Effect of a Triage‐Based Screening Protocol on Diagnosis and Treatment of Acute Coronary Syndrome in a Tanzanian Emergency Department: A Prospective Pre‐Post Study

Background Evidence suggests that acute coronary syndrome (ACS) is underdiagnosed in sub‐Saharan Africa. Triage‐based interventions have improved ACS diagnosis and management in high‐income settings but have not been evaluated in sub‐Saharan African emergency departments (EDs). Our objective was to estimate the effect of a triage‐based screening protocol on ACS diagnosis and care in a Tanzanian ED. Methods and Results All adults presenting to a Tanzanian ED with chest pain or shortness of breath were prospectively enrolled. Treatments and clinician‐documented diagnoses were observed and recorded. In the preintervention phase (August 2018 through January 2019), ACS testing and treatment were dictated by physician discretion, as per usual care. A triage‐based protocol was then introduced, and in the postintervention phase (January 2019 through October 2019), research assistants performed ECG and point‐of‐care troponin I testing on all patients with chest pain or shortness of breath upon ED arrival. Pre‐post analyses compared ACS care between phases. Of 1020 total participants (339 preintervention phase, 681 postintervention phase), mean (SD) age was 58.9 (19.4) years. Six (1.8%) preintervention participants were diagnosed with ACS, versus 83 (12.2%) postintervention participants (odds ratio [OR], 7.51; 95% CI, 3.52–19.7; P <0.001). Among all participants, 3 (0.9%) preintervention participants received aspirin, compared with 50 (7.3%) postintervention participants (OR, 8.45; 95% CI, 3.07–36.13; P <0.001). Conclusions Introduction of a triage‐based ACS screening protocol in a Tanzanian ED was associated with significant increases in ACS diagnoses and aspirin administration. Additional research is needed to determine the effect of ED‐based interventions on ACS care and clinical end points in sub‐Saharan Africa.

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Assessing the Performance of a Novel Point-of-Care Qualitative Assay for Early Diagnosis of Acute Coronary Syndrome

Cardiology ◽

10.1159/000511435 ◽

2020 ◽

pp. 1-8

Author(s):

Ronny Alcalai ◽

Boris Varshisky ◽

Ahmad Marhig ◽

David Leibowitz ◽

Larissa Kogan-Boguslavsky ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Diagnostic Accuracy ◽

Diagnostic Performance ◽

Troponin I ◽

Point Of Care ◽

Final Diagnosis ◽

Cardiac Biomarkers ◽

Fatty Acid Binding ◽

Coronary Syndrome

Background: Early and accurate diagnosis of acute coronary syndrome (ACS) is essential for initiating lifesaving interventions. In this article, the diagnostic performance of a novel point-of-care rapid assay (SensAheart©) is analyzed. This assay qualitatively determines the presence of 2 cardiac biomarkers troponin I and heart-type fatty acid-binding protein that are present soon after onset of myocardial injury. Methods: We conducted a prospective observational study of consecutive patients who presented to the emergency department with typical chest pain. Simultaneous high-sensitive cardiac troponin T (hs-cTnT) and SensAheart testing was performed upon hospital admission. Diagnostic accuracy was computed using SensAheart or hs-cTnT levels versus the final diagnosis defined as positive/negative. Results: Of 225 patients analyzed, a final diagnosis of ACS was established in 138 patients, 87 individuals diagnosed with nonischemic chest pain. In the overall population, as compared to hs-cTnT, the sensitivity of the initial SensAheart assay was significantly higher (80.4 vs. 63.8%, p = 0.002) whereas specificity was lower (78.6 vs. 95.4%, p = 0.036). The overall diagnostic accuracy of SensAheart assay was similar to the hs-cTnT (82.7% compared to 76.0%, p = 0.08). Conclusions: Upon first medical contact, the novel point-of-care rapid SensAheart assay shows a diagnostic performance similar to hs-cTnT. The combination of 2 cardiac biomarkers in the same kit allows for very early detection of myocardial damage. The SensAheart assay is a reliable and practical tool for ruling-in the diagnosis of ACS.

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Provider-perceived barriers to diagnosis and treatment of acute coronary syndrome in Tanzania: a qualitative study

International Health ◽

10.1093/inthealth/ihz061 ◽

2019 ◽

Vol 12 (2) ◽

pp. 148-154 ◽

Cited By ~ 2

Author(s):

Julian T Hertz ◽

Godfrey L Kweka ◽

Preeti Manavalan ◽

Melissa H Watt ◽

Francis M Sakita

Keyword(s):

Acute Coronary Syndrome ◽

Healthcare Providers ◽

Care Patient ◽

Cost Of Care ◽

Sub Saharan Africa ◽

Coronary Syndrome ◽

Provider Perspectives ◽

Northern Tanzania ◽

Sub Saharan ◽

Clinical Officers

Abstract Background The incidence of acute coronary syndrome (ACS) is growing across sub-Saharan Africa and many healthcare systems are ill-equipped for this growing burden. Evidence suggests that healthcare providers may be underdiagnosing and undertreating ACS, leading to poor health outcomes. The goal of this study was to examine provider perspectives on barriers to ACS care in Tanzania in order to identify opportunities for interventions to improve care. Methods Semistructured in-depth interviews were conducted with physicians and clinical officers from emergency departments and outpatient departments in northern Tanzania. Thematic analysis was conducted using an iterative cycle of coding and consensus building. Results The 11 participants included six physicians and five clinical officers from health centers, community hospitals and one referral hospital. Providers identified barriers related to providers, systems and patients. Provider-related barriers included inadequate training regarding ACS and poor application of textbook-based knowledge. System-related barriers included lack of diagnostic equipment, unavailability of treatments, referral system delays, lack of data regarding disease burden, absence of locally relevant guidelines and cost of care. Patient-related barriers included inadequate ACS knowledge, inappropriate healthcare-seeking behavior and non-adherence. Conclusions This study identified actionable barriers to ACS care in northern Tanzania. Multifaceted interventions are urgently needed to improve care.

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Study of Cardiac Troponin I level in Acute Coronary Syndrome and its correlation with Left Ventricular Systolic Function

Cardiovascular Journal ◽

10.3329/cardio.v12i1.43415 ◽

2019 ◽

Vol 12 (1) ◽

pp. 24-29

Author(s):

Mohammad Jakir Hossain ◽

Khondoker Asaduzzaman ◽

Solaiman Hossain ◽

Muhammad Badrul Alam ◽

Nur Hossain

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Cardiac Troponin ◽

Troponin I ◽

Systolic Function ◽

Left Ventricular ◽

Cardiac Troponin I ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Coronary Syndrome

Background: In the diagnosis of acute coronary syndrome, cardiac troponin I is highly reliable and widely available biomarker. Serum level of cardiac troponin I is related to amount of myocardial damage and also closely relates to infarct size. Our aim of the study is to find out the relationship between cardiac troponin I and left ventricular systolic function after acute coronary syndrome. Methods: Total of 132 acute coronary syndrome patients were included in this study after admission in coronary care unit of Sir Salimullah Medical College, Mitford Hospital. Troponin I level was measured at admission and left ventricular ejection fraction (LVEF) was measured by echocardiography between 12-48 hours of onset of chest pain. Results: There was negative correlation between Troponin I at 12 to 48 hours of chest pain with LVEF in these study patients. With a cutoff value of troponin I e”6.8 ng/ml in STEMI patients there is a significant negative relation between 12 to 48 hrs troponin I and LVEF (p<0.001). Sensitivity of troponin I e” 6.8 ng/ml between 12 to 48 hours of chest pain in predicting LVEF <50% in STEMI was 93.75% and specificity was 77.78%. In NSTEMI sensitivity of troponin I e” 4.5 ng/ml between 12 to 48 hours of chest pain in predicting LVEF <50% was 65% and specificity was 54.05%. Conclusion: Serum troponin I level had a strong negative correlation with left ventricular ejection fraction after acute coronary syndrome and hence can be used to predict the LVEF in this setting. Cardiovasc. j. 2019; 12(1): 24-29

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Fitting a Square Peg in a Round Hole: A Simple Case of Chest Pain

Clinical Practice and Cases in Emergency Medicine ◽

10.5811/cpcem.2019.10.44141 ◽

2020 ◽

Vol 4 (1) ◽

pp. 1-7

Author(s):

Mary McLean ◽

Jennifer Beck-Esmay

Keyword(s):

Risk Factors ◽

Chest Pain ◽

Young Women ◽

Point Of Care ◽

Round Hole ◽

Shortness Of Breath ◽

Cardiac Enzymes ◽

Coronary Syndrome ◽

St Elevation ◽

Atherosclerotic Risk Factors

A 39-year-old female presents to the emergency department with chest pain and shortness of breath. Her electrocardiogram suggests ST-elevation myocardial infarction, but she has no atherosclerotic risk factors. She is gravida 4, para 4, and four weeks postpartum from uncomplicated vaginal delivery. She is diaphoretic and anxious, but otherwise her exam is unremarkable. Cardiac enzymes are markedly elevated and point-of-care echocardiogram shows inferolateral hypokinesis and ejection fraction of 50%. In this clinicopathological case, we explore a classically underappreciated cause of acute coronary syndrome in healthy young women.

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The association between Point-of-Care testing of Troponin and the management of patients with chest pain suspected of acute coronary syndrome: a systematic review protocol

The JBI Database of Systematic Reviews and Implementation Reports ◽

10.11124/jbisrir-2014-1521 ◽

2014 ◽

Vol 12 (3) ◽

pp. 99-112 ◽

Cited By ~ 2

Author(s):

Fen Li ◽

Robyn Clark ◽

Vincent Versace ◽

Peter Newman

Keyword(s):

Systematic Review ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Point Of Care ◽

Systematic Review Protocol ◽

Point Of Care Testing ◽

Coronary Syndrome ◽

Review Protocol

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P4689Comparison of high-sensitivity troponin T (hs-TnT) and high-sensitivity troponin I (hs-TnI) in the exclusion of acute coronary syndrome in patients with chest pain in the emergency department

European Heart Journal ◽

10.1093/eurheartj/ehx504.p4689 ◽

2017 ◽

Vol 38 (suppl_1) ◽

Author(s):

H.J.G. Tan ◽

S.H. Lim ◽

T.S.J. Chua ◽

A.S.L. Wong ◽

A.O. Sahlen ◽

...

Keyword(s):

Emergency Department ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Troponin I ◽

Troponin T ◽

High Sensitivity ◽

Coronary Syndrome ◽

High Sensitivity Troponin ◽

High Sensitivity Troponin T

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Acute Coronary Syndromes in Sub‐Saharan Africa: A 10‐Year Systematic Review

Journal of the American Heart Association ◽

10.1161/jaha.120.021107 ◽

2021 ◽

Author(s):

Hermann Yao ◽

Arnaud Ekou ◽

Thierry Niamkey ◽

Sandra Hounhoui Gan ◽

Isabelle Kouamé ◽

...

Keyword(s):

South Africa ◽

Systematic Review ◽

Acute Coronary Syndrome ◽

Cote D'ivoire ◽

Côte D’Ivoire ◽

Sub Saharan Africa ◽

Cote D’Ivoire ◽

Coronary Syndrome ◽

Côte D'ivoire ◽

Sub Saharan

Background Data in the literature on acute coronary syndrome in sub‐Saharan Africa are scarce. Methods and Results We conducted a systematic review of the MEDLINE (PubMed) database of observational studies of acute coronary syndrome in sub‐Saharan Africa from January 1, 2010 to June 30, 2020. Acute coronary syndrome was defined according to current definitions. Abstracts and then the full texts of the selected articles were independently screened by 2 blinded investigators. This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses standards. We identified 784 articles with our research strategy, and 27 were taken into account for the final analysis. Ten studies report a prevalence of acute coronary syndrome among patients admitted for cardiovascular disease ranging from 0.21% to 22.3%. Patients were younger, with a minimum age of 52 years in South Africa and Djibouti. There was a significant male predominance. Hypertension was the main risk factor (50%–55% of cases). Time to admission tended to be long, with the longest times in Tanzania (6.6 days) and Burkina Faso (4.3 days). Very few patients were admitted by medicalized transport, particularly in Côte d'Ivoire (only 34% including 8% by emergency medical service). The clinical presentation is dominated by ST–elevation sudden cardiac arrest. Percutaneous coronary intervention is not widely available but was performed in South Africa, Kenya, Côte d'Ivoire, Sudan, and Mauritania. Fibrinolysis was the most accessible means of revascularization, with streptokinase as the molecule of choice. Hospital mortality was highly variable between 1.2% and 24.5% depending on the study populations and the revascularization procedures performed. Mortality at follow‐up varied from 7.8% to 43.3%. Some studies identified factors predictive of mortality. Conclusions The significant disparities in our results underscore the need for a multicenter registry for acute coronary syndrome in sub‐Saharan Africa in order to develop consensus‐based strategies, propose and evaluate tailored interventions, and identify prognostic factors.

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Long-Term Experience With an Accelerated Protocol for Diagnosis of Chest Pain

Archives of Pathology & Laboratory Medicine ◽

10.5858/2000-124-1434-ltewaa ◽

2000 ◽

Vol 124 (10) ◽

pp. 1434-1439

Author(s):

Timothy E. Caragher ◽

Balbino B. Fernandez ◽

Lawrence A. Barr

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Troponin I ◽

Cost Savings ◽

Test Group ◽

Control Group ◽

Coronary Syndrome ◽

Diagnostic Sensitivity And Specificity ◽

Group B ◽

Accelerated Protocol

Abstract Context.—More than 6 million patients present annually with chest pain suggestive of acute coronary syndrome. Rapid and accurate diagnosis is essential for best clinical outcomes, for optimal management of hospital resources, and for minimizing medicolegal exposure. Objective.—To evaluate the clinical and cost outcomes of an accelerated protocol for chest pain triage in a community-based hospital of moderate size. Methods.—One hundred successive patients with chest pain were diagnosed according to the Traditional Chest Pain Protocol, which included testing of serial blood samples for creatine kinase (CK)-MB and total CK. These patients were also subjected to the Accelerated Chest Pain Protocol under evaluation, which included testing at shortened intervals for myoglobin and cardiac troponin I in addition to CK and CK-MB. Diagnostic sensitivity and specificity were compared versus the final assigned diagnosis. The Accelerated Chest Pain Protocol was implemented for routine use. Follow-up evaluations were conducted at 1 month (test group A, N = 180) and 22 months (test group B, N = 180). Costs for diagnosis and treatment of the 2 test groups were compared with those for the control group. Results.—The 2 protocols had equivalent specificity values (99%). The sensitivity of the Accelerated Chest Pain Protocol was higher than that of the Traditional Chest Pain Protocol (95% vs 58%). Cost savings of 29% and a reduction in length of stay of 33% were achieved in test group B versus the control group. Conclusions.—The Accelerated Chest Pain Protocol improved the accuracy and timeliness of diagnosis of acute coronary syndrome while reducing costs.

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