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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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2
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Harada Y, Otaka Y, Katsukura S, Shimizu T. Prevalence of atypical presentations among outpatients and associations with diagnostic error. Diagnosis (Berl) 2024; 11:40-48. [PMID: 38059495 DOI: 10.1515/dx-2023-0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 11/17/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVES This study aimed to assess the prevalence of atypical presentations and their association with diagnostic errors in various diseases. METHODS This retrospective observational study was conducted using cohort data between January 1 and December 31, 2019. Consecutive outpatients consulted by physicians from the Department of Diagnostic and Generalist Medicine at a university hospital in Japan were included. Patients for whom the final diagnosis was not confirmed were excluded. Primary outcomes were the prevalence of atypical presentations, and the prevalence of diagnostic errors in groups with typical and atypical presentations. Diagnostic errors and atypical presentations were assessed using the Revised Safer Dx Instrument. We performed primary analyses using a criterion; the average score of less than five to item 12 of two independent reviewers was an atypical presentation (liberal criterion). We also performed additional analyses using another criterion; the average score of three or less to item 12 was an atypical presentation (conservative criterion). RESULTS A total of 930 patients were included out of a total of 2022 eligible. The prevalence of atypical presentation was 21.7 and 6.7 % when using liberal and conservative criteria for atypical presentation, respectively. Diagnostic errors (2.8 %) were most commonly observed in the cases with slight to moderate atypical presentation. Atypical presentation was associated with diagnostic errors with the liberal criterion for atypical presentation; however, this diminished with the conservative criterion. CONCLUSIONS An atypical presentation was observed in up to 20 % of outpatients with a confirmed diagnosis, and slight to moderate atypical presentation may be the highest risk population for diagnostic errors.
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Affiliation(s)
- Yukinori Harada
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Shimotsugagun, Tochigi, Japan
| | - Yumi Otaka
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Shimotsugagun, Tochigi, Japan
| | - Shinichi Katsukura
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Shimotsugagun, Tochigi, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Shimotsugagun, Tochigi, Japan
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3
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 601] [Impact Index Per Article: 601.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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4
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Wouters LTCM, Zwart DLM, Erkelens DCA, De Groot E, van Smeden M, Hoes AW, Damoiseaux RAMJ, Rutten FH. Gender-stratified analyses of symptoms associated with acute coronary syndrome in telephone triage: a cross-sectional study. BMJ Open 2021; 11:e042406. [PMID: 34172542 PMCID: PMC8237735 DOI: 10.1136/bmjopen-2020-042406] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To identify clinical variables that are associated with the diagnosis acute coronary syndrome (ACS) in women and men with chest discomfort who contact out-of-hours primary care (OHS-PC) by telephone, and to explore whether there are indications whether these variables differ among women and men. DESIGN Cross-sectional study in which we compared patient and call characteristics of triage call recordings between women with and without ACS, and men with and without ACS. SETTING Nine OHS-PC in the Netherlands. PARTICIPANTS 993 women and 802 men who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2016. PRIMARY OUTCOME MEASURE Diagnosis of ACS retrieved from the patient's medical record in general practice, including hospital specialists' discharge letters. RESULTS Among 1795 patients (mean age 58.8 (SD 19.5) years, 55.3% women), 15.0% of men and 8.6% of women had an ACS. In both sexes, retrosternal chest pain was associated with ACS (women with ACS vs without 62.3% vs 40.3%, p=0.002; men with ACS vs without 52.5% vs 39.7%, p=0.032; gender interaction, p=0.323), as was pressing/heavy/tightening pain (women 78.6% vs 61.5%, p=0.011; men 82.1% vs 57.4%, p=<0.001; gender interaction, p=0.368) and radiation to the arm (women 75.6% vs 45.9%, p<0.001; men 56.0% vs 34.8%, p<0.001; gender interaction, p=0.339). Results indicate that only in women were severe pain (65.4% vs 38.1%, p=0.006; gender interaction p=0.007) and radiation to jaw (50.0% vs 22.9%, p=0.007; gender interaction p=0.015) associated with ACS.Ambulances were dispatched equally in women (72.9%) and men with ACS (70.0%). CONCLUSION Our results indicate there were more similarities than differences in symptoms associated with the diagnosis ACS for women and men. Important exceptions were pain severity and radiation of pain in women. Whether these differences have an impact on predicting ACS needs to be further investigated with multivariable analyses. TRIAL REGISTRATION NUMBER NTR7331.
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Affiliation(s)
- Loes T C M Wouters
- Julius Center for Health Sciences and Primary Care, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Dorien L M Zwart
- Julius Center for Health Sciences and Primary Care, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Daphne C A Erkelens
- Julius Center for Health Sciences and Primary Care, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Esther De Groot
- Julius Center for Health Sciences and Primary Care, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Maarten van Smeden
- Epidemiology, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Roger A M J Damoiseaux
- Julius Center for Health Sciences and Primary Care, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
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5
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Gender Disparities in Cardiac Catheterization Rates Among Emergency Department Patients With Chest Pain. Crit Pathw Cardiol 2021; 20:67-70. [PMID: 33116062 DOI: 10.1097/hpc.0000000000000247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Previous studies have noted differences in rates of cardiac testing based on gender of patients. We evaluated cardiac catheterization rates for men and women presenting to the emergency department (ED) with chest pain, particularly among patients without a history of myocardial infarction (MI) or recent positive stress test. METHODS We performed a prospective evaluation of patients presenting to an urban, academic medical center for assessment of chest pain. We recorded baseline information, testing, and outcomes related to ED, observation unit, and inpatient stay. Primary outcomes included gender differences in cardiac catheterization and stenting rates among patients without an MI or positive stress test. RESULTS Over the 5.5 year study period, 2242 ED patients with chest pain participated in the study (45% male). Men and women had similar rates of cardiac stress testing (16.7% vs. 15.2%, P = 0.317) as well as similar rates of positive cardiac stress testing (2.9% vs. 1.9%, P = 0.116). Men were more likely to undergo cardiac catheterization (10.4% vs. 4.9%, P < 0.001). Men who had neither MI nor positive stress test were more likely than women to undergo cardiac catheterization: 5.8% versus 3.3%, P = 0.010. Similarly, men in this group were more likely to experience stent placement: 2.1% versus 0.7%, P = 0.003. CONCLUSIONS Similar to previous studies, we noted disparities in cardiac testing by gender. Men were more likely to go to cardiac catheterization without an MI or a positive stress test. This disparity in a more aggressive strategy of cardiac catheterization in men may result in higher stenting rates in this group.
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6
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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7
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2695] [Impact Index Per Article: 898.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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8
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Koechlin L, Boeddinghaus J, Nestelberger T, Miró Ò, Fuenzalida C, Martinez-Nadal G, López B, Wussler D, Walter J, Zimmermann T, Troester V, Lopez-Ayala P, Baumgartner B, Ratmann PD, Diebold M, Prepoudis A, Huber J, Christ M, Wildi K, Rubini Giménez M, Strebel I, Gualandro DM, Martin-Sanchez FJ, Kawecki D, Keller DI, Reuthebuch O, Eckstein FS, Reichlin T, Twerenbold R, Mueller C. Clinical presentation of patients with prior coronary artery bypass grafting and suspected acute myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 10:746-755. [PMID: 33620434 DOI: 10.1093/ehjacc/zuaa020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/19/2020] [Accepted: 09/04/2020] [Indexed: 11/14/2022]
Abstract
AIMS Diagnosis of acute myocardial infarction (AMI) can be challenging in patients with prior coronary artery bypass grafting (CABG). METHODS AND RESULTS Final diagnoses were adjudicated by two independent cardiologists using the universal definition of AMI among patients presenting to the emergency department (ED) with suspected AMI. Diagnostic accuracy of 34 chest pain characteristics (CPCs) and four electrocardiogram (ECG) signatures stratified according to the presence or absence of prior CABG were prospectively quantified. Among 4015 patients (no prior CABG: n = 3686; prior CABG: n = 329), prevalence of AMI and unstable angina were higher in patients with prior CABG (35% vs. 18%; 26% vs. 8%; both P < 0.001). Three CPCs (9%) and two electrocardiographic findings (50%) showed a different diagnostic performance (interaction P < 0.05) with loss of diagnostic value in patients with prior CABG. The diagnostic accuracy as quantified by the area under the curve (AUC) of the integrated clinical judgement was moderate to good in patients with prior CABG, and significantly lower compared to patients without prior CABG [AUC 0.80 (95% confidence interval (CI) 0.75-0.84) vs. AUC 0.87 (95% CI 0.86-0.89); P = 0.004]. Time to discharge from the ED was significantly longer in patients with prior CABG [359 (215-525) min vs. 300 (192-435) min; P < 0.001]. Key findings were confirmed in a large independent external validation cohort (n = 13 653). CONCLUSIONS Patients with prior CABG presenting with suspected AMI have a high prevalence of AMI and unstable angina and lower diagnostic accuracy of CPCs and the ECG, possibly justifying liberal use of early coronary angiography in these vulnerable patients. CLINICALTRIALS.GOV REGISTRY Number NCT00470587.
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Affiliation(s)
- Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Òscar Miró
- GREAT Network, Rome, Italy.,Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Carolina Fuenzalida
- GREAT Network, Rome, Italy.,Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Gemma Martinez-Nadal
- GREAT Network, Rome, Italy.,Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Beatriz López
- GREAT Network, Rome, Italy.,Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Division of Internal Medicine, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Joan Walter
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Division of Internal Medicine, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Division of Internal Medicine, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Valentina Troester
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Benjamin Baumgartner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Paul David Ratmann
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Matthias Diebold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Division of Internal Medicine, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Alexandra Prepoudis
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Jeffrey Huber
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Emergency Department, Kantonsspital Luzern, Spitalstrasse, 6000 Luzern, Switzerland
| | - Michael Christ
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,Emergency Department, Kantonsspital Luzern, Spitalstrasse, 6000 Luzern, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Cardiology Department, Herzzentrum Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - F Javier Martin-Sanchez
- GREAT Network, Rome, Italy.,Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain
| | - Damian Kawecki
- GREAT Network, Rome, Italy.,2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Katowice, Poland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Friedrich S Eckstein
- Department of Cardiac Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy.,Department of Cardiology, Inselspital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.,GREAT Network, Rome, Italy
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9
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Gamborg ML, Mehlsen M, Paltved C, Tramm G, Musaeus P. Conceptualizations of clinical decision-making: a scoping review in geriatric emergency medicine. BMC Emerg Med 2020; 20:73. [PMID: 32928158 PMCID: PMC7489001 DOI: 10.1186/s12873-020-00367-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/31/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Clinical decision-making (CDM) is an important competency for young doctors especially under complex and uncertain conditions in geriatric emergency medicine (GEM). However, research in this field is characterized by vague conceptualizations of CDM. To evolve and evaluate evidence-based knowledge of CDM, it is important to identify different definitions and their operationalizations in studies on GEM. OBJECTIVE A scoping review of empirical articles was conducted to provide an overview of the documented evidence of findings and conceptualizations of CDM in GEM. METHODS A detailed search for empirical studies focusing on CDM in a GEM setting was conducted in PubMed, ProQuest, Scopus, EMBASE and Web of Science. In total, 52 publications were included in the analysis, utilizing a data extraction sheet, following the PRISMA guidelines. Reported outcomes were summarized. RESULTS Four themes of operationalization of CDM emerged: CDM as dispositional decisions, CDM as cognition, CDM as a model, and CDM as clinical judgement. Study results and conclusions naturally differed according to how CDM was conceptualized. Thus, frailty-heuristics lead to biases in treatment of geriatric patients and the complexity of this patient group was seen as a challenge for young physicians engaging in CDM. CONCLUSIONS This scoping review summarizes how different studies in GEM use the term CDM. It provides an analysis of findings in GEM and call for more stringent definitions of CDM in future research, so that it might lead to better clinical practice.
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Affiliation(s)
- Maria Louise Gamborg
- Centre for Health Sciences Education, Faculty of Health, Aarhus University, Aarhus, Denmark.
- Corporate HR MidtSim, Central Region of Denmark & Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.
| | - Mimi Mehlsen
- Department of Psychology, Faculty of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Charlotte Paltved
- Corporate HR MidtSim, Central Region of Denmark & Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Gitte Tramm
- Department of Psychology, Faculty of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Peter Musaeus
- Centre for Health Sciences Education, Faculty of Health, Aarhus University, Aarhus, Denmark
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10
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Mueller KAL, Hanna DB, Ehinger E, Xue X, Baas L, Gawaz MP, Geisler T, Anastos K, Cohen MH, Gange SJ, Heath SL, Lazar JM, Liu C, Mack WJ, Ofotokun I, Tien PC, Hodis HN, Landay AL, Kaplan RC, Ley K. Loss of CXCR4 on non-classical monocytes in participants of the Women's Interagency HIV Study (WIHS) with subclinical atherosclerosis. Cardiovasc Res 2019; 115:1029-1040. [PMID: 30520941 PMCID: PMC6735712 DOI: 10.1093/cvr/cvy292] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 11/07/2018] [Accepted: 12/04/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS To test whether human immunodeficiency virus (HIV) infection and subclinical cardiovascular disease (sCVD) are associated with expression of CXCR4 and other surface markers on classical, intermediate, and non-classical monocytes in women. METHODS AND RESULTS sCVD was defined as presence of atherosclerotic lesions in the carotid artery in 92 participants of the Women's Interagency HIV Study (WIHS). Participants were stratified into four sets (n = 23 each) by HIV and sCVD status (HIV-/sCVD-, HIV-/sCVD+, HIV+/sCVD-, and HIV+/sCVD+) matched by age, race/ethnicity, and smoking status. Three subsets of monocytes were determined from archived peripheral blood mononuclear cells. Flow cytometry was used to count and phenotype surface markers. We tested for differences by HIV and sCVD status accounting for multiple comparisons. We found no differences in monocyte subset size among the four groups. Expression of seven surface markers differed significantly across the three monocyte subsets. CXCR4 expression [median fluorescence intensity (MFI)] in non-classical monocytes was highest among HIV-/CVD- [628, interquartile range (IQR) (295-1389)], followed by HIV+/CVD- [486, IQR (248-699)], HIV-/CVD+ (398, IQR (89-901)), and lowest in HIV+/CVD+ women [226, IQR (73-519)), P = 0.006 in ANOVA. After accounting for multiple comparison (Tukey) the difference between HIV-/CVD- vs. HIV+/CVD+ remained significant with P = 0.005 (HIV-/CVD- vs. HIV+/CVD- P = 0.04, HIV-/CVD- vs. HIV-/CVD+ P = 0.06, HIV+/CVD+ vs. HIV+/CVD- P = 0.88, HIV+/CVD+ vs. HIV-/CVD+ P = 0.81, HIV+/CVD- vs. HIV-/CVD+, P = 0.99). All pairwise comparisons with HIV-/CVD- were individually significant (P = 0.050 vs. HIV-/CVD+, P = 0.028 vs. HIV+/CVD-, P = 0.009 vs. HIV+/CVD+). CXCR4 expression on non-classical monocytes was significantly higher in CVD- (501.5, IQR (249.5-887.3)) vs. CVD+ (297, IQR (81.75-626.8) individuals (P = 0.028, n = 46 per group). CXCR4 expression on non-classical monocytes significantly correlated with cardiovascular and HIV-related risk factors including systolic blood pressure, platelet and T cell counts along with duration of antiretroviral therapy (P < 0.05). In regression analyses, adjusted for education level, study site, and injection drug use, presence of HIV infection and sCVD remained significantly associated with lower CXCR4 expression on non-classical monocytes (P = 0.003), but did not differ in classical or intermediate monocytes. CONCLUSION CXCR4 expression in non-classical monocytes was significantly lower among women with both HIV infection and sCVD, suggesting a potential atheroprotective role of CXCR4 in non-classical monocytes.
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Affiliation(s)
- Karin A L Mueller
- La Jolla Institute of Immunology, Athena Circle Drive La Jolla, CA, USA
- Eberhard Karls University, Tuebingen University Hospital, Department of Cardiology, Otfried-Mueller-Strasse 10, Tuebingen, Germany
| | - David B Hanna
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Belfer 13th floor, Bronx, NY, USA
| | - Erik Ehinger
- La Jolla Institute of Immunology, Athena Circle Drive La Jolla, CA, USA
| | - Xiaonan Xue
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Belfer 13th floor, Bronx, NY, USA
| | - Livia Baas
- La Jolla Institute of Immunology, Athena Circle Drive La Jolla, CA, USA
- Eberhard Karls University, Tuebingen University Hospital, Department of Cardiology, Otfried-Mueller-Strasse 10, Tuebingen, Germany
| | - Meinrad P Gawaz
- Eberhard Karls University, Tuebingen University Hospital, Department of Cardiology, Otfried-Mueller-Strasse 10, Tuebingen, Germany
| | - Tobias Geisler
- Eberhard Karls University, Tuebingen University Hospital, Department of Cardiology, Otfried-Mueller-Strasse 10, Tuebingen, Germany
| | - Kathryn Anastos
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Belfer 13th floor, Bronx, NY, USA
| | - Mardge H Cohen
- John H. Stroger, Jr. Hospital of Cook County, 1969 Ogden Ave, Chicago, IL, USA
| | - Stephen J Gange
- Department of Epidemiology, Johns Hopkins University, 265 Garland Hall, 3400 North Charles Street, Baltimore, MD, USA
| | - Sonya L Heath
- Department of Medicine, University of Alabama at Birmingham, 908 20th Street South, Birmingham, AL, USA
| | - Jason M Lazar
- Department of Medicine, SUNY-Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY, USA
| | - Chenglong Liu
- Georgetown University Medical Center, Washington, DC, USA
| | - Wendy J Mack
- Department of Preventive Medicine, University of Southern California, 2001 N Soto St, Los Angeles, CA, USA
| | - Igho Ofotokun
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr. Drive, Atlanta, GA, USA
| | - Phyllis C Tien
- Department of Medicine, VAMC, Infectious Disease Section, 111W 4150 Clement St., San Francisco, CA, USA
| | - Howard N Hodis
- Department of Preventive Medicine, University of Southern California, 2001 N Soto St, Los Angeles, CA, USA
| | - Alan L Landay
- Department of Internal Medicine, Rush University Medical Center, 1735 West Harrison St, Chicago, IL, USA
| | - Robert C Kaplan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Belfer 13th floor, Bronx, NY, USA
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Klaus Ley
- La Jolla Institute of Immunology, Athena Circle Drive La Jolla, CA, USA
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11
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Sriha Belguith A, Beltaief K, Msolli MA, Bouida W, Abroug H, Ben Fredj M, Zemni I, Grissa MH, Boubaker H, Hsairi M, Nouira S. Management of acute coronary syndrome in emergency departments: a cross sectional multicenter study (Tunisia). BMC Emerg Med 2018; 18:50. [PMID: 30509187 PMCID: PMC6276213 DOI: 10.1186/s12873-018-0201-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 11/15/2018] [Indexed: 01/25/2023] Open
Abstract
Background We aimed to describe diagnosed acute coronary syndrome (ACS) and its care management and outcomes in emergency departments (EDs) and to determine related cardiovascular risk factors (CVRFs). Methods We conducted a cross sectional multicenter study that included 1173 adults admitted to EDs for acute chest pain (ACP) in 2015 at 14 sites in Tunisia. Data included patients’ baseline characteristics, diagnosis, treatment and output. Results ACS represented 49.7% of non-traumatic chest pain [95% CI: 46.7–52.6]; 74.2% of ACS cases were unstable angina/non-ST-segment-elevation myocardial infarction (UA/NSTEMI). Males represented 67.4% of patients with ACS (p < 0.001). The median age was 60 years (IQR 52–70). Emergency medical service transportation was used in 11.9% of cases. The median duration between chest pain onset and ED arrival was two hours (Inter quartile ranges (IQR) 2–4 h). The age-standardized prevalence rate was 69.9/100,000 PY; the rate was 96.24 in men and 43.7 in women. In the multivariable analysis, CVRFs related to ST segment elevation myocardial infarction were age correlated to sex and active smoking. CVRFs related to UA/NSTEMI were age correlated to sex, familial and personal vascular history and type 2 diabetes. We reported 27 cases of major adverse cardiovascular events (20.0%) in patients with STEMI and 36 in patients with UA/NSTEMI (9.1%). Conclusion Half of the patients consulting EDs with ACP had ACS. Emergency medical service transportation calls were rare. Management delays were acceptable. The risk of developing an UA/NSTEMI was equal to the number of CVRFs + 1. To improve patient outcomes, it is necessary to increase adherence to international management guidelines.
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Affiliation(s)
- Asma Sriha Belguith
- Epidemiology and Preventive Medicine Department, University Hospital of Monastir, Monastir, Tunisia.
| | - Kaouthar Beltaief
- Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia
| | | | - Wahid Bouida
- Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia
| | - Hela Abroug
- Epidemiology and Preventive Medicine Department, University Hospital of Monastir, Monastir, Tunisia
| | - Manel Ben Fredj
- Epidemiology and Preventive Medicine Department, University Hospital of Monastir, Monastir, Tunisia
| | - Imen Zemni
- Epidemiology and Preventive Medicine Department, University Hospital of Monastir, Monastir, Tunisia
| | | | - Hamdi Boubaker
- Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia
| | | | | | - Samir Nouira
- Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia
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12
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Sörensen NA, Neumann JT, Ojeda F, Schäfer S, Magnussen C, Keller T, Lackner KJ, Zeller T, Karakas M, Münzel T, Blankenberg S, Westermann D, Schnabel RB. Relations of Sex to Diagnosis and Outcomes in Acute Coronary Syndrome. J Am Heart Assoc 2018; 7:e007297. [PMID: 29525782 PMCID: PMC5907542 DOI: 10.1161/jaha.117.007297] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 01/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The atypical presentation of women with acute coronary syndrome (ACS) has been related to delayed diagnosis and treatment, which may explain worse outcome compared with men. METHODS AND RESULTS We analyzed pooled data of 2520 patients of 2 prospective cohorts in terms of differences in presentation and management of women and men suggestive of ACS. Using logistic regression, we established 2 diagnostic models and tested their diagnostic performance in both sexes separately. Sex-specific differences in management of patients with ACS were ascertained and a 2-year follow-up was performed. Women were older than men (median 67 versus 61 years, P=0.001), had more often dyspnea (22% versus 18%, P=0.024), nausea or vomiting (26% versus 16%, P=0.001) and radiating chest pain (47% versus 40%, P=0.001). Classical risk factors (smoking, diabetes mellitus, dyslipidemia or known coronary artery disease) were less frequent in women. Diagnostic models showed no significant sex-related differences in diagnostic performance in a "first contact" setting (medical history and symptoms) or after "complete triage" (including ECG and biomarkers). Women with ACS underwent coronary angiography (73.8% versus 84.3%, P<0.001) and revascularization (53.8% versus 70.1%, P<0.001) less frequently. Two-year incidence of myocardial infarction and death was similar in both sexes, but revascularization and cardiac rehospitalization were more frequent in men. CONCLUSIONS In a large cohort of patients with suspected ACS, sex differences in clinical presentation did not impair diagnostic accuracy. Two-year outcomes were comparable. Our findings suggest a benefit of chest pain units to minimize sex differences in ACS management and prognosis. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifiers: NCT02355457 (BACC), NCT03227159 (stenoCardia).
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Affiliation(s)
- Nils Arne Sörensen
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Johannes Tobias Neumann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Francisco Ojeda
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
| | - Sarina Schäfer
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Christina Magnussen
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Till Keller
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
- German Center for Cardiovascular Research, Partner Site RheinMain, Hamburg, Germany
| | - Karl J Lackner
- German Center for Cardiovascular Research, Partner Site RheinMain, Hamburg, Germany
- Department of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Tanja Zeller
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Mahir Karakas
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Thomas Münzel
- German Center for Cardiovascular Research, Partner Site RheinMain, Hamburg, Germany
- Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Renate B Schnabel
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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13
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Nestelberger T, Boeddinghaus J, Badertscher P, Twerenbold R, Wildi K, Breitenbücher D, Sabti Z, Puelacher C, Rubini Giménez M, Kozhuharov N, Strebel I, Sazgary L, Schneider D, Jann J, du Fay de Lavallaz J, Miró Ò, Martin-Sanchez FJ, Morawiec B, Kawecki D, Muzyk P, Keller DI, Geigy N, Osswald S, Reichlin T, Mueller C. Effect of Definition on Incidence and Prognosis of Type 2 Myocardial Infarction. J Am Coll Cardiol 2017; 70:1558-1568. [PMID: 28935032 DOI: 10.1016/j.jacc.2017.07.774] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/24/2017] [Accepted: 07/24/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Uncertainties regarding the most appropriate definition and treatment of type 2 myocardial infarction (T2MI) due to supply-demand mismatch have contributed to inconsistent adoption in clinical practice. OBJECTIVES This study sought a better understanding of the effect of the definition of T2MI on its incidence, treatment, and event-related mortality, thereby addressing an important unmet clinical need. METHODS The final diagnosis was adjudicated in patients presenting with symptoms suggestive of myocardial infarction by 2 independent cardiologists by 2 methods: 1 method required the presence of coronary artery disease, a common interpretation of the 2007 universal definition (T2MI2007); and 1 method did not require coronary artery disease, the 2012 universal definition (T2MI2012). RESULTS Overall, 4,015 consecutive patients were adjudicated. The incidence of T2MI based on the T2MI2007 definition was 2.8% (n = 112). The application of the more liberal T2MI2012 definition resulted in an increase of T2MI incidence of 6% (n = 240), a relative increase of 114% (128 reclassified patients, defined as T2MI2012reclassified). Among T2MI2007, 6.3% of patients received coronary revascularization, 22% dual-antiplatelet therapy, and 71% high-dose statin therapy versus 0.8%, 1.6%, and 31% among T2MI2012reclassified patients, respectively (all p < 0.01). Cardiovascular mortality at 90 days was 0% among T2MI2012reclassified, which was similar to patients with noncardiac causes of chest discomfort (0.2%), and lower than T2MI2007 (3.6%) and type 1 myocardial infarction (T1MI) (4.8%) (T2MI2012reclassified vs. T2MI2007 and T1MI: p = 0.03 and 0.01, respectively). CONCLUSIONS T2MI2012reclassified has a substantially lower event-related mortality rate compared with T2MI2007 and T1MI. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] Study; NCT00470587).
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Affiliation(s)
- Thomas Nestelberger
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, University Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, University Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy; Department of General and Interventional Cardiology, Hamburg University Heart Center, Hamburg, Germany
| | - Karin Wildi
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Dominik Breitenbücher
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Zaid Sabti
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Christian Puelacher
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Nikola Kozhuharov
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Ivo Strebel
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Lorraine Sazgary
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Deborah Schneider
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Janina Jann
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Òscar Miró
- GREAT Network, Rome, Italy; Emergency Department, Hospital Clinic, Barcelona, Spain
| | | | - Beata Morawiec
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Damian Kawecki
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Piotr Muzyk
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Liestal, Liestal, Switzerland
| | - Stefan Osswald
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tobias Reichlin
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland; GREAT Network, Rome, Italy.
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14
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Eick C, Duckheim M, Groga-Bada P, Klumpp N, Mannes S, Zuern CS, Gawaz M, Rizas KD, Bauer A. Point-of-care testing of cardiac autonomic function for risk assessment in patients with suspected acute coronary syndromes. Clin Res Cardiol 2017; 106:686-694. [DOI: 10.1007/s00392-017-1104-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 03/08/2017] [Indexed: 12/22/2022]
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