Pericarditis masking a localised thoracic aorta dissection: Making a point for point-of-care ultrasound

Early detection of aortic dissection (AD) remains essential due to high mortality rates. We report a case of localised thoracic AD initially misdiagnosed as pericarditis, but subsequently diagnosed through point-of-care ultrasound (POCUS). A 35-year-old gentleman presented with sudden-onset jaw and chest pain. An initial electrocardiogram revealed changes consistent with pericarditis, and high-sensitive troponin levels on admission were not raised. An initial diagnosis of pericarditis was made. However, due to persistent symptoms despite treatment, an urgent POCUS was performed, revealing a prominently dilated aortic root, with evidence of an intimal flap near the coronary cusps. Computed tomography imaging revealed a focal aortic root dissection confined within the sinus of Valsalva, with no involvement of coronary arteries or descending thoracic or abdominal aorta. This case highlights how commonly a misdiagnosis of AD can occur and how concurrent pericarditis can often mask AD. Our report highlights the need for better incorporation of POCUS in the initial assessment of acute chest pain, as studies have shown both high sensitivity and specificity in diagnosing AD, with no additional burden on treatment start-up time and mortality.

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Faculty Opinions recommendation of High-sensitivity troponin T concentrations in acute chest pain patients evaluated with cardiac computed tomography.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.2811956.2477054 ◽

2010 ◽

Author(s):

Christopher de Filippi ◽

Puneet Gandotra

Keyword(s):

Computed Tomography ◽

Chest Pain ◽

Troponin T ◽

Cardiac Computed Tomography ◽

Acute Chest Pain ◽

High Sensitivity ◽

High Sensitivity Troponin ◽

High Sensitivity Troponin T ◽

Pain Patients

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Adding stress biomarkers to high sensitivity troponin measurements increases precision and efficacy of rapid rule out protocols for NSTEMI

European Heart Journal ◽

10.1093/ehjci/ehaa946.1698 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

I Restan ◽

O.T Steiro ◽

H.L Tjora ◽

J Langoergen ◽

T Omland ◽

...

Keyword(s):

Chest Pain ◽

Acute Chest Pain ◽

High Sensitivity ◽

Final Diagnosis ◽

Public Institution ◽

P Value ◽

Funding Source ◽

University Hospitals ◽

High Sensitivity Troponin ◽

Rule Out

Abstract Background NSTEMI may be ruled out in patients presenting with acute chest pain based on low baseline high sensitivity troponin (cTn) at admission. This procedure is limited by a low expected frequency of ruled out non-cardiac chest pain (NCCP) patients. Purpose To investigate if stress-induced biomarkers (glucose or copeptin) combined with cTn can increase the rate of NCCP ruled out without an unacceptable increase in incorrectly ruled out NSTEMI. Method 971 patients with suspected NSTE-ACS were included. Final diagnosis was adjudicated by two independent cardiologists using clinical data including routine cTnT. Additionally, baseline cTnI, cTnI from Singulex Clarity System (cTnI(sgx)), copeptin and glucose were measured. Diagnostic performance to rule out NSTEMI was compared between the ESC rule out algorithms for cTnT and cTnI(Abbott), a local cTnI(sgx) algorithm and different combinations of cTn with copeptin or glucose Results Median age 61 years, 60% male. 13% had NSTEMI, 12% had UAP and 60% NCCP. Distribution of copeptin and glucose concentrations (NSTEMI and NCCP) is shown in figure 1. Copeptin and cTnT produces an algorithm with lower miss rate for NSTEMI, increased rule out rate for NCCP and significantly higher AUC (DeLong test, p value <0.001) compared to the ESC algorithm (Table 1). cTnI(sgx) and copeptin showed higher rule out for NCCP and higher AUC (p value <0.001), however an increased rule out rate for NSTEMIs. Combining cTnI(Abbott) and glucose gave a similar miss rate for NSTEMI as ESC, but increased rule out rate for NCCP and higher AUC (p value <0.001). Conclusion Combining cTnT or cTnI(sgx) with copeptin; or cTnI with glucose, improves diagnostic precision and efficacy of rule out protocols for NSTEMI in patients presenting with acute chest pain. Figure 1 Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Western Norway Regional Health Authority; Haukeland and Stavanger University Hospitals

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Integrating point-of-care ultrasound in the ED evaluation of patients presenting with chest pain and shortness of breath

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2018.10.059 ◽

2019 ◽

Vol 37 (2) ◽

pp. 298-303 ◽

Cited By ~ 10

Author(s):

Rasha E. Buhumaid ◽

Julie St-Cyr Bourque ◽

Hamid Shokoohi ◽

Irene W.Y. Ma ◽

Mckenna Longacre ◽

...

Keyword(s):

Chest Pain ◽

Point Of Care ◽

Point Of Care Ultrasound ◽

Shortness Of Breath

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The Accuracy of Point-of-Care Ultrasound in Detecting Small Bowel Obstruction in Emergency Department

Emergency Medicine International ◽

10.1155/2018/3684081 ◽

2018 ◽

Vol 2018 ◽

pp. 1-5 ◽

Cited By ~ 9

Author(s):

A. Pourmand ◽

U. Dimbil ◽

A. Drake ◽

H. Shokoohi

Keyword(s):

Small Bowel ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Imaging Modality ◽

Point Of Care ◽

High Sensitivity ◽

Point Of Care Ultrasound ◽

Emergency Physicians ◽

Short Term ◽

Intestinal Peristalsis

Radiological imaging plays an essential role in the evaluation of a patient with suspected small bowel obstruction (SBO). In a few studies, point-of-care ultrasound (POCUS) has been utilized as a primary imaging modality in patients with suspected SBO. POCUS has been shown to be an accurate tool in the diagnosis of SBO with multiple research studies noting a consistent high sensitivity with a range of 94–100% and specificity of 81–100%. Specific sonographic findings that increase the likelihood of SBO include dilatation of small bowel loops > 25 mm, altered intestinal peristalsis, increased thickness of the bowel wall, and intraperitoneal fluid accumulation. Studies also reported that emergency physicians could apply this technique with limited and short-term ultrasound training. In this article, we aim to review the sensitivity and specificity of ultrasound examinations performed by emergency physicians in patients with suspected SBO.

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P2674Rapid rule-out of myocardial infarction with a novel high precision point-of-care troponin assay appears safe and effective

European Heart Journal ◽

10.1093/eurheartj/ehz748.0992 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

S Aldous ◽

J Pickering ◽

J Young ◽

P George ◽

A Watson ◽

...

Keyword(s):

Myocardial Infarction ◽

Decision Making ◽

Emergency Department ◽

Chest Pain ◽

High Precision ◽

Primary Outcome ◽

Point Of Care ◽

High Sensitivity ◽

Research Fellowship ◽

Rule Out

Abstract Background High sensitivity troponin assays were developed to improve analytical sensitivity and precision at the decision cut-points for the diagnosis and rule out of acute myocardial infarction (AMI). Central laboratory assays have achieved this but point of care assays, which have the ability to accelerate decision making due to much shorter turnaround times, have remained lacking. Purpose To ascertain the threshold for decision making and subsequent clinical utility for ruling out AMI on presentation in patients attending the emergency department acutely with chest pain, using a high precision point of care troponin assay (TnI Nx), (i-STAT, Abbott). Methods We measured arrival TnI-Nx concentrations in stored plasma samples in adults presenting acutely to the emergency department with chest pain. The primary outcome was an AMI or cardiac death on index admission or within 30 days. We used 2000 bootstrapped data sets to derive and validate a suitable threshold for TnI-Nx before calculating diagnostic test performance. We pre-specified this threshold must have a <1% false negative rate for the primary outcome. We compared this with a core laboratory high sensitivity troponin I (hs-TnI) (Abbott Architect) using the early rule-out cut-point (European Society of Cardiology) at the limit of detection (2 ng/L). Results We recruited 1320 patients of whom 192 (14.1%) had the primary outcome. The TnI-Nx threshold was determined to be 8 ng/L with subsequent sensitivity of 99.0% (95% confidence interval: 97.3% to 100%), negative predictive value of 99.7% (99.2% to 100%) and specificity of 59.0% (56.0% to 62.0%). The hs-TnI had a sensitivity of 99.5% (98.2% to 100%), negative predictive value of 99.7% (99.0% to 100%), and specificity of 28.4% (25.8% to 31.2%) at 2ng/L. Conclusion A high precision point of care assay, TnI-Nx, with a decision threshold of 8ng/L, has comparable rule out performance compared with a core laboratory high sensitivity assay and therefore could potentially be used for early decision making in the assessment of acute chest pain. Acknowledgement/Funding Research grant from Abbott Point of Care. Senior Research Fellowship from ECF, CMRF and CDHB. Clinical Research Fellowship from NZ HRC

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Usefulness of high-sensitivity troponin T for the evaluation of patients with acute chest pain and no or minimal myocardial damage

American Heart Journal ◽

10.1016/j.ahj.2012.05.015 ◽

2012 ◽

Vol 164 (2) ◽

pp. 194-200.e1 ◽

Cited By ~ 24

Author(s):

Juan Sanchis ◽

Alfredo Bardají ◽

Xavier Bosch ◽

Pablo Loma-Osorio ◽

Francisco Marín ◽

...

Keyword(s):

Chest Pain ◽

Troponin T ◽

Acute Chest Pain ◽

Myocardial Damage ◽

High Sensitivity ◽

High Sensitivity Troponin ◽

High Sensitivity Troponin T

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High-sensitivity troponin assays in the evaluation of patients with acute chest pain in the emergency department

Clinical Chemistry and Laboratory Medicine (CCLM) ◽

10.1515/cclm.2011.695 ◽

2011 ◽

Vol 49 (12) ◽

Cited By ~ 15

Author(s):

Michael Christ ◽

Thomas Bertsch ◽

Steffen Popp ◽

Philipp Bahrmann ◽

Hans-Jürgen Heppner ◽

...

Keyword(s):

Emergency Department ◽

Chest Pain ◽

Emergency Physician ◽

Acute Chest Pain ◽

High Sensitivity ◽

Clinical Work ◽

Life Threatening ◽

Acute Mi ◽

Minor Disease ◽

Pain Patients

AbstractEvaluating patients with acute chest pain presenting to the emergency department remains an ongoing challenge. The spectrum of etiologies in acute chest pain ranges from minor disease entities to life-threatening diseases, such as pulmonary embolism, acute aortic dissection or acute myocardial infarction (MI). The diagnosis of acute MI is usually made integrating the triad of patient history and clinical presentation, readings of 12-lead ECG and measurement of cardiac troponins (cTn). Introduction of high-sensitivity cTn assays substantially increases sensitivity to identify patients with acute MI even at the time of presentation to the emergency department at the cost of specificity. However, the proportion of patients presenting with cTn positive, non-vascular cardiac chest pain triples with the implementation of new sensitive cTn assays increasing the difficulty for the emergency physician to identify those patients who are at need for invasive diagnostics. The main objectives of this mini-review are 1) to discuss elements of disposition decision made by the emergency physician for the evaluation of chest pain patients, 2) to summarize recent advances in assay technology and relate these findings into the clinical context, and 3) to discuss possible consequences for the clinical work and suggest an algorithm for the clinical evaluation of chest pain patients in the emergency department.

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