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Thesen T, Himle JA, Pripp AH, Sunde T, Walseth LT, Thorup F, Gallefoss F, Jonsbu E. Patients with depression symptoms are more likely to experience improvements of internet-based cognitive behavioral therapy: a secondary analysis of effect modifiers in patients with non-cardiac chest pain in a randomized controlled trial. BMC Psychiatry 2023; 23:751. [PMID: 37838653 PMCID: PMC10576305 DOI: 10.1186/s12888-023-05238-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 09/30/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND Non-cardiac chest pain is common and associated with increased anxiety and reduced health-related quality of life. Randomized controlled trials on psychological interventions for patients with non-cardiac chest pain have reported mixed results. Patients with non-cardiac chest pain are a heterogeneous group. Identifying sub-groups that could potentially benefit more (or less) from an intervention would be valuable knowledge. We have conducted a randomized controlled trial where internet-based cognitive behavioural therapy (iCBT) had effect on reducing cardiac anxiety and increasing health-related quality of life at 12-month follow-up. The aim of the present study was to explore potential effect modifiers of iCBT in patients with non-cardiac chest pain on cardiac anxiety and/or health related quality of life at 12-month follow-up. METHODS We analysed data from our randomized, controlled trial where 161 patients with non-cardiac chest pain were included and randomized to either iCBT or a treatment as usual (control). Cardiac anxiety measured by the Cardiac Anxiety Questionnaire and health-related quality of life measured by the EuroQol Visual Analog Scale at 12 month follow-up were the primary outcomes. Four potential baseline characteristics where identified as potential effect modifiers by a theory-based approach: (1) depression measured by the Patient Health Questionnaire; (2) anxiety measured by the Body Sensations Questionnaire; (3) prior healthcare contacts measured by a self-developed question; and (4) chest pain frequency measured by a self-developed question. Each potential effect modifier was analysed in a linear regression model where cardiac anxiety and EQ-VAS scores at 12-month follow-up, separately, were used as dependent variables. The potential differential treatment effect for each effect modifier was assessed by the interaction term: effect modifier x treatment group. RESULTS Depression symptoms at baseline predicted a differential treatment effect at 12-month follow-up on health-related quality of life in favor of the iCBT group (regression coefficient of the interaction term: -1.85 (CI -3.28 to -0.41), p = 0.01), but not on cardiac anxiety at 12-month follow-up. Fear of bodily symptoms, chest pain frequency and prior health care contacts at baseline did not predict a treatment effect on either health-related quality of life or cardiac anxiety. CONCLUSIONS Depression symptoms at baseline predicted a positive treatment effect of iCBT on health-related quality of life in patients suffering from non-cardiac chest pain. This indicates that it is important to identify patients with non-cardiac chest pain and co-occurring depression symptoms given that they are particularly likely to benefit from iCBT. TRIAL REGISTRATION ClinicalTrials.gov NCT03096925 .
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Affiliation(s)
- Terje Thesen
- DPS Solvang, Sørlandet Hospital, SSHF, Servicebox 416, Kristiansand, 4604, Norway.
- Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Joseph A Himle
- School of Social Work and School of Medicine-Psychiatry, University of Michigan, Ann Arbor, USA
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Tor Sunde
- DPS Solvang, Sørlandet Hospital, SSHF, Servicebox 416, Kristiansand, 4604, Norway
| | - Liv T Walseth
- Department of Clinical Research, Sørlandet Hospital, SSHF, Kristiansand, Norway
| | - Frode Thorup
- Department of Cardiology, Sørlandet Hospital, SSHF, Kristiansand, Norway
| | - Frode Gallefoss
- Department of Clinical Research, Sørlandet Hospital, SSHF, Kristiansand, Norway
- Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Egil Jonsbu
- Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Psychiatry, Møre and Romsdal Hospital Trust, Molde, Norway
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Flóvenz SÓ, Salkovskis P, Svansdóttir E, Karlsson HD, Andersen K, Sigurðsson JF. Non-Cardiac Chest Pain as a Persistent Physical Symptom: Psychological Distress and Workability. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2521. [PMID: 36767887 PMCID: PMC9915178 DOI: 10.3390/ijerph20032521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/13/2023] [Accepted: 01/27/2023] [Indexed: 06/18/2023]
Abstract
Non-Cardiac Chest Pain (NCCP) is persistent chest pain in the absence of identifiable cardiac pathology. Some NCCP cases meet criteria for Persistent Physical Symptoms (PPS), where the symptoms are both persistent and distressing/disabling. This study aimed to identify patients that might need specialist treatment for PPS by examining cases of NCCP that meet PPS criteria. We analysed data from 285 chest pain patients that had received an NCCP diagnosis after attending an emergency cardiac department. We compared NCCP patients who did and did not meet the additional criteria for heart-related PPS and hypothesised that the groups would differ in terms of psychological variables and workability. We determined that NCCP patients who meet PPS criteria were more likely than other NCCP patients to be inactive or unable to work, reported more general anxiety and anxiety about their health, were more depressed, ruminated more, and, importantly, had a higher number of other PPS. A high proportion of NCCP patients meet PPS criteria, and they are similar to other PPS patients in terms of comorbidity and disability. This highlights the importance of focusing psychological interventions for this subgroup on the interplay between the range of physical and psychological symptoms present.
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Affiliation(s)
| | - Paul Salkovskis
- Oxford Centre for Psychological Health, Oxford Institute of Clinical Psychology Training and Research Oxford Cognitive Therapy Centre, Warneford Hospital, Oxford University, Oxford OX3 7JX, UK
| | - Erla Svansdóttir
- The National Hospital of Iceland, 101 Reykjavik, Iceland
- Faculty of Psychology, School of Health Sciences, University of Iceland, 101 Reykjavik, Iceland
| | | | - Karl Andersen
- The National Hospital of Iceland, 101 Reykjavik, Iceland
- Faculty of Medicine, School of Health Sciences, University of Iceland, 102 Reykjavik, Iceland
| | - Jón Friðrik Sigurðsson
- Department of Psychology, Reykjavik University, 101 Reykjavik, Iceland
- Faculty of Medicine, School of Health Sciences, University of Iceland, 102 Reykjavik, Iceland
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Mu D, Cheng J, Qiu L, Cheng X. Copeptin as a Diagnostic and Prognostic Biomarker in Cardiovascular Diseases. Front Cardiovasc Med 2022; 9:901990. [PMID: 35859595 PMCID: PMC9289206 DOI: 10.3389/fcvm.2022.901990] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/07/2022] [Indexed: 12/11/2022] Open
Abstract
Copeptin is the carboxyl-terminus of the arginine vasopressin (AVP) precursor peptide. The main physiological functions of AVP are fluid and osmotic balance, cardiovascular homeostasis, and regulation of endocrine stress response. Copeptin, which is released in an equimolar mode with AVP from the neurohypophysis, has emerged as a stable and simple-to-measure surrogate marker of AVP and has displayed enormous potential in clinical practice. Cardiovascular disease (CVD) is currently recognized as a primary threat to the health of the population worldwide, and thus, rapid and effective approaches to identify individuals that are at high risk of, or have already developed CVD are required. Copeptin is a diagnostic and prognostic biomarker in CVD, including the rapid rule-out of acute myocardial infarction (AMI), mortality prediction in heart failure (HF), and stroke. This review summarizes and discusses the value of copeptin in the diagnosis, discrimination, and prognosis of CVD (AMI, HF, and stroke), as well as the caveats and prospects for the application of this potential biomarker.
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Affiliation(s)
- Danni Mu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jin Cheng
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ling Qiu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xinqi Cheng
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Thesen T, Himle JA, Martinsen EW, Walseth LT, Thorup F, Gallefoss F, Jonsbu E. Effectiveness of Internet-Based Cognitive Behavioral Therapy With Telephone Support for Noncardiac Chest Pain: Randomized Controlled Trial. J Med Internet Res 2022; 24:e33631. [PMID: 35072641 PMCID: PMC8822426 DOI: 10.2196/33631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/27/2021] [Accepted: 11/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background Noncardiac chest pain has a high prevalence and is associated with reduced quality of life, anxiety, avoidance of physical activity, and high societal costs. There is a lack of an effective, low-cost, easy to distribute intervention to assist patients with noncardiac chest pain. Objective In this study, we aimed to investigate the effectiveness of internet-based cognitive behavioral therapy with telephone support for noncardiac chest pain. Methods We conducted a randomized controlled trial, with a 12-month follow-up period, to compare internet-based cognitive behavioral therapy to a control condition (treatment as usual). A total of 162 participants aged 18 to 70 years with a diagnosis of noncardiac chest pain were randomized to either internet-based cognitive behavioral therapy (n=81) or treatment as usual (n=81). The participants in the experimental condition received 6 weekly sessions of internet-based cognitive behavioral therapy. The sessions covered different topics related to coping with noncardiac chest pain (education about the heart, physical activity, interpretations/attention, physical reactions to stress, optional panic treatment, and maintaining change). Between sessions, the participants also engaged in individually tailored physical exercises with increasing intensity. In addition to internet-based cognitive behavioral therapy sessions, participants received a brief weekly call from a clinician to provide support, encourage adherence, and provide access to the next session. Participants in the treatment-as-usual group received standard care for their noncardiac chest pain without any restrictions. Primary outcomes were cardiac anxiety, measured with the Cardiac Anxiety Questionnaire, and fear of bodily sensations, measured with the Body Sensations Questionnaire. Secondary outcomes were depression, measured using the Patient Health Questionnaire; health-related quality of life, measured using the EuroQol visual analog scale; and level of physical activity, assessed with self-report question. Additionally, a subgroup analysis of participants with depressive symptoms at baseline (PHQ-9 score ≥5) was conducted. Assessments were conducted at baseline, posttreatment, and at 3- and 12-month follow-ups. Linear mixed models were used to evaluate treatment effects. Cohen d was used to calculate effect sizes. Results In the main intention-to-treat analysis at the 12-month follow-up time point, participants in the internet-based cognitive behavioral therapy group had significant improvements in cardiac anxiety (–3.4 points, 95% CI –5.7 to –1.1; P=.004, d=0.38) and a nonsignificant improvement in fear of bodily sensations (–2.7 points, 95% CI –5.6 to 0.3; P=.07) compared with the treatment-as-usual group. Health-related quality of life at the 12-month follow-up improved with statistical and clinical significance in the internet-based cognitive behavioral therapy group (8.8 points, 95% CI 2.8 to 14.8; P=.004, d=0.48) compared with the treatment-as-usual group. Physical activity had significantly (P<.001) increased during the 6-week intervention period for the internet-based cognitive behavioral therapy group. Depression significantly improved posttreatment (P=.003) and at the 3-month follow-up (P=.03), but not at the 12-month follow-up (P=.35). Participants with depressive symptoms at baseline seemed to have increased effect of the intervention on cardiac anxiety (d=0.55) and health-related quality of life (d=0.71) at the 12-month follow-up. In the internet-based cognitive behavioral therapy group, 84% of the participants (68/81) completed at least 5 of the 6 sessions. Conclusions This study provides evidence that internet-based cognitive behavioral therapy with minimal therapist contact and a focus on physical activity is effective in reducing cardiac anxiety and increasing health related quality of life in patients with noncardiac chest pain. Trial Registration ClinicalTrials.gov NCT03096925; http://clinicaltrials.gov/ct2/show/NCT03096925
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Affiliation(s)
- Terje Thesen
- Distriktspsykiatrisk senter Solvang, Sørlandet Hospital, Sørlandet sykehus Helse Foretak, Kristiansand, Norway
- Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Joseph A Himle
- School of Social Work and School of Medicine-Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Egil W Martinsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Liv T Walseth
- Distriktspsykiatrisk senter Solvang, Sørlandet Hospital, Sørlandet sykehus Helse Foretak, Kristiansand, Norway
| | - Frode Thorup
- Department of Cardiology, Sørlandet Hospital, Sørlandet sykehus Helse Foretak, Kristiansand, Norway
| | - Frode Gallefoss
- Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Clinical Research, Sørlandet Hospital, Sørlandet sykehus Helse Foretak, Kristiansand, Norway
| | - Egil Jonsbu
- Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Psychiatry, Møre and Romsdal Hospital Trust, Molde, Norway
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Harbrücker M, Natale M, Kim SH, Müller J, Ansari U, Huseynov A, Zworowsky MV, Borggrefe M, Hoffmann U, Lang S, Fatar M, Roth T, Kittel M, Bertsch T, Akin I, Behnes M. Copeptin reliably reflects longitudinal right ventricular function. Ann Clin Biochem 2021; 58:270-279. [PMID: 33430599 DOI: 10.1177/0004563221989364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Data is limited evaluating novel biomarkers in right ventricular dysfunction. Normal right heart function improves the prognosis of patients with heart failure. Therefore, this study investigates the association between the novel biomarker copeptin and right heart function compared to NT-proBNP. METHODS Patients undergoing routine echocardiography were enrolled prospectively. Right ventricular function was assessed by tricuspid annular plane systolic excursion (TAPSE) and further right ventricular and atrial parameters. Exclusion criteria were age under 18 years, left ventricular ejection fraction < 50% and moderate to severe valvular heart disease. Blood samples were taken for biomarker measurements within 72 h of echocardiography. RESULTS Ninety-one patients were included. Median values of copeptin increased significantly according to decreasing values of TAPSE (P = 0.001; right heart function grade I: tricuspid annular plane systolic excursion; TAPSE > 24 mm: 5.20 pmol/L; grade II: TAPSE 18-24 mm: 8.10 pmol/L; grade III: TAPSE < 18 mm: 26.50 pmol/L). Copeptin concentrations were able to discriminate patients with decreased right heart function defined as TAPSE < 18 mm (area under the curves [AUC]: copeptin: 0.793; P = 0.001; NT-proBNP: 0.805; P = 0.0001). Within a multivariable linear regression model, copeptin was independently associated with TAPSE (copeptin: T: -4.43; P = 0.0001; NT-proBNP: T: -1.21; P = 0.23). Finally, copeptin concentrations were significantly associated with severely reduced right heart function (TAPSE < 18 mm) within a multivariate logistic regression model (copeptin: odds ratio: 0.94; 95% confidence interval: 0.911-0.975; P = 0.001). CONCLUSIONS This study demonstrates that the novel biomarker copeptin reflects longitudinal right heart function assessed by standardized transthoracic echocardiography compared with NT-proBNP.
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Affiliation(s)
- Melissa Harbrücker
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michèle Natale
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Seung-Hyun Kim
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Julian Müller
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Uzair Ansari
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Aydin Huseynov
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Max von Zworowsky
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ursula Hoffmann
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Siegfried Lang
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Marc Fatar
- Department of Neurology (M.F.), University Medical Centre Mannheim, Mannheim, Germany
| | - Thomas Roth
- Central Laboratory (T.R.), University Hospital Erlangen, Erlangen, Germany
| | - Maximilian Kittel
- Faculty of Medicine Mannheim, Institute of Clinical Chemistry and Laboratory Medicine (M.K.), University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine (T.B.), Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
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Gender-based differences of copeptin alone or combined with troponin for early rule-out of non-ST-elevation myocardial infarction. Am J Emerg Med 2020; 45:248-253. [PMID: 33041108 DOI: 10.1016/j.ajem.2020.08.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/12/2020] [Accepted: 08/16/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Little is known about the role of gender in the dual biomarker strategy using copeptin and troponin for the early rule-out of non-ST-elevation myocardial infarction (NSTEMI). We aimed to evaluate gender-based differences on copeptin levels, combined negative predictive value (NPV) and predictors of copeptin elevation at admission. METHODS Biomarkers were measured in 852 adult patients presenting to the emergency department with chest pain and suspected NSTEMI. Logistic regression analyses on predictors of copeptin elevation were evaluated by gender. RESULTS Overall, 362 women (42.5%) and 490 men (57.5%) were included. Copeptin levels were higher in men (median 7.36 pmol/L vs. 4.8 pmol/L; P < .001). Men had a similar NPV (100%) as women (99.6%, CI: 98.8-100) using the dual biomarker rule-out strategy and when compared to troponin alone (men, NPV = 98.7%, CI: 97.5-99.8; and women, NPV = 98.7%, CI: 97.5-100). Multivariate logistic regression showed positive association of male gender with copeptin elevation (OR = 2.37; CI: 1.61-3.49; P < .001). In men, diastolic blood pressure was a negative predictor of copeptin elevation (OR = 0.98, 95% CI: 0.96-0.99), while positive predictors were current MI (OR = 2.16, 95% CI: 1.19-3.91), chronic renal insufficiency (OR = 3.58, 95% CI: 1.33-9.62), and atrial fibrillation (OR = 2.56, 95% CI: 1.23-5.32), respectively (all P < .05). In women, current MI (OR = 2.98, CI: 1.23-7.24), atrial fibrillation (OR = 2.90, CI: 1.26-6.70) and syncope-like events (OR = 7.56, CI: 2.26-25.30) were significant predictors of copeptin elevation. CONCLUSIONS Men with suspected NSTEMI have higher copeptin levels. The dual biomarker rule-out strategy has a similar performance in both male and female patients. Certain predictors of copeptin elevation are gender-specific.
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Use of the PEPTEST™ tool for the diagnosis of GERD in the Emergency Department. Am J Emerg Med 2019; 37:2115-2116. [PMID: 31272754 DOI: 10.1016/j.ajem.2019.06.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/10/2019] [Accepted: 06/24/2019] [Indexed: 11/23/2022] Open
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Möckel M. [Biomarkers in the diagnosis of cardiovascular emergencies : Acute coronary syndrome and differential diagnoses]. Internist (Berl) 2019; 60:564-570. [PMID: 31062038 DOI: 10.1007/s00108-019-0620-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In emergency situations, patients present with symptoms rather than diagnoses. Due to its high prevalence, the acute coronary syndrome (ACS) dominates acute diagnostics as a consequence of its chief complaint chest pain. The challenge for the attending physicians is that only a minor part of patients with chest pain are finally diagnosed with an acute myocardial infarction (AMI) and that other rare but dangerous differential diagnoses have to be kept in mind and-vice versa-severely ill patients with AMI may present with symptoms other than chest pain. Against this background, the initial evaluation of patients requires a process-orientated view beyond the key roles of clinical assessment and biomarkers. The use of cardiac troponin is mandatory for the diagnosis of ACS, but challenging in broader utilization due to the reduced clinical specificity. Further relevant biomarkers are copeptin in combination with cardiac troponin or natriuetic peptides, which help to diagnose relevant cardiac dysfunction in (acute) heart failure. In addition, patients who present with the symptom of a suspected cardiac syncope need the differential diagnosis of an underlying arrhythmia, which may be due to an ACS or reduced left ventricular (LV) function and other causes like pulmonary embolism or structural heart disease (e. g. aortic valve stenosis). This highlights that biomarker-based diagnostics are often crucial to decide after the initial clinical evaluation whether early imaging is needed or early discharge is possible.
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Affiliation(s)
- Martin Möckel
- Notfall- und Akutmedizin mit Chest Pain Units, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum und Charité Mitte, Augustenburger Platz 1, 13363, Berlin, Deutschland. .,Medizinische Klinik mit Schwerpunkt Kardiologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Deutschland.
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Liu CH, Huang SC, Lin WS, Lin CS. Unrecognized esophageal fish bone impaction with delayed presentation of acute spastic central chest pain: A case report. Medicine (Baltimore) 2019; 98:e14627. [PMID: 30813196 PMCID: PMC6408047 DOI: 10.1097/md.0000000000014627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
RATIONALE Esophageal chest pain is difficult to be identified, and the diagnosis requires a high index of clinical suspicion. Upon presentation, they are difficult to be differentiated from acute coronary syndrome (ACS) by symptomatology alone. PATIENT CONCERNS We report a 71-year-old woman with multiple risk factors for coronary heart disease who presented with acute central spastic chest pain and was diagnosed as ACS in emergency department. DIAGNOSES Chest computed tomography revealed 1 radiopaque lesion over the upper-third of the esophagus. One fishbone with 3-pointed heads stuck in the esophagus was noted under esophagogastroscopic examination. INTERVENTIONS The fishbone was extracted successfully via endoscopy under general anesthesia. OUTCOMES The woman was discharged uneventfully after 3 days' hospitalization. LESSONS This case illustrates that, even in emergency, clinicians should always keep in mind the possibility of esophageal foreign body impaction when confronted with frank central chest pain without associated gastrointestinal symptoms. This holds true even in the scenario of multiple cardiovascular risk factors and absence of ingestion history.
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Affiliation(s)
- Ching-Han Liu
- Division of Cardiology, Department of Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Shih-Chung Huang
- Division of Cardiology, Department of Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung
| | - Wei-Shiang Lin
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Chin-Sheng Lin
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
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Abstract
Background Non-cardiac chest pain (NCCP) is recurrent angina pectoris-like pain without evidence of coronary heart disease in conventional diagnostic evaluation. The prevalence of NCCP is up to 70% and may be detected (in this order) at all levels of the medical health care system (general practitioner, emergency department, chest pain unit, coronary care). Reduction of quality of life due to NCCP is comparable, and partially even higher, to that caused by cardiac chest pain. Reasons for psychological strain are symptom recurrence in approximately 50%, nonspecific diagnosis with resulting uncertainty, and insufficient integration of other medical disciplines in the diagnostic workup. Methods and Results The management of patients with chest pain has to be multidisciplinary because non-cardiac causes may be frequently encountered. Especially gastroenterological expertise is required since the cause of chest pain is gastroesophageal reflux disease (GERD) in 50-60%, hypercontractile esophageal motility disorders with nutcracker/jackhammer esophagus or diffuse esophageal spasm or achalasia in 15-18%, and other esophageal alterations (e.g., infectious esophageal inflammation, drug-induced ulcers, rings, webs, eosinophilic esophagitis) in 32-35%. Conclusion This review highlights the importance of regular interdisciplinary ward rounds and management of chest pain units.
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Affiliation(s)
- Thomas Frieling
- Department of Gastroenterology, Hepatology, Infectiology, Neurogastroenterology, Hematology, Oncology, and Palliative Medicine, HELIOS-Clinic Krefeld, Krefeld, Germany
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Ilangkovan N, Mickley H, Diederichsen A, Lassen A, Sørensen TL, Sheta HM, Stæhr PB, Mogensen CB. Clinical features and prognosis of patients with acute non-specific chest pain in emergency and cardiology departments after the introduction of high-sensitivity troponins: a prospective cohort study. BMJ Open 2017; 7:e018636. [PMID: 29275346 PMCID: PMC5770919 DOI: 10.1136/bmjopen-2017-018636] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To determine the incidence of clinical, cardiac-related endpoints and mortality among patients presenting to an emergency or cardiology department with non-specific chest pain (NSCP), and who receive testing with a high-sensitivity troponin. A second objective was to identify risk factors for the above-noted endpoints during 12 months of follow-up. DESIGN A prospective multicentre study. SETTING Emergency and cardiology departments in Southern Denmark. SUBJECTS The study enrolled 1027 patients who were assessed for acute chest pain in an emergency or cardiology department, and in whom a myocardial infarction or another obvious reason for chest pain had been ruled out. Patients were enrolled from September 2014 to June 2015 and followed for 1 year. MAIN OUTCOME MEASURES Clinical, cardiac-related endpoints (cardiac-related death, acute myocardial infarction, unstable angina and coronary revascularisation) and all-cause mortality. RESULTS Over a period of 1 year, cardiac-related endpoints were found in 19 patients (1.9%): 0 patients experienced cardiac-related death, 2 (0.2%) had myocardial infarction, 4 (0.4%) had unstable angina pectoris and 17 (1.7%) underwent coronary revascularisation. All-cause mortality was observed in seven patients (0.7%). When compared with the general population, the standardised mortality ratio did not differ. The risk factors associated with the study endpoints included male gender, body mass index >25 kg/m2, previous known coronary artery disease, hypertension, hypercholesterolaemia, diabetes mellitus and the use of statins. A total of 73% of the endpoints occurred in males. CONCLUSION The prognosis for patients with NSCP is favourable, with a 1-year mortality after discharge that is comparable with the background population. Few clinical endpoints took place during follow-up, and those that did were predominantly in males.
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Affiliation(s)
| | - Hans Mickley
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Axel Diederichsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Annmarie Lassen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Thomas L Sørensen
- Department of Internal Medicine, Hospital of Southern Denmark, Sonderborg, Denmark
| | | | - Peter B Stæhr
- Department of Cardiology, Hospital of Southern Denmark, Aabenraa, Denmark
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12
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Abstract
PURPOSE OF REVIEW Cardiac troponin (cTn) plays an essential role for assessment of outcome in acute coronary syndrome (ACS). However, the prognostic value of cTn is not absolute. In this mini-review, we summarize the evidence on the utility of established biomarkers of left-ventricular dysfunction, hemodynamic stress, inflammation, and renal dysfunction for risk prediction beyond cTn in ACS. RECENT FINDINGS Only few biomarkers consistently demonstrate additive prognostic value to cTn levels. The B-type natriuretic peptides (NPs) and growth-differentiation factor-15 (GDF-15) are most promising in this regard. However, there are uncertainties regarding the role of these biomarkers for guidance of treatment decisions, and their prognostic increment to cTn levels measured with high-sensitivity assays is largely unknown. The NPs and GDF-15 provide the strongest prognostic increment to cTn levels in ACS. However, the role of these biomarkers for clinical decision-making in contemporary settings has still to be defined.
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Affiliation(s)
- K M Eggers
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, S-751 85, Uppsala, Sweden.
| | - B Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, S-751 85, Uppsala, Sweden
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13
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McDevitt-Petrovic O, Kirby K, Shevlin M. The prevalence of non-cardiac chest pain (NCCP) using emergency department (ED) data: a Northern Ireland based study. BMC Health Serv Res 2017; 17:549. [PMID: 28793910 PMCID: PMC5550987 DOI: 10.1186/s12913-017-2493-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 08/01/2017] [Indexed: 11/18/2022] Open
Abstract
Background The aim of this study was to assess the frequency of chest pain presentations and the subsequent non-cardiac chest pain diagnoses in an emergency department (ED) over a 3 year period. Methods Administrative data on ED attendances to an urban general hospital in Northern Ireland between March 2013 and March 2016 were used. Data were coded and analysed to estimate frequencies of ‘chest pain’ presentation and the subsequent diagnoses for each year. Results Both chest pain presentations and chest pain presentations with a subsequent diagnosis of unknown cause increased each year. In total, 58.7% of all chest presentations across 3 years resulted in a non-cardiac diagnosis of either ‘anxiety’, ‘panic’ or ‘chest pain of unknown cause’. Discussion There is a significant amount of patients in the ED leaving with a non-cardiac diagnosis, following an initial presentation with chest pain. Conclusion Given the link between non-cardiac chest pain and frequent use of services, the degree of repeat attendance should be investigated.
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Affiliation(s)
- Orla McDevitt-Petrovic
- School of Psychology and Psychology research Institute, Ulster University, Derry, BT48 7JL, UK
| | - Karen Kirby
- School of Psychology and Psychology research Institute, Ulster University, Derry, BT48 7JL, UK.
| | - Mark Shevlin
- School of Psychology and Psychology research Institute, Ulster University, Derry, BT48 7JL, UK
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14
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Mueller C, Möckel M, Giannitsis E, Huber K, Mair J, Plebani M, Thygesen K, Jaffe AS, Lindahl B. Use of copeptin for rapid rule-out of acute myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 7:570-576. [PMID: 28593800 DOI: 10.1177/2048872617710791] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Copeptin is currently understood as a quantitative marker of endogenous stress. It rises rapidly in multiple acute disorders including acute myocardial infarction. As a single variable, it has only modest diagnostic accuracy for acute myocardial infarction. However, the use of copeptin within a dual-marker strategy together with conventional cardiac troponin increases the diagnostic accuracy and particularly the negative predictive value of cardiac troponin alone for acute myocardial infarction. The rapid rule-out of acute myocardial infarction is the only application in acute cardiac care mature enough to merit consideration for routine clinical care. However, the dual-marker approach seems to provide only very small incremental value when used in combination with sensitive or high-sensitivity cardiac troponin assays. This review aims to update and educate regarding the potential and the procedural details, as well as the caveats and challenges of using copeptin in clinical practice.
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Affiliation(s)
- Christian Mueller
- 1 Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Martin Möckel
- 2 Division of Emergency Medicine, Charite, Universitätsmedizin Berlin, Germany
| | | | - Kurt Huber
- 4 Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
| | - Johannes Mair
- 5 Department of Internal Medicine III - Cardiology and Angiology, Innsbruck Medical University, Austria
| | - Mario Plebani
- 6 Department of Laboratory Medicine, University Hospital, Padova, Italy
| | | | | | - Bertil Lindahl
- 9 Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Centre, Uppsala University, Sweden
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15
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Gesualdo M, Scicchitano P, Carbonara S, Ricci G, Principi M, Ierardi E, Di Leo A, Cortese F, Ciccone MM. The association between cardiac and gastrointestinal disorders: causal or casual link? J Cardiovasc Med (Hagerstown) 2017; 17:330-8. [PMID: 26702598 DOI: 10.2459/jcm.0000000000000351] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cardiovascular diseases are the leading cause of death worldwide: among them, coronary artery disease and arrhythmias represent the most frequent pathological conditions. Similarly, the gastrointestinal disorders, that is, gastroesophageal reflux and inflammatory bowel diseases, have a high incidence in the general population. Several pieces of evidence have documented a link between cardiac and gastrointestinal disorders as they often share similar risk factors and symptoms. Furthermore, both can simultaneously occur in the same patient, thus creating problems in the correct clinical diagnosis. It is well known that gastrointestinal disorders may present with chest pain and mimic angina pectoris. In contrast, they can also unmask heart disease, such as in the case of the angina-linked ischemia. The aim of this review was to elucidate the mechanisms underlying the relationship between cardiac and gastrointestinal diseases to better understand the causal or casual character of such a linkage.
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Affiliation(s)
- Michele Gesualdo
- aCardiovascular Diseases Section bDivision of Gastroenterology, Department of Emergency and Organ Transplantation (DETO), University of Bari, Bari, Italy
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16
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Copeptin for the early rule-out of non-ST-elevation myocardial infarction. Int J Cardiol 2016; 223:797-804. [DOI: 10.1016/j.ijcard.2016.08.304] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 08/19/2016] [Indexed: 12/19/2022]
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18
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Copeptin improves the sensitivity of cardiac troponin in patients 70 years or older, but not enough to rule out myocardial infarction at emergency department presentation. Eur J Emerg Med 2015; 24:142-148. [PMID: 26375360 DOI: 10.1097/mej.0000000000000316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES We aimed to evaluate the diagnostic performance of the combination of cardiac troponin (cTn) and copeptin in a population older than 70 years of age to rule out non-ST-elevation myocardial infarction (NSTEMI) at emergency department (ED) presentation. METHODS Among 885 analyzed patients with acute chest pain presenting to the ED, 218 (25%) were aged at least 70 years. RESULTS Patients with elevated copeptin values at presentation were more often aged at least 70 years and had higher blood pressure. Patients at least 70 years without NSTEMI more frequently had elevated copeptin values than younger counterparts (42 vs. 25%, P<0.0001). Bootstrap analysis for the diagnosis of NSTEMI indicated an optimal copeptin threshold value at 8.1 pmol/l in patients less than 70 years and at 10.7 pmol/l in patients at least 70 years. In patients at least 70 years, the combination of copeptin with cTnI significantly improved the sensitivity for the diagnosis of NSTEMI, at all copeptin thresholds tested, but the negative predictive value remained below 95%. CONCLUSION The combination of copeptin with conventional cTnI significantly improved sensitivity for the diagnosis of NSTEMI in patients at least 70 years. However, this improvement was not enough to rule out NSTEMI with a single draw strategy at ED presentation.
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19
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Chambers JB, Marks EM, Hunter MS. The head says yes but the heart says no: what is non-cardiac chest pain and how is it managed? Heart 2015; 101:1240-9. [PMID: 25882503 DOI: 10.1136/heartjnl-2014-306277] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 03/08/2015] [Indexed: 12/20/2022] Open
Affiliation(s)
- J B Chambers
- Cardiothoracic Centre, Guy's and St Thomas Hospital, London, UK
| | - E M Marks
- Cardiothoracic Centre, Guy's and St Thomas Hospital, London, UK Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - M S Hunter
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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20
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Copeptin testing in acute myocardial infarction: ready for routine use? DISEASE MARKERS 2015; 2015:614145. [PMID: 25960596 PMCID: PMC4415476 DOI: 10.1155/2015/614145] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 01/12/2015] [Indexed: 01/11/2023]
Abstract
Suspected acute myocardial infarction is one of the leading causes of admission to emergency departments. In the last decade, biomarkers revolutionized the management of patients with suspected acute coronary syndromes. Besides their pivotal assistance in timely diagnosis, biomarkers provide additional information for risk stratification. Cardiac troponins I and T are the most sensitive and specific markers of acute myocardial injury. Nonetheless, in order to overcome the remaining limitations of these markers, novel candidate biomarkers sensitive to early stage of disease are being extensively investigated. Among them, copeptin, a stable peptide derived from the precursor of vasopressin, emerged as a promising biomarker for the evaluation of suspected acute myocardial infarction. In this review, we summarize the currently available evidence for the usefulness of copeptin in the diagnosis and risk stratification of patients with suspected acute myocardial infarction in comparison with routine biomarkers.
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