Initial approach to the patient who has chest pain

A Heart Rate-Dependent Protocol of "One-Stop" Computed Tomography Angiography of Coronary Combined with Pulmonary Arteries Reduces the Dosages of Contrast Agent

Background:

The personalized, heart rate-dependent computed tomography angiography (CTA) protocol can reduce the use of contrast medium (CM) and the radiation dose. This is especially beneficial for patients with CTA of coronary combined with pulmonary arteries.

Purpose:

To evaluate the feasibility of low CM in one-stop coronary and pulmonary arterial CTA tailored by patients’ heart rate.

Material and Methods:

94 patients set to undergo CTA of coronary combined with pulmonary arteries with one-stop scans. Patients were prospectively randomized into two groups: For group A (n = 47), the timing of the scans was determined according to the patient’s HR using 30 mL CM; For group B (n = 47), in which the routine bolus tracking was applied by setting the ascending aortic threshold of 80 HU with 70 mL CM, scans were performed simultaneously.

Results:

Compared with group B, group A had slightly higher computed tomography (CT) value and image quality of pulmonary artery (CT value: group A 484.7HU; group B 457.9HU; t = 2.446, P = .016; image quality: χ2 = 8.292, P = .016), but in coronary artery wasn’t statistically different between two groups(image quality: χ2 = 2.516, P = .642).

Conclusion:

The heart rate-dependent CM injection protocol can greatly reduce the use of CM, simplify the work-flow, and may obtain comparable or even better image quality compared with the routine bolus tracking.

Age and clinical outcomes in patients presenting with acute coronary syndromes

CONTEXT

Elderly patients have more cardiovascular risk factors and a greater burden of ischemic disease than younger patients.

AIMS

To examine the impact of age on clinical presentation and outcomes in patients presenting with acute coronary syndrome (ACS).

METHODS AND MATERIAL

Collected data from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2), which is a prospective multicenter study from six adjacent Arab Middle Eastern Gulf countries. Patients were divided into 3 groups according to their age: ≤50 years, 51-70 years and >70 years and their clinical characteristics and outcomes were analyzed. Mortality was assessed at one and 12 months.

STATISTICAL ANALYSIS USED

One-way ANOVA test for continuous variables, Pearson chi-square (X (2)) test for categorical variables and multivariate logistic regression analysis for predictors were performed.

RESULTS

Among 7930 consecutive ACS patients; 2755 (35%) were ≤50 years, 4110 (52%) were 51-70 years and 1065 (13%) >70 years old. The proportion of women increased with increasing age (13% among patients ≤50 years to 31% among patients > 70 years). The risk factor pattern varied with age; younger patients were more often obese, smokers and had a positive family history of CAD, whereas older patients more likely to have diabetes mellitus, hypertension, and dyslipidemia. Advancing age was associated with under-treatment evidence-based therapies. Multivariate logistic regression analysis after adjusting for relevant covariates showed that old age was independent predictors for re-ischemia (OR 1.29; 95% CI 1.03-1.60), heart failure (OR 2.8; 95% CI 2.17-3.52) and major bleeding (OR 4.02; 95% CI 1.37-11.77) and in-hospital mortality (age 51-70: OR 2.67; 95% CI 1.86-3.85, and age >70: OR 4.71; 95% CI 3.11-7.14).

CONCLUSION

Despite being higher risk group, elderly are less likely to receive evidence-based therapies and had worse outcomes. Guidelines adherence is highly recommended in elderly.

Shifting up cutoff value of d-dimer in the evaluation of pulmonary embolism: a viable option? Possible risks and benefits

Objectives. To evaluate the viability of the possibility to use a higher D-dimer value than the one used today in the clinical algorithms evaluating patients suspected to have pulmonary embolism. Methods. A retrospective analysis of 300 serial patients for whom D-dimer values were taken during a 10 month period in the emergency room of a tertiary medical center. Results. Our analysis showed that it may be safe and cost effective to use a D-dimer value of 900 ng/ml rather than the value of 500 ng/ml accepted today, with sensitivity of 94.4%. In younger patients [under 40 years] the sensitivity reached was even higher-100%. Conclusions. Raising cutoff values of D-dimer in screening for pulmonary embolism seems a viable option. There may be a place for "tailoring" cutoff values according individual patient characteristics, such as according age groups. More studies of the subject are warranted.

The triple work-up for emergency department patients with acute chest pain: how often does it occur?

OBJECTIVES

To measure the degree of overlap and diagnostic yield for evaluations of acute coronary syndrome (ACS), pulmonary embolism (PE), and aortic dissection (AD) among Emergency Department (ED) patients.

METHODS

We conducted a cross-sectional descriptive study of consecutive adult patients seen in the ED of a 78,000-annual-visit urban academic medical center. Patients who had received at least one of eight of the tests used in our ED to diagnose these three diseases were identified through three methods, and a final study population list was created. Overlap of evaluations and diagnostic yields were calculated by simple descriptive statistics.

RESULTS

Over a 2-week period, 626 patient encounters among 622 unique patients were identified. Among these 626 visits, 139 (22%) included diagnostic tests for more than one of the three diagnoses of interest. The majority of these multiple tests were for ACS plus PE (n = 121, 87% of all multiple tests), whereas a minority of patients received tests for ACS plus AD (n = 14, 10% of all multiple tests) or for the "triple work-up" of ACS plus PE plus AD (n = 4, 2.9% of all multiple tests).

CONCLUSION

Although the "triple work-up" evaluation for ACS, PE, and AD is relatively uncommon, a significant number of ED patients who are evaluated for at least one of these three major chest pain syndromes receive simultaneous testing for one of the others.

Evaluation of the Elderly Patient with Acute Chest Pain

Chest pain is one of the most common and serious chief complaints. Geriatricians must be well versed in evaluating elderly patients who have chest pain. This article discusses the initial diagnostic evaluation of elderly patients with chest pain. Specific emphasis is placed on identifying acute coronary syndromes, aortic dissection, pulmonary embolism, and pericarditis with cardiac tamponade. By understanding the different presentations of these potentially life-threatening emergencies, the geriatrician will be better prepared to distinguish them from less dire conditions and to initiate prompt treatment.