The Unusual Presentation of Acute Pericarditis Mimicking Acute Coronary Syndrome

Pericarditis is a common disorder that might present in various settings, including primary-care and emergency department. However, the clinical features in some cases did not match with the written theory, which could lead to a misdiagnosis. A 46-year-old man presented to the emergency room with progressive tightness chest pain, epigastric pain, nausea, and vomiting in the past 2 days. Based on the clinical, electrocardiograph (ECG), and laboratory evaluation, the patient was diagnosed with unstable angina pectoris and treated accordingly but did not showed an improvement. Clinical re-examination and echocardiography evaluation showed a pathognomonic finding of pericarditis feature. Combination therapy of colchicine and ibuprofen was given for 3 weeks. One-month follow-up evaluation showed normal ECG and echocardiography result without any remaining symptoms. Acute pericarditis does not always show typical finding. Therefore, clinician must always aware with other differential diagnosis of chest pain and ECG variation of acute pericarditis.

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Abstract 12162: Association of Symptom Clusters With Mode of Transportation to Emergency Department in Patients Diagnosed With Acute Coronary Syndrome

Circulation ◽

10.1161/circ.132.suppl_3.12162 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Leslie L Davis ◽

Thomas P McCoy ◽

Barbara Riegel ◽

Sharon McKinley ◽

Lynn Doering ◽

...

Keyword(s):

Emergency Department ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Delay Time ◽

Symptom Clusters ◽

Prehospital Delay ◽

Coronary Syndrome ◽

Stress Symptoms ◽

Mode Of Transportation

Background: Prompt treatment of acute coronary syndrome (ACS) has been shown to reduce mortality and morbidity; yet many patients delay seeking care. In order to receive timely care, symptoms of ACS need to be recognized, interpreted, and acted upon. Patients who experience symptoms matching their expectations and those with correct symptom attribution are more likely to use emergency medical services (EMS) as a means of transportation to the hospital. The connection between symptom type and EMS use has not been fully explored. Purpose: To assess if clusters of presenting symptoms are associated with EMS transportation to the emergency department (ED) in patients with ACS and to evaluate if EMS transportation or symptom clusters are associated with prehospital delay time. Methods: A secondary analysis was conducted from the PROMOTION trial, a randomized controlled trial to reduce patient prehospital delay in ACS. Results: Of the 3,522 subjects with coronary artery disease enrolled, 3,087 completed 2-year follow-up. Of these, 331 subjects visited an ED for ACS symptoms during follow-up. Among the 331, 84% (278) had mode of transportation documented; 44% arrived by EMS. Having classic ACS symptoms (chest pain, pressure, or discomfort) in combination with pain symptoms (AOR=2.66, p = 0.011), classic ACS symptoms in combination with stress symptoms (AOR=2.61, p = 0.007) or classic ACS symptoms in combination with both pain and stress symptoms (AOR=3.90, p = 0.012) were associated with higher odds of arriving to the ED by EMS compared to classic ACS symptoms alone. Among 260 patients with prehospital delay time available, arriving by EMS decreased median delay time by 68.5 minutes compared to those with other transportation, after accounting for symptom clusters, patient and study characteristics (p = 0.002). Symptom clusters did not predict delay time in adjusted modeling (p = 0.952). Conclusion: While chest pain was the most prevalent symptom of ACS for most (85%), these findings suggest that it is the cluster of classic ACS symptoms with other types of symptom that motivate patients to use EMS. With less than half of patients using EMS, further research is needed to better understand how symptom clusters influence care-seeking behavior.

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Rationale and design of a cohort study evaluating triage of acute chest pain in out-of-hours primary care in the Netherlands (TRACE)

Primary Health Care Research & Development ◽

10.1017/s1463423620000122 ◽

2020 ◽

Vol 21 ◽

Author(s):

Amy Manten ◽

Cuny J.J. Cuijpers ◽

Remco Rietveld ◽

Emma Groot ◽

Freek van de Graaf ◽

...

Keyword(s):

Primary Care ◽

Cohort Study ◽

Chest Pain ◽

The Netherlands ◽

Clinical Outcomes ◽

Acute Chest Pain ◽

Urgent Care ◽

Triage System ◽

Out Of Hours ◽

Coronary Syndrome

Abstract The aims of this study are (1) to evaluate the performance of current triage for chest pain; (2) to describe the case mix of patients undergoing triage for chest pain; and (3) to identify opportunities to improve performance of current Dutch triage system for chest pain. Chest pain is a common symptom, and identifying patients with chest pain that require urgent care can be quite challenging. Making the correct assessment is even harder during telephone triage. Temporal trends show that the referral threshold has lowered over time, resulting in overcrowding of first responders and emergency services. While various stakeholders advocate for a more efficient triage system, careful evaluation of the performance of the current triage in primary care is lacking. TRiage of Acute Chest pain Evaluation in primary care (TRACE) is a large cohort study designed to describe the current Dutch triage system for chest pain and subsequently evaluate triage performance in regard to clinical outcomes. The study consists of consecutive patients who contacted the out-of-hours primary care facility with chest pain in the region of Alkmaar, the Netherlands, in 2017, with follow-up for clinical outcomes out to August 2019. The primary outcome of interest is ‘major event’, which is defined as the occurrence of death from any cause, acute coronary syndrome, urgent coronary revascularization, or other high-risk diagnoses in which delay is inadmissible and hospitalization is necessary. We will evaluate the performance of the triage system by assessing the ability of the triage system to correctly classify patients regarding urgency (accuracy), the proportion of safe actions following triage (safety) as well as rightfully deployed ambulances (efficacy). TRACE is designed to describe the current Dutch triage system for chest pain in primary care and to subsequently evaluate triage performance in regard to clinical outcomes.

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Systematic review and modeling of the investigation of acute and chronic chest pain presenting in primary care

International Journal of Technology Assessment in Health Care ◽

10.1017/s0266462305280194 ◽

2005 ◽

Vol 21 (1) ◽

pp. 148-149

Author(s):

J. Mant ◽

R. J. McManus ◽

R. A. L. Oakes ◽

B. C. Delaney ◽

P. M. Barton ◽

...

Keyword(s):

Myocardial Infarction ◽

Systematic Review ◽

Primary Care ◽

Acute Myocardial Infarction ◽

Chest Pain ◽

Early Management ◽

Coronary Syndrome ◽

Pain Clinics ◽

Exertional Angina ◽

Suspected Acute Myocardial Infarction

Objectives: The objectives were to ascertain the value of a range of methods—including clinical features, resting and exercise electrocardiography, and rapid access chest pain clinics (RACPCs)—used in the diagnosis and early management of acute coronary syndrome (ACS), suspected acute myocardial infarction (MI), and exertional angina.

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Abstract 2004: Usefulness of Coronary CT Angiography in the Early Triage of Patients with Acute Chest Pain

Circulation ◽

10.1161/circ.118.suppl_18.s_655-a ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Udo Hoffmann ◽

Fabian Bamberg ◽

Claudia U Chae ◽

Ian S Rogers ◽

Sujith K Seneviratne ◽

...

Keyword(s):

Chest Pain ◽

Hospital Admission ◽

Acute Chest Pain ◽

Coronary Plaque ◽

Discriminatory Power ◽

Coronary Cta ◽

Coronary Syndrome ◽

Coronary Ct ◽

Increased Risk

Background: Early triage of patients with acute chest pain in the emergency department (ED) may be improved by rapid noninvasive assessment of coronary artery disease (CAD) by coronary computed tomography angiography (CTA). We sought to determine the usefulness of coronary CTA for the early triage of patients with acute chest pain but an inconclusive initial ED evaluation. Methods: Single center, double-blinded observational cohort study in the ED of a large tertiary academic hospital enrolling 368 consecutive patients with acute chest pain and inconclusive initial ED evaluation (normal initial troponin and an initial ECG without evidence of myocardial ischemia) who were awaiting hospital admission between May 2005 and May 2007. All patients underwent 64-slice contrast-enhanced coronary CTA prior to hospital admission with caregivers and patients blinded to the results of the examination. Diagnostic accuracy and discriminatory power of coronary CTA findings (coronary plaque and stenosis [>50% luminal narrowing]) for acute coronary syndrome (ACS) during index hospitalization and major adverse cardiac events (MACE) during 6- month follow-up. Results: Among 368 patients (mean age 53±12 years, 61% male) 31 (8%) developed ACS but no MACE occurred during follow-up. Fifty percent (n=183) of the study population had neither plaque nor stenosis, a finding which had 100% negative predictive value (95% confidence interval [CI]: 98 to 100%) for ACS. In adjusted analysis, the extent of coronary plaque and presence of stenosis were associated with an increased risk for ACS (OR: 1.28, 95% CI: 1.14 to 1.43 and OR: 11.69, 95% CI: 4.4 to 31.0; respectively). Coronary CT findings (no CAD, plaque but no stenosis, and stenosis) discriminated patients at low, intermediate, or high risk of ACS (OR: 8.65, 95% CI: 3.69 to 20.26; AUC: 0.91). Conclusion : Half of the patients with acute chest pain and low to intermediate likelihood of ACS have no CAD and may be safely discharged directly from the ED. Coronary CT has excellent discriminatory power in defining patient risk for ACS.

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Abstract 13550: Understanding Associations of Hospital Admission or Observation With Patient Outcomes After Emergency Department Evaluation for Suspected Acute Coronary Syndrome

Circulation ◽

10.1161/circ.142.suppl_3.13550 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Adam L Sharp ◽

Aniket A Kawatkar ◽

Aileen S Baecker ◽

Rita F Redberg ◽

Mingsum Lee ◽

...

Keyword(s):

Health Care ◽

Emergency Department ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Hospital Admission ◽

Risk Reduction ◽

Patient Outcomes ◽

Coronary Revascularization ◽

Coronary Syndrome

Introduction: Evaluation for suspected acute coronary syndrome (ACS) results in millions of emergency department (ED) visits annually, and accounts for billions in health care costs. Understanding the benefits of hospitalization among patients who ruled out for an acute myocardial infarction (AMI) will inform physician decision making and future health care policies. Hypothesis: Hospital admission does not improve 30-day patient outcomes (death/AMI) compared to those discharged after ED evaluation for suspected ACS. Methods: We compared the effectiveness of hospitalization vs outpatient follow-up for a cohort of patients with chest pain presenting to one of 13 EDs within the Kaiser Permanente Southern California region between January 1, 2015 and December 1, 2017. The primary outcome was AMI or all-cause mortality, and secondary outcomes included revascularization and a composite MACE outcome within 30-days of ED visit. Adjusting for patient age, gender, race, ACS risk factors and chronic co-morbidities an instrumental variable (IV) analysis was used to evaluate the effect of hospitalization on patient outcomes Results: Of 77,562 chest pain patient encounters not identified as an AMI during the ED encounter, 322 (0.4%) went on to have an AMI (n=193, 0.2%) or died (n=137, 0.2%) within 30-days of ED visit (1.5% admitted vs 0.2% discharged). This included 200 (0.3%) patients who underwent coronary revascularization (0.7% admitted vs 0.2% discharged). IV analysis found no adjusted differences in 30-day patient outcomes between the hospitalized cohort and those discharged (risk reduction 0.002, 95% CI -0.002 to 0.007). Similarly, there were no differences in coronary revascularization (risk reduction 0.003, 95% CI -0.002 to 0.007). Conclusions: Among ED patients with chest pain who are not identified with an AMI, there does not appear to be a benefit in 30-day outcomes for patients who are hospitalized compared to those discharged with outpatient follow-up.

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The role of primary care physician and cardiologist follow-up for low-risk patients with chest pain after emergency department assessment

American Heart Journal ◽

10.1016/j.ahj.2014.05.016 ◽

2014 ◽

Vol 168 (3) ◽

pp. 289-295 ◽

Cited By ~ 14

Author(s):

Andrew Czarnecki ◽

Julie T. Wang ◽

Jack V. Tu ◽

Douglas S. Lee ◽

Michael J. Schull ◽

...

Keyword(s):

Primary Care ◽

Emergency Department ◽

Chest Pain ◽

Primary Care Physician ◽

Care Physician ◽

Low Risk ◽

Risk Patients

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3298Prehospital assessment of the one-hour rule-in/rule-out algorithm using a high-sensitivity cardiac troponin t assay in a low-prevalence population for acute coronary syndrome (OUT-ACS)

European Heart Journal ◽

10.1093/eurheartj/ehz745.0062 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

T R Johannessen ◽

D Atar ◽

S Halvorsen ◽

A C Larstorp ◽

I Mdala ◽

...

Keyword(s):

Primary Care ◽

Chest Pain ◽

Predictive Value ◽

Cardiac Troponin ◽

Troponin T ◽

High Sensitivity ◽

Cardiac Troponin T ◽

Emergency Setting ◽

Coronary Syndrome ◽

Rule Out

Abstract Background The majority of patients with chest pain in Norway initially present to the primary health care system, which serves to triage them to the specialist health care services including hospitals. In some emergency primary care institutions, patients who are not hospitalised directly undergo further diagnostic testing to rule out acute myocardial infarction (AMI). Purpose Several studies have shown the advantage of using high-sensitivity assays for fast interpretation of cardiac troponins. The majority of these studies included patient populations from hospital emergency departments. In contrast, we aimed to investigate whether the 1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) is safe and useful for implementation in a primary care emergency setting where the patients have a much lower pre-test probability for an acute coronary syndrome. Methods In this prospective cohort study, we included 1672 patients with acute non-specific chest pain from November 2016 to October 2018 at a primary care emergency outpatient clinic in Norway. Serial hs-cTnT samples were analysed after 0, 1 and 4 hours on the Cobas 8000 e602 analyzer. We divided the results into one of three groups (rule-out, rule-in, or further observation), according to the 0/1-hour algorithm for hs-cTn from the current ESC guidelines on non-ST-elevation myocardial infarction. In the rule-out group, the 0/1-hour results were compared to the standard 4-hour hs-cTnT. Final hospital diagnoses were collected as a gold standard for the patients in the rule-in group. Results A total of 44 (2.6%) of 1672 patients were diagnosed with AMI. By applying the algorithm, 1274 (76.2%) patients were assigned to the rule-out group. One of the rule-out patients had a significant increase in hs-cTnT in the 4-hour sample. This results in a sensitivity for AMI of 97.7% (95% confidence interval [CI] 88.0–99.9) and negative predictive value of 99.9% (95% CI 99.6–100.0). There were 50 (3.0%) patients in the rule-in group, amongst whom 35 had a verified AMI. This gives a specificity for AMI of 99.1% (95% CI 98.5–99.5) and a positive predictive value at 70.0% (95% CI 55.4–82.1). Among the 348 (20.8%) patients assigned to further observation, eight patients had an AMI. The 15 rule-in patients who did not have an AMI, had other acute illnesses that required further diagnostic work-up at the hospital. Conclusions With a negative predictive value at 99.9%, the 1-hour algorithm for hs-cTnT seems safe and applicable for a faster assessment of patients with non-specific chest pain in a primary care emergency setting. Prehospital implementation of this algorithm may reduce the need for hospitalisation of these patients and hence may probably lower the costs. ClinicalTrial.gov identifier: NCT02983123 Acknowledgement/Funding Norwegian Research Fund for General Practice, The Norwegian Physicians' Association Fund for Quality Improvement and Patient Safety

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Insurance Coverage, and Having a Regular Provider, and Utilization of Cancer Follow-up and Noncancer Health Care Among Childhood Cancer Survivors

INQUIRY The Journal of Health Care Organization Provision and Financing ◽

10.1177/0046958018817996 ◽

2019 ◽

Vol 56 ◽

pp. 004695801881799 ◽

Cited By ~ 2

Author(s):

Michael R. Cousineau ◽

Sue E. Kim ◽

Ann S. Hamilton ◽

Kimberly A. Miller ◽

Joel Milam

Keyword(s):

Primary Care ◽

Los Angeles ◽

Cancer Survivors ◽

Childhood Cancer ◽

Private Insurance ◽

Insurance Coverage ◽

Childhood Cancer Survivors ◽

Primary Care Visit ◽

The Past

The objective of this study was to assess the role of health insurance coverage on patterns of health care utilization and access to cancer-related follow-up and non-cancer care among childhood cancer survivors (CCS). Cross-sectional survey design was used. Childhood cancer survivors were from 2 large hospitals in Los Angeles County. In all, 235 were identified through the Los Angeles Cancer Surveillance Program, diagnosed between the ages of 5 and 18 in 2000-2007 with any cancer type except Hodgkin lymphoma. At data collection in 2009-2010, participants were between 15 and 25 years old. Study exposure was health insurance coverage (private, public, and uninsured). Main outcomes and measures were respondents’ regular source of care for cancer follow-up, noncancer care, and both; and having a cancer follow-up visit, primary care visit, and hospital emergency department visit in the past 2 years. Compared with those with private insurance, the uninsured were less likely to have a regular source for cancer follow-up (odds ratio [OR] = 4.3, 95% confidence interval [CI] = 1.9-9.4), less likely to have a source for noncancer care (OR = 3.3, 95% CI 1.6-6.9), and less likely to have a source of care for both (OR = 5.3, 95% CI = 2.1-13.5). Furthermore, uninsured CCS were less likely to have made visits to cancer specialists (OR = 4.5, 95% CI = 2.1-9.50) and were less likely to have seen a primary care physician in the past 2 years (OR = 3.9, 95% CI = 1.8-8.2). In addition, those with public (vs private) insurance were less likely to have a regular provider for primary care (OR = 2.5, 95% CI = 1.1-5.4) and less likely to have made a primary care visit in the past year (OR = 2.8, 95% CI = 2.1-13.5). Uninsured CCS are at risk of not obtaining cancer follow-up care, and those with public (vs. private) insurance have less access to primary care. Policies that ensure continuity of coverage for survivors as they age into adulthood may result in fewer barriers to needed care, which may lead to fewer health problems for CCS in the future.

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Nursing Team Training to Use a Flowchart to Care for Patients with Chest Pain

International Archives of Medicine ◽

10.3823/2632 ◽

2021 ◽

Vol 14 ◽

Author(s):

Bruna Carolina Lima ◽

Regimar Carla Machado ◽

Ana Lúcia Gargione Galvão Sant`Anna ◽

Rosângela Claudia Novembre ◽

Victoria Dorneles Nery ◽

...

Keyword(s):

Chest Pain ◽

Emergency Care ◽

Professional Training ◽

Small Sample ◽

Coronary Syndrome ◽

High Prevalence ◽

Nursing Team ◽

Prior Application ◽

Emergency Care Units

Background: chest pain, of multicausal etiology, associated with a cardiac cause or not, is one of the most frequently presented symptoms by patients in Emergency Care Units. Despite its high prevalence in health services, there is still a deficiency in care standardization, which raises difficulties in acute coronary syndrome diagnosis and delay in treatment. The objective was to assess the efficiency of professional training of nursing teams in Emergency Care Units on the use of a flowchart to care for patients with chest pain. Methods and Findings: this educational intervention study was conducted with 25 nursing team professionals. It has been developed in four steps: Step 1 referred to prior application of the validated research instrument. Step 2 comprised training to use the flowchart with an expository lesson on care of patients with chest pain and guidance regarding the flowchart to be implemented. Step 3 reapplied the validated instrument after class. Step 4 reapplied the instrument after 2 months of training for flowchart implementation. When comparing the results of the instrument applied to nursing team professionals, post-training and follow-up performance surpassed that of pre-training. It was observed that professionals with less than five years of experience showed better performance. This study had as limitation the small sample of health professionals participating in the offered training. Conclusion: training was satisfactory and significant, and professionals demonstrated content assimilation, obtaining higher scores than at the beginning of the research.

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Complement component 7 is associated with total- and cardiac death in chest-pain patients with suspected acute coronary syndrome

BMC Cardiovascular Disorders ◽

10.1186/s12872-021-02306-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Reidun Aarsetøy ◽

Thor Ueland ◽

Pål Aukrust ◽

Annika E. Michelsen ◽

Ricardo Leon de la Fuente ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Cardiac Death ◽

Complement Component ◽

Coronary Syndrome ◽

Norwegian Population ◽

All Cause Mortality ◽

Total Death ◽

Pain Patients

Abstract Background Complement activation has been associated with atherosclerosis, atherosclerotic plaque destabilization and increased risk of cardiovascular events. Complement component 7 (CC7) binds to the C5bC6 complex which is part of the terminal complement complex (TCC/C5b-9). High-sensitivity C-reactive protein (hsCRP) is a sensitive marker of systemic inflammation and may reflect the increased inflammatory state associated with cardiovascular disease. Aim To evaluate the associations between CC7 and total- and cardiac mortality in patients hospitalized with chest-pain of suspected coronary origin, and whether combining CC7 with hsCRP adds prognostic information. Methods Baseline levels of CC7 were related to 60-months survival in a prospective, observational study of 982 patients hospitalized with a suspected acute coronary syndrome (ACS) at 9 hospitals in Salta, Argentina. A cox regression model, adjusting for conventional cardiovascular risk factors, was fitted with all-cause mortality, cardiac death and sudden cardiac death (SCD) as the dependent variables. A similar Norwegian population of 871 patients was applied to test the reproducibility of results in relation to total death. Results At follow-up, 173 patients (17.7%) in the Argentinean cohort had died, of these 92 (9.4%) were classified as cardiac death and 59 (6.0%) as SCD. In the Norwegian population, a total of 254 patients (30%) died. In multivariable analysis, CC7 was significantly associated with 60-months all-cause mortality [hazard ratio (HR) 1.26 (95% confidence interval (CI), 1.07–1.47) and cardiac death [HR 1.28 (95% CI 1.02–1.60)], but not with SCD. CC7 was only weakly correlated with hsCRP (r = 0.10, p = 0.002), and there was no statistically significant interaction between the two biomarkers in relation to outcome. The significant association of CC7 with total death was reproduced in the Norwegian population. Conclusions CC7 was significantly associated with all-cause mortality and cardiac death at 60-months follow-up in chest-pain patients with suspected ACS. Clinical trial registration ClinicalTrials.gov Identifier: NCT01377402, NCT00521976.

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