performed to rule out an acute coronary syndrome. Eligible candidates included the majority of patients with non-diagnostic electrocardiograms and normal troponin measurements. The results have been impressive; chest pain units have markedly reduced adverse events, while simultaneously increasing the rate of safe discharge by 36%. Despite evidence to suggest that care in chest pain units is more effective for such patients, the percentage of emergency or cardiology departments setting up chest pain units remains very low in Europe.

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Initial Appraisal of Acute Coronary Syndromes

Journal of Pharmacy Practice ◽

10.1177/0897190005280045 ◽

2005 ◽

Vol 18 (5) ◽

pp. 377-393

Author(s):

Roshanak Aazami

Keyword(s):

Emergency Department ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Risk Groups ◽

The United States ◽

Rapid Identification ◽

Emergency Department Care ◽

Coronary Syndrome ◽

Emergency Department Patients ◽

Pharmacologic Treatments

Acute coronary syndrome remains a daunting health care problem in the United States. One third of emergency department patients with chest pain will eventually have a diagnosis of acute coronary syndrome. During the past decade, there have been many advances in the treatment of acute coronary syndrome as well as a widespread movement in emergency medicine to streamline the process of its treatment. Goals of emergency department care include rapid identification of patients with acute myocardial infarction, exclusion of causes of nonischemic chest pain, stratification of patients with acute coronary ischemia into low-risk and high-risk groups, and initiation of pharmacologic treatments. These goals will be discussed in this review, with particular emphasis on pharmacologic treatments.

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Prognosis and follow-up of young patients admitted to a critical coronary care unit with acute coronary syndrome

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.069 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

DF Arroyo Monino ◽

C Barea Gonzalez ◽

MP Ruiz Garcia ◽

T Seoane Garcia ◽

JC Garcia Rubira

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Coronary Artery ◽

Hospital Mortality ◽

Coronary Care Unit ◽

Young Patients ◽

St Segment Elevation ◽

Coronary Syndrome ◽

Coronary Care

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The presence of young patients admitted to a Critical Coronary Care Unit (CCCU) with the diagnosis of Acute Coronary Syndrome (ACS) is very common nowadays. The prognosis of these patients seems to be better than the elderly ones, although there are few records that endorse this statement. Objective Our aim is to carry out a follow-up of this population and study their prognosis during the index hospitalization and the follo-up. Methods Retrospective, descriptive, unicentric and observational registry of young patients (<45 years old) admitted to one CCCU with the diagnosis of ACS between January 2.010 and November 2.020. The follow-up of these patients was performed using the electronic platform of Andalusian Health Security System. Results A total number of 252 patients were included in the registry, with a mean age of 40 years old, being male 206 (81,7%). The main reason of the admission was ACS with persistent ST segment elevation (STEMI) (177 patients – 70,2%). The most prevalent risk factor in this population was active smoking (198 patients – 78,6%). The main underlying mechanism of the ACS was the rupture of an atherosclerotic plaque (194 patients – 77%) and in most cases, there was only 1 coronary artery affected (153 patients – 60,7%). Intra-hospital mortality was low (2 patients died of cardiovascular cause – 0,8%, and 1 died of non-cardiovascular cause – 0,4%). Left ventricle ejection fraction (LVEF) at the discharge was preserved in 166 patients (65,9% - mean 58%), and reduced (<40%) in 37 patients (14,7%). The median of the follow-up was 77 months (minimum 1 month and maximum 132 months). A total number of 5 patients died during this follow-up (2%, 3 during the first year), 3 of them of cardiovascular cause; these 3 patients had reduced LVEF at the discharge. During this follow-up, 64 (25,4%) patients were re-admitted to the hospital due to cardiovascular causes, most of them (30 – 11,9%) with the diagnosis of chest pain and 20 of them (7,9%) with the diagnosis of a new ACS. Conclusions Young patients admitted to our CCCU with the diagnosis of ACS presented most frequently with STEMI, affecting predominantly one coronary artery. Most of them had preserved LVEF at the discharge. The prognosis of this group of patients is good, with a low intra-hospital mortality and during the follow-up, with clear relation with the presence of reduced LVEF at the discharge. Re-admission was relatively frequent, mostly due to chest pain.

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Do You Know How Young Your Heart Is?

ARS Medica Tomitana ◽

10.2478/arsm-2018-0012 ◽

2018 ◽

Vol 24 (2) ◽

pp. 66-71

Author(s):

Tase Cristina Ramona ◽

Cojocaru Lucia ◽

Rusali Andrei ◽

Suta Cristina

Keyword(s):

Risk Factors ◽

Myocardial Infarction ◽

Acute Coronary Syndrome ◽

Cardiovascular Risk ◽

Chest Pain ◽

Young Patients ◽

Good Clinical Outcome ◽

Know How ◽

Coronary Syndrome ◽

First Time

Abstract We present the case of a 25 years old patient who was submitted to our unit with a first time acute coronary syndrome. Despite his young age he had multiple cardiovascular risk factors. Although the chest pain was atypical and the electrocardiogram on presentation had unspecific changes, repeated investigations established the diagnosis of anterolateral myocardial infarction. Per primam angioplasty with stent implantation in the proximal segment of left anterior descending artery was performed, with good clinical outcome. Awareness is the key in establishing the diagnosis of myocardial infarction in young patients.

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Delayed Presentation of Acute Coronary Syndrome: A Challenge in its Early Management

Journal of Nepal Medical Association ◽

10.31729/jnma.173 ◽

2009 ◽

Vol 48 (173) ◽

Author(s):

Pramod Acharya ◽

RR Adhikari ◽

J Bhattarai ◽

NR Shrestha

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Care Center ◽

Tertiary Care ◽

Late Presentation ◽

Delayed Presentation ◽

Tertiary Care Center ◽

Early Management ◽

Coronary Syndrome ◽

District Hospitals

INTRODUCTION:The time of presentation of acute coronary syndrome from the onset of chest pain determines the treatment modality and prognosis. Delayed presentation is associated with a poor outcome. In the present study, we tried to find out the causes of late presentation of ACS in a tertiary care center in the eastern part of Nepal.METHODS:It was a cross-sectional descriptive study that included 100 consecutive patients with ACS presenting to our institute over a period of 8 months. They were studied for their demographic profile, delay in presentation, the management done at the local centers and their final diagnosis.RESULTS:We found that patients living within Dharan City reached BPKIHS within 20 hours of the onset of chest pain while those from outside the city who came directly reached within 63 hours. Other patients reached their respective local centers (health posts, district hospitals and private clinics) within 39 hours. The commonest cause of delay was vehicular problem followed by unnecessary delay at the local centers. The work up for chest pain was inadequate in these centers. Late presentation to our institute significantly affected the optimal management.CONCLUSIONS: We found that significant number of patients with ACS from eastern Nepal presented late in our tertiary care center. In order to improve ACS outcome in this region, we advise equipping the local centers with electrocardiogram machines, improvement in ambulance services and a greater emphasis on coronary artery disease awareness programs as well as initiating preventive measures.KEY WORDS:acute coronary syndrome, chest pain, delayed presentation, electrocardiogram

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Approach to the Patient Presenting with Chest Pain

10.2310/em.4074 ◽

2019 ◽

Author(s):

Elizabeth Temin

Keyword(s):

Emergency Department ◽

Chest Pain ◽

High Sensitivity ◽

Emergency Department Patient ◽

The United States ◽

Benign Condition ◽

Heart Score ◽

Coronary Syndrome ◽

Ct Angiogram ◽

Important Challenge

Caring for the emergency department patient with chest pain represents an important challenge to the emergency physician. Chest pain is the second most common presentation among all emergency department patients, accounting for approximately 6 million visits per year in the United States. Chest pain may represent a benign condition or a time-critical life threat; symptom overlap between benign and serious conditions can make an accurate chest pain diagnosis challenging. This review covers the pathophysiology, assessment, stabilization, diagnosis and treatment, and disposition and outcomes of chest pain. This review contains 1 figure, 25 tables, and 36 references. Key words: acute coronary syndrome, acute myocardial infarction, angina pectoris, chest pain, coronary artery disease, pulmonary embolism, high sensitivity troponin, HEART Score, EDAC score, cardiac CT Angiogram

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Impact of D-Dimers on the Differential Diagnosis of Acute Chest Pain: Current Aspects besides the Widely Known

Clinical Medicine Insights Cardiology ◽

10.4137/cmc.s15948 ◽

2014 ◽

Vol 8s2 ◽

pp. CMC.S15948 ◽

Cited By ~ 3

Author(s):

Kathrin Hahne ◽

Pia Lebiedz ◽

Frank Breuckmann

Keyword(s):

Acute Coronary Syndrome ◽

Differential Diagnosis ◽

Chest Pain ◽

Acute Chest Pain ◽

Cost Effective ◽

Coronary Syndrome ◽

Age Related ◽

Acute Aortic Syndromes ◽

High Negative Predictive Value ◽

D Dimer

D-dimers are cleavage products of fibrin that occur during plasmin-mediated fibrinolysis of blood clots. In the emergency department, D-dimer measurement represents a valuable and cost-effective tool in the differential diagnosis of acute chest pain including the main life-threatening entities: acute coronary syndrome, pulmonary embolism, and acute aortic syndrome. Whereas the diagnostic and prognostic values of D-dimer testing in acute coronary syndrome is of less priority, increases of D-dimers are frequently found in venous thromboembolism and acute aortic syndromes, especially acute aortic dissection. As to the high negative predictive value of D-dimer in those disorders, patients with low to intermediate pretest probability may profit in terms of less necessity of further non-invasive or even invasive imaging, simultaneously reducing potential complications and healthcare-related costs. However, because of the low specificity of the different D-dimer tests in contrast to its frequent usage, adequate interpretation is required. Age-related adjustment of D-dimer levels may be used to increase its diagnostic power.

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Ritka etiológiájú fiatalkori szívinfarktus

Orvosi Hetilap ◽

10.1556/650.2015.30161 ◽

2015 ◽

Vol 156 (25) ◽

pp. 1020-1025

Author(s):

Gábor Zoltán Nagy ◽

Gábor Gerges ◽

Kálmán Csapó ◽

Erika Csengő ◽

Károly Minik

Keyword(s):

Chest Pain ◽

Coronary Artery ◽

Aortic Dissection ◽

Young Patients ◽

Coronary Artery Occlusion ◽

Artery Occlusion ◽

Left Main ◽

Diagnostic Challenge ◽

Total Occlusion ◽

Coronary Syndrome

Chest pain is not uncommon among young patients below the age of 35 years, however, it is rarely caused by acute coronary syndrome. The rarity of coronary artery occlusion in this population can easily lead to diagnostic mistakes. The authors present the case history of a 19-year-old young female, who was admitted to the emergency department of a local hospital due to the sudden onset of chest pain and malaise. ST-segment elevation was seen on the electrocardiogram raising the possibility of aortic dissection, therefore, emergency thoracic computed tomographic scan was performed. This proved to be negative and the patient was transferred to the coronary care unit. Urgent coronarography was carried out, which revealed the total occlusion of the left main coronary artery. The occluded artery was successfully opened with percutaneous coronary intervention, but despite revascularisation the patient died on the second postoperative day due to asystole. Autopsy revealed thrombotic embolization of the left main artery with consequent extensive haemorrhagic necrosis, involving almost the whole left ventricle. The source of embolization was not found. The authors note that left coronary artery occlusion in young patients can be a diagnostic challenge, because symptoms can be mistaken with aortic dissection or pulmonary embolism. Orv. Hetil., 2015, 156(25), 1020–1025.

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A case report of an acute coronary syndrome in a 10-year-old boy with homozygous familial hypercholesterolaemia

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytz233 ◽

2020 ◽

Vol 4 (1) ◽

pp. 1-5

Author(s):

Thibault Leclercq ◽

Sylvie Falcon-Eicher ◽

Michel Farnier ◽

Emmanuel Le Bret ◽

Raphaëlle Maudinas ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Familial Hypercholesterolaemia ◽

Cardiac Computed Tomography ◽

Bypass Graft ◽

Young Patients ◽

Lipid Lowering ◽

Coronary Syndrome ◽

Clinical Diagnoses ◽

Homozygous Familial Hypercholesterolaemia ◽

Pain At Rest

Abstract Background Familial hypercholesterolaemia is a well-known disorder, but clinical diagnoses tend to be delayed. Acute coronary syndrome may occur in childhood. Case summary Our patient, a young boy with homozygous familial hypercholesterolaemia, complained of persistent chest pain at rest and suffered a non-ST-elevation myocardial infarction (NSTEMI). The diagnosis of NSTEMI was made on the basis of his clinical features, dynamic electrocardiogram changes, troponin elevation, and cardiac computed tomography findings. The patient was managed surgically by intrathoracic artery (ITA) bypass graft. During post-operative follow-up, the young patient suffered from angina pectoris from unexpected and exceptional atheroma stenosis on the ITA. Discussion Familial hypercholesterolaemia needs to be identified quickly in young patients and lipid lowering therapies should be started without delay.

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