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Corredor-Rojas G, García-Chabur MA, Castellanos J, Moreno S, Pinzón M, Peñaranda A. Nasal Obstruction and Quality of Life Assessment After Septoplasty With Turbinoplasty: Correlation Between Subjective Scales. Am J Rhinol Allergy 2020; 35:568-573. [PMID: 33297717 DOI: 10.1177/1945892420978956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Assessment of nasal obstruction is imprecise due to a low correlation between findings on the physical examination and objective measures with the severity of symptoms reported by the patient even after septoplasty with turbinoplasty is performed. The aim of this study is to evaluate the use of subjective scales, and the correlation between them for the evaluation of nasal obstruction after surgery. OBJECTIVE To assess the impact of undergoing septoplasty with turbinoplasty to relieve nasal obstructive symptoms and the quality of life in a mid-term period by using the Visual Analogue Scale (VAS), Nasal Obstruction Symptom Evaluation (NOSE), and Glasgow Benefit Inventory (GBI). METHODS A retrospective study was conducted of patients who underwent a septoplasty with turbinoplasty due to nasal septodeviation and secondary nasal obstructive symptoms at the Hospital Universitario Fundación Santa Fe de Bogotá. Three scales were used to measure the outcomes one year after surgery: VAS (0-10), NOSE (0-100), and GBI (-100 to 100). RESULTS Data from 56 patients (21 females, mean age 37.5 years of age, SD 12.13) was collected. The results showed that 75% of the patients had a post-surgical NOSE score below 50 and a VAS score below 6. Regarding the GBI scale, 75% of the patients improved in their quality of life. An inverse proportional correlation was found between the NOSE and GBI scales (rho = -0.3682) (95% CI -0.579 to -0.111), and there was a directly proportional correlation between the NOSE and VAS scales (rho = 0.7440) (95% CI 0.595 to 0.844). CONCLUSION Subjective measures suggest there was an improvement in nasal obstructive symptoms and quality of life after surgery. Non-anatomical causes such as rhinitis can be confounding factors to consider in subsequent studies. VAS stands out as a possible interchangeable scale with NOSE to measure nasal obstruction in these patients.
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Affiliation(s)
- Gloria Corredor-Rojas
- School of Medicine, Universidad de Los Andes, Bogotá, Colombia.,Department of Otorhinolaryngology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - María A García-Chabur
- Department of Otorhinolaryngology, Fundación Universitaria de Ciencias de la Salud-Hospital de San José, Bogotá, Colombia
| | - Juliana Castellanos
- Department of Otorhinolaryngology, Fundación Universitaria de Ciencias de la Salud-Hospital de San José, Bogotá, Colombia
| | - Sergio Moreno
- Department of Otorhinolaryngology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Martin Pinzón
- Department of Otorhinolaryngology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia.,Department of Otorhinolaryngology, Fundación Universitaria de Ciencias de la Salud-Hospital de San José, Bogotá, Colombia
| | - Augusto Peñaranda
- School of Medicine, Universidad de Los Andes, Bogotá, Colombia.,Department of Otorhinolaryngology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia.,Department of Otorhinolaryngology, Fundación Universitaria de Ciencias de la Salud-Hospital de San José, Bogotá, Colombia
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2
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Proposed clinical scale for the diagnosis of acute coronary syndrome in patients with an inconclusive electrocardiogram and myocardial injury biomarkers. Rev Clin Esp 2018. [DOI: 10.1016/j.rceng.2017.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Propuesta de una escala clínica para el diagnóstico de síndrome coronario agudo en pacientes con electrocardiograma y biomarcadores de lesión miocárdica no concluyentes. Rev Clin Esp 2018; 218:49-57. [DOI: 10.1016/j.rce.2017.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 12/11/2017] [Accepted: 12/15/2017] [Indexed: 11/21/2022]
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4
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Tewelde SZ, Mattu A, Brady WJ. Pitfalls in Electrocardiographic Diagnosis of Acute Coronary Syndrome in Low-Risk Chest Pain. West J Emerg Med 2017; 18:601-606. [PMID: 28611879 PMCID: PMC5468064 DOI: 10.5811/westjem.2017.1.32699] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 02/01/2017] [Accepted: 01/30/2017] [Indexed: 01/13/2023] Open
Abstract
Less than half of patients with a chest pain history indicative of acute coronary syndrome have a diagnostic electrocardiogram (ECG) on initial presentation to the emergency department. The physician must dissect the ECG for elusive, but perilous, characteristics that are often missed by machine analysis. ST depression is interpreted and often suggestive of ischemia; however, when exclusive to leads V1–V3 with concomitant tall R waves and upright T waves, a posterior infarction should first and foremost be suspected. Likewise, diffuse ST depression with elevation in aVR should raise concern for left main- or triple-vessel disease and, as with the aforementioned, these ECG findings are grounds for acute reperfusion therapy. Even in isolation, certain electrocardiographic findings can suggest danger. Such is true of the lone T-wave inversion in aVL, known to precede an inferior myocardial infarction. Similarly, something as ordinary as an upright and tall T wave or a biphasic T wave can be the only marker of ischemia. ECG abnormalities, however subtle, should give pause and merit careful inspection since misinterpretation occurs in 20–40% of misdiagnosed myocardial infarctions.
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Affiliation(s)
- Semhar Z Tewelde
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Amal Mattu
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - William J Brady
- University of Virginia School of Medicine, Department of Emergency Medicine, Charlottesville, Virginia
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5
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Merchan Ortega G, Bonaque Gonzalez JC, Sanchez Espino AD, Aguado Martin MJ, Navarro Garcia F, Ruiz Lopez F, Ramos Perales F, Zamorano Gomez JL. Long-term prognostic value of peak exercise echocardiogram in patients hospitalized with acute chest pain. Echocardiography 2017; 34:869-875. [PMID: 28378340 DOI: 10.1111/echo.13530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Peak exercise echocardiogram (EEcho) has shown reasonable sensitivity and specificity in detecting significant coronary artery disease (CAD). The objective was to evaluate the prognostic value of EEcho in patients hospitalized for acute chest pain (CP) and its additional prognostic information regarding exercise electrocardiogram test (EECG). METHODS Prospective observational study performed between May 2011 and September 2013, including 250 patients consecutively admitted for acute CP with normal cardiac biomarkers and nondiagnostic electrocardiogram. All patients were prospectively followed for 1 year, and major adverse cardiovascular events (MACE) were recorded: cardiac death, nonfatal myocardial infarction (MI), or angina with coronary revascularization. RESULTS EEcho was positive in 16%. Patients with positive EEcho had a higher incidence of hypertension and higher TIMI risk score, showing significant CAD in 66%. We observed contradictory results (EECG-EEcho) in 20%. Patients with positive EEcho and negative EECG had significant CAD in the 66%, and patients undergoing coronary angiography with negative EEcho and positive EECG did not show significant coronary artery disease. Only positive EEcho (P<.001, HR 0.169; 95% CI, 0.088-0.250) and atrial fibrillation (P<.025, HR 0.125; 95% CI, 0.016-0.233) were independently associated with MACE during follow-up. In patients with negative EEcho, the presence of MACE was 2%. CONCLUSIONS EEcho in patients hospitalized for acute chest pain presents good ability to diagnose acute coronary syndrome, while providing additional information when combined with an EECG in up to 20% of cases. Moreover, a negative EEcho in this cohort seems to provide prognostic information beyond the acute event to predict long-term MACE.
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Ziegler M, Alt K, Paterson BM, Kanellakis P, Bobik A, Donnelly PS, Hagemeyer CE, Peter K. Highly Sensitive Detection of Minimal Cardiac Ischemia using Positron Emission Tomography Imaging of Activated Platelets. Sci Rep 2016; 6:38161. [PMID: 27909290 PMCID: PMC5133579 DOI: 10.1038/srep38161] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 11/04/2016] [Indexed: 01/12/2023] Open
Abstract
A reliable method for the diagnosis of minimal cardiac ischemia would meet a strong demand for the sensitive diagnosis of coronary artery disease in cardiac stress testing and risk stratification in patients with chest pain but unremarkable ECGs and biomarkers. We hypothesized that platelets accumulate early on in ischemic myocardium and a newly developed technology of non-invasive molecular PET imaging of activated platelets can thus detect minimal degrees of myocardial ischemia. To induce different degrees of minimal cardiac ischemia, the left anterior descending artery (LAD) was ligated for 10, 20 or 60 min. Mice were injected with a newly generated scFvanti-GPIIb/IIIa-64CuMeCOSar radiotracer, composed of a single-chain antibody that only binds to activated integrin GPIIb/IIIa (αIIbβIII) and thus to activated platelets, and a sarcophagine cage MeCOSar complexing the long half-life PET tracer copper-64. A single PET/CT scan was performed. Evans Blue/TTC staining to detect necrosis as well as classical serological biomarkers like Troponin I and heart-type fatty acid-binding protein (H-FABP) were negative, whereas PET imaging of activated platelets was able to detect small degrees of ischemia. Taken together, molecular PET imaging of activated platelets represents a unique and highly sensitive method to detect minimal cardiac ischemia.
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Affiliation(s)
- Melanie Ziegler
- Atherothrombosis and Vascular Biology, Baker IDI Heart &Diabetes Institute, Melbourne, Australia
| | - Karen Alt
- Atherothrombosis and Vascular Biology, Baker IDI Heart &Diabetes Institute, Melbourne, Australia.,Vascular Biotechnology, Baker IDI Heart &Diabetes Institute, Melbourne, Australia
| | - Brett M Paterson
- School of Chemistry and Bio21 Molecular Science and Biotechnology Institute, The University of Melbourne, Melbourne, Australia
| | - Peter Kanellakis
- Vascular Biology &Atherosclerosis, Baker IDI Heart &Diabetes Institute, Melbourne, Australia
| | - Alex Bobik
- Vascular Biology &Atherosclerosis, Baker IDI Heart &Diabetes Institute, Melbourne, Australia
| | - Paul S Donnelly
- School of Chemistry and Bio21 Molecular Science and Biotechnology Institute, The University of Melbourne, Melbourne, Australia
| | - Christoph E Hagemeyer
- Vascular Biotechnology, Baker IDI Heart &Diabetes Institute, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia.,RMIT University, Melbourne, Australia
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology, Baker IDI Heart &Diabetes Institute, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia.,RMIT University, Melbourne, Australia
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Heldeweg MLA, Liu N, Koh ZX, Fook-Chong S, Lye WK, Harms M, Ong MEH. A novel cardiovascular risk stratification model incorporating ECG and heart rate variability for patients presenting to the emergency department with chest pain. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:179. [PMID: 27286655 PMCID: PMC4903012 DOI: 10.1186/s13054-016-1367-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 06/01/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Risk stratification models can be employed at the emergency department (ED) to evaluate patient prognosis and guide choice of treatment. We derived and validated a new cardiovascular risk stratification model comprising vital signs, heart rate variability (HRV) parameters, and demographic and electrocardiogram (ECG) variables. METHODS We conducted a single-center, observational cohort study of patients presenting to the ED with chest pain. All patients above 21 years of age and in sinus rhythm were eligible. ECGs were collected and evaluated for 12-lead ECG abnormalities. Routine monitoring ECG data were processed to obtain HRV parameters. Vital signs and demographic data were obtained from electronic medical records. Thirty-day major adverse cardiac events (MACE) were the primary endpoint, including death, acute myocardial infarction, and revascularization. Candidate variables were identified using univariate analysis; the model for the final risk score was derived by multivariable logistic regression. We compared the performance of the new model with that of the thrombolysis in myocardial infarct (TIMI) score using receiver operating characteristic (ROC) analysis. RESULTS In total, 763 patients were included in this study; 254 (33 %) met the primary endpoint, the mean age was 60 (σ = 13) years, and the majority was male (65 %). Nineteen candidate predictors were entered into the multivariable model for backward variable elimination. The final model contained 10 clinical variables, including age, gender, heart rate, three HRV parameters (average R-to-R interval (RR), triangular interpolation of normal-to-normal (NN) intervals, and high-frequency power), and four 12-lead ECG variables (ST elevation, ST depression, Q wave, and QT prolongation). Our proposed model outperformed the TIMI score for prediction of MACE (area under the ROC curve 0.780 versus 0.653). At the cutoff score of 9 (range 0-37), our model had sensitivity of 0.709 (95 % CI 0.653, 0.765), specificity of 0.674 (95 % CI 0.633, 0.715), positive predictive value of 0.520 (95 % CI 0.468, 0.573), and negative predictive value of 0.823 (95 % CI 0.786, 0.859). CONCLUSIONS A non-invasive and objective ECG- and HRV-based risk stratification tool performed well against the TIMI score, but future research warrants use of an external validation cohort.
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Affiliation(s)
| | - Nan Liu
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore. .,Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore.
| | - Zhi Xiong Koh
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Stephanie Fook-Chong
- Department of Clinical Research, Singapore General Hospital, Singapore, Singapore
| | - Weng Kit Lye
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Mark Harms
- Department of Internal Medicine, University Medical Centre Groningen, Groningen, Netherlands
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.,Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
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Boubaker H, Grissa MH, Beltaief K, Amor MH, Mdimagh Z, Boukhris A, Ben Amor M, Dridi Z, Letaief M, Bouida W, Boukef R, Najjar F, Nouira S. A new score for the diagnosis of acute coronary syndrome in acute chest pain with non-diagnostic ECG and normal troponin. Emerg Med J 2015; 32:764-8. [PMID: 25560250 DOI: 10.1136/emermed-2013-203151] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 12/14/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND Acute coronary syndrome (ACS) represents a difficult diagnostic challenge in patients with undifferentiated chest pain. There is a need for a valid clinical score to improve diagnostic accuracy. OBJECTIVES To compare the performance of a model combining the Thrombolysis in Myocardial Infarction (TIMI) score and a score describing chest pain (ACS diagnostic score: ACSD score) with that of both scores alone in the diagnosis of ACS in ED patients with chest pain associated with a non-diagnostic ECG and normal troponin. METHODS In this observational cohort study, we enrolled 809 patients admitted to a chest pain unit with normal ECG and normal troponin. They were prospectively evaluated in order to calculate TIMI score, chest pain characteristics score and ACSD score. Diagnosis of ACS was the primary outcome and defined on the basis of 2 cardiologists after reviewing the patient medical records and follow-up data. Mortality and major cardiovascular events were followed for 1 month for patients discharged directly from ED. Discriminative power of scores was evaluated by the area under the ROC curve. RESULTS ACS was confirmed in 90 patients (11.1%). The area under the ROC curve for ACSD score was 0.85 (95% CI 0.80 to 0.90) compared with 0.74 (95% CI 0.67 to 0.81) for TIMI and 0.79 (95% CI 0.74 to 0.84) for chest pain characteristics score. A threshold value of 9 appeared to optimise sensitivity (92%) and negative predictive value (99%) without excessively compromising specificity (62%) and positive predictive value (23%). CONCLUSIONS The ACSD score showed a good discrimination performance and an excellent negative predictive value which allows safely ruling out ACS in ED patients with undifferentiated chest pain. Our findings should be validated in a larger multicentre study.
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Affiliation(s)
- Hamdi Boubaker
- Emergency Department and Research Laboratory (LR12SP18), Fattouma Bourguiba University Hospital, Monastir, Tunisia Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Mohamed Habib Grissa
- Emergency Department and Research Laboratory (LR12SP18), Fattouma Bourguiba University Hospital, Monastir, Tunisia Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Kaouther Beltaief
- Emergency Department and Research Laboratory (LR12SP18), Fattouma Bourguiba University Hospital, Monastir, Tunisia Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Mohamed Haj Amor
- Emergency Department and Research Laboratory (LR12SP18), Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | - Zouhaier Mdimagh
- Emergency Department and Research Laboratory (LR12SP18), Fattouma Bourguiba University Hospital, Monastir, Tunisia Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Amor Boukhris
- Emergency Department and Research Laboratory (LR12SP18), Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | - Mehdi Ben Amor
- Emergency Department, Moknine Hospital, Moknine, Tunisia
| | - Zohra Dridi
- Faculty of Medicine, University of Monastir, Monastir, Tunisia Department of Cardiology, Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | - Mondher Letaief
- Faculty of Medicine, University of Monastir, Monastir, Tunisia Department of Preventive Epidemiology, Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | - Wahid Bouida
- Emergency Department and Research Laboratory (LR12SP18), Fattouma Bourguiba University Hospital, Monastir, Tunisia Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Riadh Boukef
- Emergency Department and Research Laboratory (LR12SP18), Fattouma Bourguiba University Hospital, Monastir, Tunisia Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Fadhel Najjar
- Biochemical Laboratory, Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | - Semir Nouira
- Emergency Department and Research Laboratory (LR12SP18), Fattouma Bourguiba University Hospital, Monastir, Tunisia Faculty of Medicine, University of Monastir, Monastir, Tunisia
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Evaluación del dolor torácico agudo mediante ecocardiografía de ejercicio y tomografía computarizada multidetectores. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2014.05.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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10
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Risk Scoring for Prediction of Acute Cardiac Complications from Imbalanced Clinical Data. IEEE J Biomed Health Inform 2014; 18:1894-902. [DOI: 10.1109/jbhi.2014.2303481] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Exercise echocardiography and multidetector computed tomography for the evaluation of acute chest pain. ACTA ACUST UNITED AC 2014; 68:17-24. [PMID: 25212286 DOI: 10.1016/j.rec.2014.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 05/12/2014] [Indexed: 11/21/2022]
Abstract
INTRODUCTION AND OBJECTIVES Up to 4% of patients with acute chest pain, normal electrocardiogram, and negative troponins present major adverse cardiac events as a result of undiagnosed acute coronary syndrome. Our aim was to compare the diagnostic performance of multidetector computed tomography and exercise echocardiography in patients with a low-to-intermediate probability of coronary artery disease. METHODS We prospectively included 69 patients with acute chest pain, normal electrocardiogram, and negative troponins who underwent coronary tomography angiography and exercise echocardiography. Patients with coronary stenosis ≥ 50% or Agatston calcium score ≥ 400 on coronary tomography angiography or positive exercise echocardiography, or with inconclusive results, were admitted to rule out acute coronary syndrome. RESULTS An acute coronary syndrome was confirmed in 17 patients (24.6%). This was lower than the suspected 42% based on coronary tomography angiography (P<.05) and not significantly different than the suspected 29% based on the results of exercise echocardiography (P=.56). Exercise echocardiography was normal in up to 37% of patients with pathological findings on coronary tomography angiography. The latter technique provided a higher sensitivity (100% vs 82.3%; P=.21) but lower specificity (76.9% vs 88.4%; P=.12) than exercise echocardiography for the diagnosis of acute coronary syndrome, although without reaching statistical significance. Increasing the stenosis cutoff point to 70% increased the specificity of coronary tomography angiography to 88.4%, while maintaining high sensitivity. CONCLUSIONS Coronary tomography angiography offers a valid alternative to exercise echocardiography for the diagnosis of acute coronary syndrome among patients with low-to-intermediate probability of coronary artery disease. A combination of both techniques could improve the diagnosis of acute coronary syndrome.
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Liu N, Koh ZX, Goh J, Lin Z, Haaland B, Ting BP, Ong MEH. Prediction of adverse cardiac events in emergency department patients with chest pain using machine learning for variable selection. BMC Med Inform Decis Mak 2014; 14:75. [PMID: 25150702 PMCID: PMC4150554 DOI: 10.1186/1472-6947-14-75] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 08/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The key aim of triage in chest pain patients is to identify those with high risk of adverse cardiac events as they require intensive monitoring and early intervention. In this study, we aim to discover the most relevant variables for risk prediction of major adverse cardiac events (MACE) using clinical signs and heart rate variability. METHODS A total of 702 chest pain patients at the Emergency Department (ED) of a tertiary hospital in Singapore were included in this study. The recruited patients were at least 30 years of age and who presented to the ED with a primary complaint of non-traumatic chest pain. The primary outcome was a composite of MACE such as death and cardiac arrest within 72 h of arrival at the ED. For each patient, eight clinical signs such as blood pressure and temperature were measured, and a 5-min ECG was recorded to derive heart rate variability parameters. A random forest-based novel method was developed to select the most relevant variables. A geometric distance-based machine learning scoring system was then implemented to derive a risk score from 0 to 100. RESULTS Out of 702 patients, 29 (4.1%) met the primary outcome. We selected the 3 most relevant variables for predicting MACE, which were systolic blood pressure, the mean RR interval and the mean instantaneous heart rate. The scoring system with these 3 variables produced an area under the curve (AUC) of 0.812, and a cutoff score of 43 gave a sensitivity of 82.8% and specificity of 63.4%, while the scoring system with all the 23 variables had an AUC of 0.736, and a cutoff score of 49 gave a sensitivity of 72.4% and specificity of 63.0%. Conventional thrombolysis in myocardial infarction score and the modified early warning score achieved AUC values of 0.637 and 0.622, respectively. CONCLUSIONS It is observed that a few predictors outperformed the whole set of variables in predicting MACE within 72 h. We conclude that more predictors do not necessarily guarantee better prediction results. Furthermore, machine learning-based variable selection seems promising in discovering a few relevant and significant measures as predictors.
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Affiliation(s)
| | | | | | | | | | | | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608, Singapore.
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13
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Dave DM, Ferencic M, Hoffmann U, Udelson JE. Imaging techniques for the assessment of suspected acute coronary syndromes in the emergency department. Curr Probl Cardiol 2014; 39:191-247. [PMID: 24952880 PMCID: PMC8323766 DOI: 10.1016/j.cpcardiol.2014.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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14
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García-Salas JM, Tello-Montoliu A, Manzano-Fernández S, Casas-Pina T, López-Cuenca A, Pérez-Berbel P, Puche-Morenilla C, Martínez-Hernández P, Valdés M, Marín F. Interleukin-6 as a predictor of cardiovascular events in troponin-negative non-ST elevation acute coronary syndrome patients. Int J Clin Pract 2014; 68:294-303. [PMID: 24372920 DOI: 10.1111/ijcp.12245] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIM Risk stratification in acute coronary syndrome without ST-segment elevation (NSTE-ACS) and troponin-negative remains a challenge. We evaluated the value of interleukin-6 (IL-6) and amino-terminal pro-B-type natriuretic peptide (NT-proBNP) in the prognosis assessment of low-moderate risk NSTE-ACS and troponin-negative, and whether these biomarkers could improve the predictive performance of the established thrombolysis in myocardial infarction (TIMI) risk score. METHODS A total of 212 low-moderate risk patients with NSTE-ACS and troponin-negative were prospectively studied. Clinical follow up at 6 months was performed for adverse endpoints. RESULTS A total of 28 patients (13.5%) presented adverse clinical events. Those with adverse clinical events were associated with higher levels of IL-6 [8.58 (5.13-20.95) ng/l vs. 6.12 (4.16-9.14) ng/l, p = 0.043] and NT-proBNP [275.3 (108.6-548.2) ng/l vs. 126.8 (55.97-430.20) ng/l, p = 0.046]. In moderate risk group, we observed a higher event rate in patients with troponin-negative but elevated levels of IL-6 (p = 0.024). Only elevated IL-6 (> 12.40 ng/l) was an independent predictor of adverse outcomes [hazard ratios: 3.62, 95% confidence interval (CI) 1.69-7.75, p = 0.001]. The addition of IL-6 and history of ischaemic heart disease (IHD) to TIMI risk score significantly improved both the discrimination (integrated discrimination improvement, p = 0.003) and reclassification (Clinical Net reclassification improvement, p = 0.010) of the model for adverse events. CONCLUSIONS Interleukin-6 is an independent predictor of adverse events in low-moderate risk patients with NSTE-ACS and troponin-negative. Its use identifies a higher risk population in moderate-risk patients. This provides together with history of IHD a better discrimination and reclassification beyond that achieved with clinical risk variables from TIMI risk score in these patients.
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Affiliation(s)
- J M García-Salas
- Department of Clinical Analysis, University Hospital Virgen de la Arrixaca, Murcia, Spain
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Goodacre SW, Bradburn M, Mohamed A, Gray A. Evaluation of Global Registry of Acute Cardiac Events and Thrombolysis in Myocardial Infarction scores in patients with suspected acute coronary syndrome. Am J Emerg Med 2012; 30:37-44. [DOI: 10.1016/j.ajem.2010.09.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 09/02/2010] [Accepted: 09/09/2010] [Indexed: 12/22/2022] Open
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Sanchis J, Bodí V, Núñez J, Núñez E, Bosch X, Pellicer M, Heras M, Bardají A, Marrugat J, Llácer A. Identification of very low risk chest pain using clinical data in the emergency department. Int J Cardiol 2011; 150:260-3. [DOI: 10.1016/j.ijcard.2010.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 01/25/2010] [Accepted: 04/03/2010] [Indexed: 11/30/2022]
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Christ M, Popp S, Pohlmann H, Poravas M, Umarov D, Bach R, Bertsch T. Implementation of high sensitivity cardiac troponin T measurement in the emergency department. Am J Med 2010; 123:1134-42. [PMID: 20932502 DOI: 10.1016/j.amjmed.2010.07.015] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Revised: 06/23/2010] [Accepted: 07/14/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND we examined the diagnostic performance of high sensitivity cardiac troponin T (cTnThs) measurement and its ability to predict risk in unselected patients presenting to the emergency department with acute chest pain. METHODS we conducted a retrospective analysis of 137 consecutive patients with chest pain (age range, 66 ± 16 years; 64% male). A final diagnosis of acute myocardial infarction was made using the "old" (cTnT fourth-generation assay, ≥ 0.04 microg/L) or the "new" cutpoint (cTnThs ≥ 0.014 microg/L). RESULTS the adjudicated final diagnosis of acute myocardial infarction significantly increased from 20 to 35 patients (a 75% increase) and troponin-positive nonvascular cardiac chest pain from 10 to 30 (a 200% increase) using cTnThs. The number of patients with unstable angina or troponin-negative nonvascular cardiac chest pain significantly decreased (P <.05). Diagnostic performance of cTnThs levels at admission was significantly higher compared to cTnT levels (area under the curve [AUC] 0.85 vs AUC 0.70; P <.05). cTnThs levels below the detection limit (<0.003 microg/L) had a negative predictive value of 100% to exclude acute myocardial infarction. The event rate during 6 months of follow-up was low in patients with cTnThs levels <0.014 microg/L, while patients with cTnT levels ≥ 0.04 μg/L were at increased, and patients with cTnThs ≥ 0.014 μg/L and cTnT <0.04 microg/L at intermediate risk of death or recurrent myocardial infarction (P = .002). Risk was highest in chest pain patients with dynamic changes of cTnThs levels >30%. CONCLUSION the introduction of cTnThs assay displays an excellent diagnostic performance for the workup of patients with chest pain at the time of their initial presentation. Even small increases of cTnThs indicate increased risk for death or myocardial infarction during follow-up.
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Affiliation(s)
- Michael Christ
- Department of Emergency and Critical Care Medicine, City Hospital Nuremberg, Nuremberg, Germany.
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Bosch X, Loma-Osorio P, Guasch E, Nogué S, Ortiz JT, Sánchez M. Prevalence, clinical characteristics and risk of myocardial infarction in patients with cocaine-related chest pain. Rev Esp Cardiol 2010; 63:1028-1034. [PMID: 20804698 DOI: 10.1016/s1885-5857(10)70206-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
INTRODUCTION AND OBJECTIVES To investigate the frequency of recent cocaine use in patients attending an emergency department for acute chest pain, to describe the clinical characteristics of these patients, and to estimate the incidence of acute coronary syndrome in this population. METHODS Observational cohort study using a standard questionnaire that includes items on recent cocaine consumption. RESULTS During a 1-year period, 1240 patients aged under 55 years presented with chest pain. Of these, 63 (5%) had cocaine-related chest pain (7% of men and 1.8% of women). These patients were younger (35+/-10 years vs. 39+/-10 years; P=.002), were more frequently male (87% vs. 62%; P< .001), and were more frequently smokers (59% vs. 35%; P< .001). Patients who had used cocaine recently had a higher incidence of acute myocardial infarction (16 vs. 4%; P< .001), especially ST-segment-elevation myocardial infarction (11.1% vs. 1.6%; P< .01). After adjusting for coronary risk factors, history of cardiovascular disease and previous treatment, the odds ratio for myocardial infarction with recent cocaine consumption was 4.3 (95% confidence interval, 2-9.4). CONCLUSIONS Cocaine-related chest pain is often encountered in emergency departments, especially in men aged under 55 years. It is associated with a four-fold increase in the risk of acute myocardial infarction. All male patients aged under 55 years with acute chest pain should be asked about cocaine use.
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Affiliation(s)
- Xavier Bosch
- Servicio de Cardiología, Institut del Tórax, Hospital Clínic e Institut d'Investigacions Biomèdiques August Pi i Sunyer, Departamento de Medicina, Universidad de Barcelona, Barcelona, España.
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Prevalencia, características clínicas y riesgo de infarto de miocardio en pacientes con dolor torácico y consumo de cocaína. Rev Esp Cardiol 2010. [DOI: 10.1016/s0300-8932(10)70224-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Respuesta. Rev Esp Cardiol (Engl Ed) 2010; 63:372-3. [DOI: 10.1016/s0300-8932(10)70104-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Sanchis J, Bosch X, Bodí V, Núñez J, Doltra A, Heras M, Mainar L, Santas E, Bragulat E, García-Alvarez A, Carratalá A, Llácer A. Randomized comparison between clinical evaluation plus N-terminal pro-B-type natriuretic peptide versus exercise testing for decision making in acute chest pain of uncertain origin. Am Heart J 2010; 159:176-82. [PMID: 20152214 DOI: 10.1016/j.ahj.2009.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Accepted: 11/12/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND Exercise testing constitutes the usual tool for decision making in chest pain units. This policy implies logistical constrains. Our aim was to evaluate a new strategy, combining a clinical risk score and N-terminal pro-B-type natriuretic peptide (NT-proBNP), in patients presenting to the emergency department with chest pain, without ischemic electrocardiogram changes or troponin elevation. METHODS A total of 320 patients were randomized to either usual management, involving exercise testing, or a new strategy combining a clinical risk score and NT-proBNP without exercise testing. In the usual management, discharge decision was guided by the result of exercise test. In the new strategy, those patients with low clinical risk score and NT-proBNP were directly discharged. The primary outcome was hospitalization at the index episode. Secondary outcomes were cardiac events at 1 year. RESULTS A total of 110 patients (69%) were hospitalized using usual management in comparison with 90 (56%) in the new strategy (P = .03). There were no differences in death or myocardial infarction (n = 11, 6.9% vs n = 6, 3.8%, P = .3) or cardiac events (n = 38, 24% vs n = 28, 18%, P = .2). Revascularizations at the index episode were more frequent under usual management (18% vs 8%, P = .01), although the new strategy was associated with higher rate of planned postdischarge revascularizations (0.6% vs 5%, P = .04). CONCLUSIONS A strategy combining clinical history and NT-proBNP is simpler and reduced initial emergency hospitalizations in patients with chest pain, in comparison with the usual strategy involving exercise testing. Larger studies to assess its impact on long-term hard end points are needed.
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Hendel RC. Is computed tomography coronary angiography the most accurate and effective noninvasive imaging tool to evaluate patients with acute chest pain in the emergency department? CT coronary angiography is the most accurate and effective noninvasive imaging tool for evaluating patients presenting with chest pain to the emergency department: antagonist viewpoint. Circ Cardiovasc Imaging 2009; 2:264-75; discussion 275. [PMID: 19808601 DOI: 10.1161/circimaging.109.858167] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Sanchis J, Bodí V, Núñez J, Mainar L, Núñez E, Merlos P, Rúmiz E, Miñana G, Bosch X, Llácer A. Efficacy of coronary revascularization in patients with acute chest pain managed in a chest pain unit. Mayo Clin Proc 2009; 84:323-9. [PMID: 19339649 PMCID: PMC2665976 DOI: 10.1016/s0025-6196(11)60540-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate the safety of discharge of patients deemed at low risk of cardiac events after evaluation in a chest pain unit and to determine the prognostic effect of revascularization of patients deemed at high risk. PATIENTS AND METHODS The study population consisted of 1088 patients presenting at the emergency department from January 15, 2001, to September 1, 2006, with chest pain but without ischemia on electrocardiography or troponin elevation. Patients were managed by a chest pain unit protocol that included early exercise testing. Three groups of patients were distinguished: (1) those discharged after exercise testing (424 [39%]); (2) those in whom unstable angina was ruled out after in-hospital evaluation (208 [19%]); and (3) those in whom unstable angina was confirmed or not ruled out (456 [42%]). Of the 456 patients in group 3, 183 (40%) were revascularized at the index episode. The primary end point was the occurrence of myocardial infarction or death within 1 year. Adjustments were made for patient characteristics and a propensity score for revascularization (c statistic [0.83]). RESULTS Groups 1 and 2 showed lower rates of the primary end point than group 3 (group 1: 7 [1.7%]; group 2: 1 [0.5%]; group 3: 62 [13.6%]; P=.001). In group 3, revascularization at the index episode did not reduce the primary end point in the univariate (22 [12%] vs 29 [11%]; P=.80) and multivariate (hazard ratio, 1.4; 95% confidence interval, 0.7-2.5; P=.40) analyses. In-hospital revascularization decreased the need for postdischarge revascularization (hazard ratio, 0.3; 95% confidence interval, 0.1-0.7; P=.01). CONCLUSION Chest pain unit protocols are associated with safe patient discharge. Although early revascularizations may decrease the need for postdischarge revascularizations, they may not improve 1-year outcomes by reducing the number of myocardial infarctions or deaths.
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Affiliation(s)
- Juan Sanchis
- Servei de Cardiologia, Hospital Clínic Universitari, Universitat deValència, València, Spain.
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Núñez J, Sanchis J, Bodí V, Núñez E, Mainar L, Heatta AM, Husser O, Miñana G, Merlos P, Darmofal H, Pellicer M, Llàcer A. Relationship between low lymphocyte count and major cardiac events in patients with acute chest pain, a non-diagnostic electrocardiogram and normal troponin levels. Atherosclerosis 2009; 206:251-7. [PMID: 19230894 DOI: 10.1016/j.atherosclerosis.2009.01.029] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2008] [Revised: 01/06/2009] [Accepted: 01/19/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Risk stratification of patients with acute chest pain, non-diagnostic electrocardiogram and normal troponin (ACPneg) remains a challenge, partly because no standardized set of biomarkers with prognostic ability has been identified in this population. Lymphopenia has been associated with atherosclerosis progression and adverse outcomes in cardiovascular diseases; although its prognostic value in ACPneg is unknown. We sought to determine the relationship between the lymphocyte count obtained in the Emergency Department (ED) and the risk of the long-term all-cause mortality or myocardial infarction (MI) in patients with ACPneg. METHODS We analyzed 1030 consecutive patients admitted with ACPneg in our institution. Lymphocyte count was determined in the ED as a part of a routine diagnostic workup to rule out an acute coronary syndrome. Patients with inflammatory, infectious diseases, or active malignancy were excluded (final sample=975). The independent association between lymphocyte count and the composite endpoint (death/MI) was assessed by survival analysis for competing risk events (revascularization procedures). RESULTS During a median follow-up of 36 months, 139 (14.3%) patients achieved the combined endpoint, with rates increasing monotonically across lymphocyte quartiles (6.2%, 10%, 20.6% and 24.1% for Q4, Q3, Q2 and Q1 (p<0.001), respectively). In a multivariable analysis, patients in lymphocytes' Q1 and Q2 as compared with those in Q4 had an increased risk for the combined endpoint: HR=2.45 (CI 95% 1.25-4.79, p=0.008) and HR=2.56 (CI 95% 1.30-5.07, p=0.007), respectively. CONCLUSION In patients with ACPneg, low lymphocytes count was associated with an increased risk for developing the combined endpoint of death or MI.
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Affiliation(s)
- Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de Valencia, Avda. Blasco Ibáñez 17, Valencia, Spain.
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Barrabés JA, Sanchís J, Sánchez PL, Bardají A. Actualización en cardiopatía isquémica. Rev Esp Cardiol (Engl Ed) 2009; 62 Suppl 1:80-91. [DOI: 10.1016/s0300-8932(09)70043-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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