chest pain – ABC CARDIOL

IJCS

Original Article

Acute Coronary Syndrome Patient Profile in Emergency Department: A cross-sectional study

Riza Fikriana et al. Al Afik Randy Eka Prasetya

Abstract

Background:

Acute Coronary Syndrome (ACS) remains one of the leading causes of high morbidity and mortality worldwide. Psychological factors are considered important contributors to increasing recurrence rates in patients.

Objective:

This study aimed to analyze the association between stress, chest pain complaints, electrocardiographic changes, and cardiac enzyme levels.

Methods:

A cross-sectional design was employed. A sample of 105 ACS patients presenting to the hospital emergency department was selected using an accidental sampling technique. Variables measured included stress scores, chest pain, electrocardiographic findings, troponin, and CK-MB levels. Data were analyzed using the Spearman rank test and linear regression, with a significance level set at p < 0.05.

Results:

Stress scores were significantly associated with chest pain (p < 0.001), electrocardiographic changes (p < 0.001), troponin levels (p < 0.001), and CK-MB levels (p < 0.001). ECG findings showed that most STEMI patients (68.9%) experienced severe pain. Linear regression analysis indicated that troponin and CK-MB levels were significantly influenced by chest pain (p < 0.001).

Conclusions:

Stress is positively correlated with chest pain in ACS patients and is reflected in ECG changes and elevated cardiac enzymes (troponin and CK-MB).

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Case Report

Exercise-Induced Bronchoconstriction: A Frequent, but Neglected Cause of Chest Pain

Renata Rodrigues Teixeira de Castro et al. João Giffoni Silveira Neto Adalgiza Mafra Moreno Marco Orsini

Introduction

Chest pain is one of the most common complaints in emergency departments, and internal medicine and cardiology clinics. Patients’ comorbidities and the clinical characterization of chest pain are cornerstones to guide symptom differentiation. Information about pain intensity, duration, localization, changes with posture/movement, and its reaction to nitroglycerin helps diagnose cardiac chest pain. Typical angina pectoris is the presence of substernal chest pain or discomfort provoked by exertion or emotional stress, and is relieved by rest and nitroglycerin. Angina pectoris is attributed to myocardial ischemia due to the unbalance between myocardial oxygen supply and myocardial oxygen demand elicited during exercise or emotional stress.

The diagnosis and treatment workup in patients with moderate to high cardiovascular risk presenting angina pectoris is quite straight-forward. Nevertheless, exertional chest pain in a young man can be challenging and yield a common but overlooked diagnosis, as in the present case report.

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Case Report

Takotsubo Cardiomyopathy and Myocardial Perfusion Image: Unusual Binomial in the Investigation of Acute Coronary Syndrome without Obstructive Lesions

Mathias Silvestre de Brida et al. Raphael Boesche Guimaraes Leonardo Rothlisberger Matheus Patricio

Introduction

Takotsubo cardiomyopathy (TC), also known as broken heart syndrome or stress-induced cardiomyopathy, was primarily described in Japan in 1990, is named after its morphological similarity to the vase used by Asian people to catch octopuses, which has a rounded bottom and a narrow bottleneck. This condition is characterized by transient left ventricular (LV) systolic dysfunction, commonly preceded by physical or emotional stress, mimicking the presentation of acute myocardial infarction. In the present article, we describe a case of TC focusing on its updated approach, highlighting the applicability of myocardial perfusion scintigraphy (MPS) in the acute phase of chest pain and presenting images rarely described in this scenario.

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IJCS

Original Article

How much do the Patients with Acute Myocardial Infarction Know about Chest Pain, Thrombolytic Therapy, and Other Factors Affecting the Treatment Time in the Emergency Room?

Banu Ozmen et al. Cenk Conkbayir Refika Hural Didem Melis Oztas … Murat Ugurlucan Barış Okcun Zerrin Yiğit

Abstract

Background:

Treatment time in the emergency room for acute myocardial infarction is very important and can be life-saving if one understands the importance of a patient’s chest pain.

Objetice:

The aim of this study is to evaluate how much patients entering the emergency room due to acute myocardial infection (AMI) know about chest pain and thrombolytic therapy.

Materials and Methods:

One hundred fifty patients (126 males,14 females) from three different institutes with complaints of chest pain were randomly chosen to participate in this study. The mean age of the patients was 55.4 ± 11.2 years (71+33). Patients were asked to fill out a questionnaire consisting of 70 questions within the first seven days. All differences in categorical variables were computed using the χ2-test and Fisher Exact test. A two-tailed hypothesis was used in all statistical evaluations, and p<0.05 was considered significant.

Results:

It was observed that 17% of the patients came to the hospital within the first 30 minutes; 18.3% of them came to the hospital between 30 minutes and 1 hour; 27.5% of them came to the hospital between 1 hour and 3 hours; and 21.4% of them came to the hospital more than 6 hours after symptoms began. It was also observed that 68% of the patients were not aware of the AMI, and 96% of them had no prior knowledge of antithrombolytic therapy.

Conclusion:

Because the majority of the patients did not have enough information about AMI, a training program should be implemented to ensure that people to come to the hospital earlier. (Int J Cardiovasc Sci. 2021; [online].ahead print, PP.0-0)

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Original Article

Risk Stratification in Chest Pain: Impact on the Diagnosis of Acute Coronary Syndrome

Ana Paula Paz Reis et al. Karen Brasil Ruschel Maria Antonieta P. de Moraes Karlyse Belli … Marco Lumertz Saffi Jaqueline Eilert Fagundes

Abstract

Background

The implementation of institutional protocols in the emergency department (ED) for risk stratification in patients with chest pain has been recommended.

Objective

To assess the sensitivity, specificity and predictive value of an institutional risk stratification protocol for chest pain suggestive of acute coronary syndrome (ACS).

Method

Cross-sectional study conducted based on the computerized records of patients treated with the use of a chest pain protocol adapted from the Manchester protocol. The level of risk was stratified by applying five colors representing the respective levels. Each color represents a level of severity and a maximum waiting time for receiving medical care. Red and orange were considered to be high priority, while patients with yellow, green or blue indications were considered to represent a low priority. To compare the type of diagnosis and the classification of priority for receiving care, the Pearson’s chi-square test was used, considering a significance level of p< 0.05 for all tests.

Results

The records of 1,074 patients admitted to the cardiology ED were analyzed. Men (54%), with a mean age of 60 ± 15 years, with complaints of chest pain (44%) of moderate intensity (80%) were predominant the study. Of these patients, 19% were classified as high priority, while 81% were considered to represent a low priority. ACS was confirmed in 23% of the patients, with 34% of them being classified as high priority and 66% as low priority. The sensitivity of the risk stratification protocol for chest pain was 33.7% and the specificity was 86.0%, with a positive and negative predictive value of 41.7% and 81.3%, respectively.

Conclusion

The Institutional risk stratification protocol for chest pain suggestive of ACS presented satisfactory specificity and a low degree of sensitivity. Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

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Case Report

The Association between Covid-19 and ST Elevation Myocardial Infarction: Variable Clinical Presentations on a Case Report Series

Vinicius Esteves et al. Cleverson Neves Zukowski Fabio Augusto de Luca Italo Bruno dos Santos Sousa … Bruno Santana Bandeira Angelina Camiletti Guilherme Arruda André Feldman Olga Ferreira de Souza

Introduction

The current global pandemic caused by the new coronavirus (COVID-19) already reaches 185 countries with approximately 3 million infected people and more than 200 thousand deaths.^, With continental dimensions and an elevated socioeconomic disparity, Brazil, by the beginning of May, presents with increasing infection rates and mortality close to 8%. The numbers may be higher considering the lack of adequate testing of the population and healthcare professionals.

According to the World Health Organization (WHO), cardiovascular diseases represent the leading cause of deaths around the world. . Recent reports confirmed that patients with cardiovascular comorbidities are at a higher risk to develop the most severe form of the COVID-19.^– The association between these two pathologies can lead to high morbidity and mortality rates and has been the object of continuous efforts by the medical community. In this sense the management of Acute Coronary Syndrome (ACS) has undergone changes in both diagnosis and treatment since the beginning of the pandemic.^– Another aggravating factor regarding the approach of ACS during this period is the multiple clinical presentations and differential diagnosis associated with COVID-19, such as myopericarditis, pulmonary embolism and arrhythmia.^–

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Viewpoint

Covid-19 and Safety in the Cath Lab: Where We Are and Where We Are Headed

Giordana Zeferino Mariano et al. Viviana Guzzo Lemke Maria Sanali Moura Paiva Gláucia Maria Moraes de Oliveira

Safety measures in the procedure preparation stage

A study conducted in China with 72,314 patients with COVID-19 (44,672 laboratory-confirmed cases, 16,186 suspected cases, and 10,567 clinically diagnosed cases) has reported fever, cough, dyspnea, myalgia, fatigue and diarrhea as the most common symptoms. Other signs and symptoms have been reported, such as sore throat, chest pain, mental confusion, and lethargy. The authors have highlighted that COVID-19 had a benign course in 80% of the cases, and that many patients, although asymptomatic, could carry the virus. It is worth noting the importance of the differential diagnosis of dyspnea and fatigue, especially when associated with the other symptoms.

During a respiratory pandemic, patients and their families should be informed about the risks of contamination, despite all additional measures taken to minimize them. Because the number of elective procedures will be drastically reduced during that period, the length of hospital stay is predicted to be the minimum necessary for each protocol consensually elaborated. Moreover, defining a procedure as elective requires clinical judgement, because postponing it might have effects that will increase the likelihood of decompensation and adverse events during the pandemic, such as in high-risk patients with unstable angina. Therefore, the decision about performing a procedure should be individualized and based on the patient’s risk and benefit analysis.

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Original Article

Correlation between Clinical and Educational Factors and Delayed Hospital Arrival in Myocardial Infarction

Andressa Sardá Maiochi Takagui et al. Daniel Medeiros Moreira Ana Teresa Glaser Carvalho Thays Fraga Duarte … Roberto Léo da Silva Tammuz Fattah

Abstract

Background:

Acute myocardial infarction is one of the main causes of morbidity and mortality in the world, and one of the factors with the greatest prognostic impact is early specialist care, but there are still many factors that delay patient’s arrival at the hospital.

Objective:

To correlate social, educational, cognitive and clinical factors with time to hospital arrival after the onset of acute myocardial infarction’s first symptoms.

Methods:

Time interval to search for medical care was measured by patient’s report of the onset of infarction’s first symptoms and hospital admission verified through electronic medical data of the emergency service. The correlation between delta-T and other variables was performed through Kendall’s correlation. Values of p < 0.05 were considered statistically significant.

Results:

There was no correlation between delta-T and scholarity, or between delta – T and Mini Mental State Examination performance, as well as no association between the presence of hypertension, diabetes mellitus, dyslipidemia, family history, sedentary lifestyle or smoking with arrival time at the hospital. Comparisons between delta-T and marital status were also not statistically significant. Transfer from another health service and city of origin were the most determinant delay factors in our population’s arrival at the hospital.

Conclusion:

The present study suggests that, in our population, educational, social and cognitive factors are not directly related to the delay in arriving at the hospital.

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Original Article

Safety, feasibility, and results of exercise testing for stratifying patients with chest pain in the emergency room

Renato Machado Macaciel et al. Evandro Tinoco Mesquita Ricardo Vivacqua Salvador Serra … Augusta Campos Marcelo Miranda Roberto Gamarski Hans Dohman Roberto Bassan

OBJECTIVE: To assess safety, feasibility, and the results of early exercise testing in patients with chest pain admitted to the emergency room of the chest pain unit, in whom acute myocardial infarction and high-risk unstable angina had been ruled out. METHODS: A study including 1060 consecutive patients with chest pain admitted to the emergency room of the chest pain unit was carried out. Of them, 677 (64%) patients were eligible for exercise testing, but only 268 (40%) underwent the test. RESULTS: The mean age of the patients studied was 51.7±12.1 years, and 188 (70%) were males. Twenty-eight (10%) patients had a previous history of coronary artery disease, 244 (91%) had a normal or unspecific electrocardiogram, and 150 (56%) underwent exercise testing within a 12-hour interval. The results of the exercise test in the latter group were as follows: 34 (13%) were positive, 191 (71%) were negative, and 43 (16%) were inconclusive. In the group of patients with a positive exercise test, 21 (62%) underwent coronary angiography, 11 underwent angioplasty, and 2 underwent myocardial revascularization. In a univariate analysis, type A/B chest pain (definitely/probably anginal) (p<0.0001), previous coronary artery disease (p<0.0001), and route 2 (patients at higher risk) correlated with a positive or inconclusive test (p<0.0001). CONCLUSION: In patients with chest pain and in whom acute myocardial infarction and high-risk unstable angina had been ruled out, the exercise test proved to be feasible, safe, and well tolerated.

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Original Article

Efficacy of a diagnostic strategy for patients with chest pain and no ST-segment elevation in the emergency room

Roberto Bassan et al. Roberto Gamarski Lúcia Pimenta André Volschan … Marcelo Scofano Hans Fernando Dohmann Monica Araujo Cristina Clare Marcelo Fabrício Carlos Henrique Sanmartin Kalil Mohallem Renato Macaciel Sergio Gaspar

PURPOSE: To evaluate the efficacy of a systematic model of care for patients with chest pain and no ST segment elevation in the emergency room. METHODS: From 1003 patients submitted to an algorithm diagnostic investigation by probability of acute ischemic syndrome. We analyzed 600 ones with no elevation of ST segment, then enrolled to diagnostic routes of median (route 2) and low probability (route 3) to ischemic syndrome. RESULTS: In route 2 we found 17% acute myocardial infarction and 43% unstable angina, whereas in route 3 the rates were 2% and 7%, respectively. Patients with normal/non–specific ECG had 6% probability of AMI whereas in those with negative first CKMB it was 7%; the association of the 2 data only reduced it to 4%. In patients in route 2 the diagnosis of AMI could only be ruled out with serial CKMB measurement up to 9 hours, while in route 3 it could be done in up to 3 hours. Thus, sensitivity and negative predictive value of admission CKMB for AMI were 52% and 93%, respectively. About one-half of patients with unstable angina did not disclose objective ischemic changes on admission. CONCLUSION: The use of a systematic model of care in patients with chest pain offers the opportunity of hindering inappropriate release of patients with ACI and reduces unnecessary admissions. However some patients even with normal ECG should not be released based on a negative first CKMB. Serial measurement of CKMB up to 9 hours is necessary in patients with medium probability of AMI.

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Original Article

Chest pain in the emergency room. Importance of a systematic approach

Roberto Bassan et al. Marcelo Scofano Roberto Gamarski Hans Fernando Dohmann … Lúcia Pimenta André Volschan Mônica Araujo Cristina Clare Marcelo Fabrício Carlos Henrique Sanmartin Kalil Mohallem Sergio Gaspar Renato Macaciel

OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a pre-established process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74% of these had a final diagnosis of acute myocardial infarction [AMI]). Of the 660 patients that remained in the emergency room under observation, 77 (12%) had AMI without ST segment elevation and 202 (31%) had unstable angina (UA). In route 2 (high probability of ACS) 17% of patients had AMI and 43% had UA, whereas in route 3 (low probability) 2% had AMI and 7 % had UA. The admission ECG has been confirmed as a poor sensitivity test for the diagnosis of AMI ( 49%), with a positive predictive value considered only satisfactory (79%). CONCLUSION: A systematic diagnostic strategy, as used in this study, is essential in managing patients with chest pain in the emergency room in order to obtain high diagnostic accuracy, lower cost, and optimization of the use of coronary care unit beds.

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