1
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Song DH, Choi JH, Lee JY. Predicting acute aortic syndrome using aortic dissection detection risk score, D-dimer, and X-ray. Heliyon 2023; 9:e20578. [PMID: 37800065 PMCID: PMC10550511 DOI: 10.1016/j.heliyon.2023.e20578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 09/22/2023] [Accepted: 09/29/2023] [Indexed: 10/07/2023] Open
Abstract
Objective Acute aortic syndrome (AAS) is a fatal disease with high mortality. There were previous studies using aortic dissection detection risk score (ADD-RS) and D-dimer (DD) to screen AAS. There were screening failures in previous studies, suggesting the need for a more accurate tool. This study investigated the effect of combining ADD-RS and age adjusted D-dimer (DDage-adj) with abnormal findings on chest radiographs on the diagnosis of AAS in patients admitted to emergency department (ED). Methods This single-center retrospective case-control study included 93 patients with AAS and 465 with chest pain (CP), diagnosis other than AAS. We attempted to compare the initial clinical presentation and laboratory examination findings. Results Age-adjusted DD (DDage-adj), defined as age x 0.01 mg/L in patients ≥50 years, showed sensitivity of 92.5% and specificity of 76.3% for patients with AAS (p < 0.001). Positive chest radiography findings were significant with AAS group; sensitivity was 89.2% with a specificity of 80.9% (p < 0.001). Multivariate logistic regression analysis was used; widened mediastinum, widening of aortic contour and aortic kinking indicates the probability of AAS in patients with CP (p < 0.05).ADD-RS was used to evaluate the risk of AAS. For low risk group, ADD-RS ≤1, combined use of chest radiography and DDage-adj showed meaningful result. Sensitivity and specificity were 100% and 67.1% with failure rate of 0% (p < 0.001). Multivariate logistic regression analysis were made; widening of the mediastinum (p = 0.035), widening of the aortic contour (p < 0.001) and aortic kinking (p < 0.001) showed significant p-value. Combining DDage-adj and these three chest radiography findings in ADD-RS≤1 patients resulted 0% failure rate with 67.8% specificity (p < 0.001). Conclusions The combination of ADD-RS, DDage-adj and chest radiography could lower the failure rate of AAS exclusion strategy. This combination strategy satisfies low failure rate (<3%) and yields relatively high specificity of 67.8%.
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Affiliation(s)
- Dae Ho Song
- Department of Emergency Medicine, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Republic of Korea
| | - Jin Ho Choi
- Department of Thoracic and Cardiovascular Surgery, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Republic of Korea
| | - Jang Young Lee
- Department of Emergency Medicine, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Republic of Korea
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2
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Umaña JP, Camacho J. Disección aórtica aguda: diagnóstico y manejo inicial. REVISTA MÉDICA CLÍNICA LAS CONDES 2022. [DOI: 10.1016/j.rmclc.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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3
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Sultan MA, Hakami AA, Alshabri MI, Alsuwailem SA, Aqeel NE, Aldosari RN, Alrazhi TH, Al-Wesabi KA, Alzayed AA, Alanazi MA, Al Yousef AS, Alromaihi AS, Aljadeed RM, Alomar SH, Alshammari M. Gastric Volvulus: A Rare Etiology of Acute Chest Pain. Cureus 2021; 13:e19067. [PMID: 34824944 PMCID: PMC8610430 DOI: 10.7759/cureus.19067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2021] [Indexed: 11/12/2022] Open
Abstract
Chest pain is one of the most common complaints in the emergency department. The etiologies of chest pain include a wide spectrum of conditions, ranging from mild and self-limited to life-threatening conditions. Gastrointestinal origins of acute chest pain, including esophageal, gastric, and biliary conditions, are not uncommon. We present the case of a 67-year-old man who presented to the emergency department with chest pain of three hours duration with pressure-like quality. The pain was associated with sweating, palpitation, nausea, and vomiting. The past medical history of the patient was remarkable for ischemic heart disease and percutaneous cardiac intervention. Both the electrocardiograph and cardiac biomarkers were normal. The patient experienced severe episodes of vomiting with one episode containing a small amount of blood. Upper gastrointestinal endoscopy revealed distorted anatomy of the stomach. Subsequently, the patient underwent a computed tomography scan which demonstrated an organoaxial gastric volvulus. The patient was resuscitated and underwent laparoscopic repair of the volvulus. Acute gastric volvulus is a very rare etiology of chest pain. Despite its rarity, physicians should keep a high index of suspicion of this condition after excluding the possible cardiac causes of chest pain.
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Affiliation(s)
| | | | | | | | | | - Rajis N Aldosari
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | | | | | - Abdullah A Alzayed
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Majed A Alanazi
- College of Medicine, Jordan University of Science and Technology, Irbid, JOR
| | | | | | - Roaa M Aljadeed
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Sahar H Alomar
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Malak Alshammari
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
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4
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Ng M, Liu Z, Tan JSL, Ponampalam R. Comparison of self-reported EDACS versus physician-reported EDACS for the triage of chest pain patients in the emergency department. J Am Coll Emerg Physicians Open 2021; 2:e12393. [PMID: 33718926 PMCID: PMC7926007 DOI: 10.1002/emp2.12393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/01/2021] [Accepted: 01/28/2021] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Currently, there are no guidelines to help triage nurses identify high-risk emergency department chest pain patients. Patient self-reporting of Emergency Department Assessment of Chest Pain Score (EDACS) could facilitate more reliable triage compared to nursing gestalt, but this novel concept is untested. This study hypothesizes that because EDACS requires minimal clinical gestalt to derive, self-reported EDACS (S-EDACS) at triage is likely to correlate well with traditional physician-reported EDACS (P-EDACS) and have potential application as a triage tool. METHODS This single-center pilot prospective cohort study analyzed 60 patients who completed a self-reported questionnaire upon triage to determine their S-EDACS. This was matched against P-EDACS, derived from an identical questionnaire completed by the blinded treating physician. Secondary endpoint of major adverse cardiovascular events (MACE) within 30 days (all-cause mortality, myocardial infarction, coronary revascularization) was assessed by 2 blinded emergency physicians who independently reviewed the electronic medical records. S/P-EDACS also were benchmarked against nursing gestalt (based on triage to low/high-acuity areas) and emergency physician gestalt (disposition and admitting/discharge diagnoses). RESULTS There was perfect agreement between S/P-EDACS in this study (K = 1.00). Fifteen patients (25.0%) had minor discordances in their absolute S/P-EDACS that did not affect risk stratification. Of these, 11/15 (73.3%) had higher S-EDACS, suggesting S-EDACS is more likely to safely overcall MACE risk. S-EDACS outperformed nursing gestalt, triaging a greater proportion of patients (71.7% vs 35.0%) as low risk without compromising patient safety, and demonstrated similar accuracy as emergency physician gestalt. CONCLUSION S-EDACS strongly correlates with P-EDACS with perfect agreement and has potential to be used as a triage tool.
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Affiliation(s)
- Mingwei Ng
- Department of Emergency MedicineSingapore General HospitalSingapore
| | - Zhenghong Liu
- Department of Emergency MedicineSingapore General HospitalSingapore
| | - Jean Su Ling Tan
- Department of Emergency MedicineSingapore General HospitalSingapore
| | - R. Ponampalam
- Department of Emergency MedicineSingapore General HospitalSingapore
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5
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Lubin IM, Lockhart ER, Frank J, See VY, Vashist S, Greene C. Challenges and opportunities for integrating genetic testing into a diagnostic workflow: heritable long QT syndrome as a model. Diagnosis (Berl) 2021; 8:17-26. [PMID: 31287796 DOI: 10.1515/dx-2019-0018] [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: 03/04/2019] [Accepted: 06/18/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND An increasing number of diagnostic evaluations incorporate genetic testing to facilitate accurate and timely diagnoses. The increasing number and complexity of genetic tests continue to pose challenges in deciding when to test, selecting the correct test(s), and using results to inform medical diagnoses, especially for medical professionals lacking genetic expertise. Careful consideration of a diagnostic workflow can be helpful in understanding the appropriate uses of genetic testing within a broader diagnostic workup. CONTENT The diagnosis of long QT syndrome (LQTS), a life-threatening cardiac arrhythmia, provides an example for this approach. Electrocardiography is the preferred means for diagnosing LQTS but can be uninformative for some patients due to the variable presentation of the condition. Family history and genetic testing can augment physiological testing to inform a diagnosis and subsequent therapy. Clinical and laboratory professionals informed by peer- reviewed literature and professional recommendations constructed a generalized LQTS diagnostic workflow. This workflow served to explore decisions regarding the use of genetic testing for diagnosing LQTS. SUMMARY AND OUTLOOK Understanding the complexities and approaches to integrating genetic testing into a broader diagnostic evaluation is anticipated to support appropriate test utilization, optimize diagnostic evaluation, and facilitate a multidisciplinary approach essential for achieving accurate and timely diagnoses.
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Affiliation(s)
- Ira M Lubin
- Division of Laboratory Systems, Centers for Disease Control and Prevention, Atlanta, USA
| | - Edward R Lockhart
- Division of Laboratory Systems, Centers for Disease Control and Prevention, Atlanta, USA
| | - Julie Frank
- Division of Genetics and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Vincent Y See
- Cardiovascular Medicine Division and Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sudhir Vashist
- Division of Cardiology and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Carol Greene
- Division of Genetics and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
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6
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Ng M, Tan HJG, Gao F, Tan JWC, Lim SH, Ong MEH, Ponampalam R. Comparative prospective study of the performance of chest pain scores and clinical assessment in an emergency department cohort in Singapore. J Am Coll Emerg Physicians Open 2020; 1:723-729. [PMID: 33145512 PMCID: PMC7593418 DOI: 10.1002/emp2.12242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/06/2020] [Accepted: 08/14/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Chest pain scores allow emergency department (ED) physicians to identify low-risk patients for whom discharge can be safely expedited. Although these have been extensively validated in Western cohorts, data in patients of Asian heritage are lacking. This study aimed to determine the accuracy of HEART, ED Assessment of Chest Pain Score (EDACS), and Global Registry of Acute Coronary Events (GRACE) in risk-stratifying which chest pain patients are at risk of major adverse cardiovascular events within 30 days (composite of all-cause mortality, acute myocardial infarction and coronary revascularization). METHODS This single-center prospective cohort-study that enrolled 1200 patients was conducted by a large urban tertiary center in Singapore. Chest pain scores were reported before disposition by research assistants blinded to the physician's clinical assessment. Outcomes were assessed independently by a blinded cardiologist and emergency physician, while another cardiologist adjudicated in the case of discrepancies. RESULTS Of the 1195 patients analyzed, 135 (11.3%) suffered major adverse cardiovascular events within 30 days. HEART, which ruled out major adverse cardiovascular events in 52.8% of patients with 88.1% sensitivity, and EDACS, which ruled out major adverse cardiovascular events in 57.5% of patients with 83.7% sensitivity, proved comparable to clinical judgment that ruled out major adverse cardiovascular events in 73.0% of patients with 85.5% sensitivity. GRACE was weaker-ruling out major adverse cardiovascular events in 79.2% of patients with a dismal sensitivity of 45.0%. The correlation-statistic for HEART (79.4%) was superior to EDACS (69.9%) and GRACE (69.2%). CONCLUSIONS HEART more accurately identified low-risk chest pain patients in an Asian ED, demonstrating comparable performance characteristics to clinical judgment. This has major implications on the use of chest pain scores to safely expedite disposition decisions for low-risk chest pain patients.
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Affiliation(s)
- Mingwei Ng
- Department of Emergency MedicineSingapore General HospitalSingapore
| | | | - Fei Gao
- Department of CardiologyNational Heart Centre SingaporeSingapore
| | | | - Swee Han Lim
- Department of Emergency MedicineSingapore General HospitalSingapore
| | | | - R Ponampalam
- Department of Emergency MedicineSingapore General HospitalSingapore
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7
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Bang C, Hansen C, Lauridsen KG, Frederiksen CA, Schmidt M, Jensen T, Hornung N, Løfgren B. Rapid use of high-sensitive cardiac troponin I for ruling-in and ruling-out of acute myocardial infarction (RACING-MI): study protocol. Open Heart 2019; 6:e000995. [PMID: 31168384 PMCID: PMC6519406 DOI: 10.1136/openhrt-2018-000995] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 02/18/2019] [Accepted: 03/04/2019] [Indexed: 12/27/2022] Open
Abstract
Introduction The European Society of Cardiology has suggested an accelerated algorithm for ruling-in and ruling-out myocardial infarction (MI) with high-sensitive cardiac troponin (hs-cTn) measured at admission (0 hour) and after 1 hour (1 hour) as an alternative to standard measurements at 0 hour and 3 hours. However, the 0 hour/1 hour algorithm has only been tested in a limited amount of patient cohorts and not for all hs-cTn assays. Moreover, it is unknown if MI can be ruled-out faster than 1 hour. In this single-centre, clinical trial, we will investigate whether MI safely can be ruled-in or ruled-out after 30 min and 1 hour. Methods and analysis Patients with chest pain suggestive of MI admitted to the emergency department will be subjected to hs-cTn measurements at the following time points: 0 hour, 30 min, 1 hour and 3 hours. Chest pain characteristics will be recorded. In total, 1000 patients with all four blood samples will be included. The diagnostic algorithms will be derived based on the first 500 patients and validated in the subsequent 500 patients. The primary endpoint is the negative predictive value of the 0 hour/30 min and the 0 hour/1 hour algorithms. Secondary endpoints include positive predictive value, sensitivity and specificity. Results will be compared with the standard 0 hour/3 hour algorithm. Ethics and dissemination Oral and written informed consent will be obtained from all patients. The trial is approved by The Regional Committee on Health Research Ethics and the Danish Data Protection Agency. Data will be disseminated and submitted to peer-reviewed scientific journals and meetings irrespective of study outcome. Trial registration number NCT03634384
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Affiliation(s)
- Camilla Bang
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
| | - Camilla Hansen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
| | - Kasper Glerup Lauridsen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
| | | | - Morten Schmidt
- Department of Cardiology, Regional Hospital West Jutland, Herning, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Tage Jensen
- Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
| | - Nete Hornung
- Department of Biochemistry, Regional Hospital West Jutland, Herning, Denmark
| | - Bo Løfgren
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
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8
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Schiffman JS. Chest pain as a manifestation of hypokalemia in a pediatric patient. Am J Emerg Med 2017; 36:342.e3-342.e5. [PMID: 29126579 DOI: 10.1016/j.ajem.2017.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 10/19/2017] [Accepted: 11/01/2017] [Indexed: 12/25/2022] Open
Abstract
Patients presenting to the emergency department with chest pain are common and a cause of significant concern to patients and families and physicians alike. The causes of chest pain are myriad. These causes span diverse categories including cardiovascular, respiratory, abdominal and gastrointestinal, musculoskeletal, psychiatric, hematologic and oncologic, and neurologic Thull-Freedman (2010) [1]. These diverse etiologies present a diagnostic and management challenge to the ER physician who is tasked to minimize unnecessary diagnostics while not missing any significant disease. Multiple reviews have discussed the various etiologies of chest pain in the pediatric patient presenting to the ER but none of these recent reviews has included hypokalemia as a cause of chest pain Talner and Carboni (2000), Cava and Sayger (2004), Ringstrom and Freedman (2006), Foy and Filippone (2015), Yeh and Yeh (2015) [2-6]. Additionally, no reviews of hypokalemia describe this condition presenting with chest pain (Mandal, 1997; Gennari, 2002; Medford-Davis and Rafique, 2014 [7-9]). This case report describes a pediatric patient who presents with chest pain that was attributed to hypokalemia. This report attempts to make practitioners aware that hypokalemia may present with chest pain and to encourage ER providers to include this in the differential diagnosis.
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Affiliation(s)
- Jonathan S Schiffman
- Valley Hospital, Department of Emergency Medicine, 223 North Van Dien Avenue, Ridgewood, NJ 07450, USA.
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9
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Asking the Patient or Measuring Blood Pressure in the Emergency Department: Which One is Best? Curr Hypertens Rep 2017; 18:53. [PMID: 27209495 DOI: 10.1007/s11906-016-0659-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Blood pressure (BP) is obtained at the emergency department (ED) in the vast majority of patients; irrespective of chief complaint, and elevated BP, above the threshold for hypertension, is a common observation. In this review, we address the predictive value of measured BP in the ED compared to that of a history of hypertension in patients with chief complaints related to cardiovascular disease. In chest pain patients, a high BP at the ED is associated to a good prognosis, whereas the history of hypertension is associated to a poor prognosis. In heart failure, a high admission BP is consistently linked to a good prognosis, whereas the clinical value of history of hypertension in the ED is unknown. In stroke, there is a U-shaped relation between admission BP and outcome. A history of hypertension is common among stroke patients but does not seem to provide any predictive value in the ED.
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10
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Zuin G, Parato VM, Groff P, Gulizia MM, Di Lenarda A, Cassin M, Cibinel GA, Del Pinto M, Di Tano G, Nardi F, Rossini R, Ruggieri MP, Ruggiero E, Scotto di Uccio F, Valente S. ANMCO-SIMEU Consensus Document: in-hospital management of patients presenting with chest pain. Eur Heart J Suppl 2017; 19:D212-D228. [PMID: 28751843 PMCID: PMC5520764 DOI: 10.1093/eurheartj/sux025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. However, the evaluation of acute chest pain remains challenging, despite many new insights over the past two decades. The percentage of patients presenting to the emergency departments because of acute chest pain appears to be increasing. Nowadays, there are two essential chest pain-related issues: (i) the missed diagnoses of acute coronary syndromes with a poor short-term prognosis; and (ii) the increasing percentage of hospitalizations of low-risk cases. It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs. Therefore, the significantly reduced financial resources of healthcare systems induce physicians and administrators to improve the efficiency of care protocols for patients with acute chest pain. Despite the efforts of the Scientific Societies in producing statements on this topic, in Italy there is still a significant difference between emergency physicians and cardiologists in managing patients with chest pain. For this reason, the aim of the present consensus document is double: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the critical pathways (describing key steps) that need to be implemented in order to standardize the management of chest pain patients, making a correct diagnosis and treatment as uniform as possible across the entire country.
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Affiliation(s)
- Guerrino Zuin
- Cardiology Unit, Ospedale dell’Angelo, Mestre, Via Paccagnella, 11 30174 VE, Italy
| | - Vito Maurizio Parato
- Cardiology Rehabilitation, Ospedale Madonna del Soccorso, Cardiology Unit, ASUR Marche/AV5—Madonna del Soccorso Hospital, 4-7, via Luciano Manara, 63074, San Benedetto del Tronto (Ascoli Piceno), Italy
| | - Paolo Groff
- Emergency Department, Ospedale Madonna del Soccorso, San Benedetto del Tronto (Ascoli Piceno), Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
| | - Matteo Cassin
- Cardiology Department, A.O. Santa Maria degli Angeli, Pordenone, Italy
| | | | | | | | - Federico Nardi
- Cardiology Department, Ospedale Castelli, Verbania, Italy
| | - Roberta Rossini
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Maria Pia Ruggieri
- Emergency-Admission Department, A.O. San Giovanni-Addolorata, Rome, Italy
| | | | | | - Serafina Valente
- Intensive Integrated Cardiology Department, AOU Careggi, Florence, Italy
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11
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Zhu Z, Islam S, Bergmann SR. Effectiveness and outcomes of a nurse practitioner–run chest pain evaluation unit. J Am Assoc Nurse Pract 2016; 28:591-595. [DOI: 10.1002/2327-6924.12377] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 03/21/2016] [Indexed: 11/06/2022]
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12
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Sénior JM, Tamayo N, Fernández A, Rodríguez AE. Anomalías de las arterias coronarias. IATREIA 2015. [DOI: 10.17533/udea.iatreia.v29n1a09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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