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Chest Pain (chest + pain)
Kinds of Chest Pain Terms modified by Chest Pain Selected AbstractsElevated Serum Cardiac Markers Predict Coronary Artery Disease in Patients With a History of Heart Failure Who Present With Chest Pain: Insights From the i*trACS RegistryCONGESTIVE HEART FAILURE, Issue 3 2007Jonathan Glauser MD The significance of a history of heart failure (HF) in patients presenting with acute coronary syndromes and elevated cardiac markers is unclear. The authors performed an analysis of patients enrolled in the Internet Tracking Registry of Acute Coronary Syndromes (i*trACS). Cardiac marker measurement and cardiac catheterization were performed in 1174 patients. Of these, 116 (9.9%) had heart failure (HF). Coronary artery disease (CAD) was found in 61 (52.6%) patients in the HF group and 581 (54.9%) in the group without HF. In the non-HF cohort, positive markers occurred in 306 patients, in whom 217 (70.9%) had CAD at catheterization. In the HF subset, 24 patients had positive biomarkers and 15 (62.5%) had CAD. A history of HF did not lessen the likelihood of CAD as evidenced by angiography and does not diminish the utility of cardiac markers in diagnosing acute coronary syndromes. [source] A Community Intervention by Firefighters to Increase 911 Calls and Aspirin Use for Chest PainACADEMIC EMERGENCY MEDICINE, Issue 4 2006Hendrika Meischke PhD Abstract Objectives: To test the effectiveness of an intervention, delivered face-to-face by local firefighters, designed to increase utilization of 911 and self-administration of aspirin for seniors experiencing chest pain. Methods: King County, Washington was divided into 126 geographically distinct areas that were randomized to intervention and control areas. A mailing list identified households of seniors within these areas. More than 20,000 homes in the intervention areas were contacted by local firefighters. Data on all 911 calls for chest pain and self-administration of aspirin were collected from the medical incident report form (MIRF). The unit of analysis was the area. Firefighters delivered a heart attack survival kit (that included an aspirin) and counseled participants on the importance of aspirin and 911 use for chest pain. Main outcome measures were 911 calls for chest pain and aspirin ingestion for a chest pain event, obtained from the MIRFs that are collected by emergency medical services personnel for 2 years after the intervention. Results: There were significantly more calls (16%) among seniors on the mailing list in the intervention than control areas in the first year after the intervention. Among the seniors who were not on the mailing list, there was little difference in the intervention and control areas. The results were somewhat sensitive to the analytical model used and to an outlier in the treatment group. Conclusions: A community-based firefighter intervention can be effective in increasing appropriate response to symptoms of a heart attack among elders. [source] Nuclear Cardiology in the Evaluation of Acute Chest Pain in the Emergency DepartmentECHOCARDIOGRAPHY, Issue 6 2000Brian G. Abbott M.D. Only a minority of patients presenting to the emergency department (ED) with acute chest pain will eventually be diagnosed with an acute coronary syndrome. The majority will have an electrocardiogram that is normal or nondiagnostic for acute myocardial ischemia or infarction. Typically, these patients are admitted to exclude myocardial infarction despite a very low incidence of coronary artery disease. However, missed myocardial infarctions in patients who are inadvertently sent home from the ED have significant adverse outcomes and associated legal consequences. This leads to a liberal policy to admit patients with chest pain, presenting a substantial burden in terms of cost and resources. Many centers have developed chest pain centers, using a wide range of diagnostic modalities to deal with this dilemma. We discuss the methods currently available to exclude myocardial ischemia and infarction in the ED, focusing on the use of myocardial perfusion imaging as both an adjunct and an alternative to routine testing. We review the available literature centering on the ED evaluation of acute chest pain and then propose an algorithm for the practical use of nuclear cardiology in this setting. [source] The Impact of Race on the Acute Management of Chest PainACADEMIC EMERGENCY MEDICINE, Issue 11 2003Arvind Venkat MD Abstract Objectives: African Americans with acute coronary syndromes receive cardiac catheterization less frequently than whites. The objective was to determine if such disparities extend to acute evaluation and noninterventional treatment. Methods: Data on adults with chest pain (N= 7,935) presenting to eight emergency departments (EDs) were evaluated from the Internet Tracking Registry of Acute Coronary Syndromes. Groups were selected from final ED diagnosis: 1) acute myocardial infarction (AMI), n= 400; 2) unstable angina/non,ST-elevation myocardial infarction (UA/NSTEMI), n= 1,153; and 3) nonacute coronary syndrome chest pain (non-ACS CP), n= 6,382. American College of Cardiology/American Heart Association guidelines for AMI and UA/NSTEMI were used to evaluate racial disparities with logistic regression models. Odds ratios (ORs) were adjusted for age, gender, guideline publication, and insurance status. Non-ACS CP patients were assessed by comparing electrocardiographic (ECG)/laboratory evaluation, medical treatment, admission rates, and invasive and noninvasive testing for coronary artery disease (CAD). Results: African Americans with UA/NSTEMI received glycoprotein IIb/IIIa receptor inhibitors less often than whites (OR, 0.41; 95% CI = 0.19 to 0.91). African Americans with non-ACS CP underwent ECG/laboratory evaluation, medical treatment, and invasive and noninvasive testing for CAD less often than whites (p < 0.05). Other nonwhites with non-ACS CP were admitted and received invasive testing for CAD less often than whites (p < 0.01). African Americans and other nonwhites with AMI underwent catheterization less frequently than whites (OR, 0.45; 95% CI = 0.29 to 0.71 and OR, 0.40; 95% CI = 0.17 to 0.92, respectively). A similar disparity in catheterization was noted in UA/NSTEMI therapy (OR, 0.53; 95% CI = 0.40 to 0.68 and OR, 0.68; 95% CI = 0.47 to 0.99). Conclusions: Racial disparities in acute chest pain management extend beyond cardiac catheterization. Poor compliance with recommended treatments for ACS may be an explanation. [source] Prospective Validation of a Modified Thrombolysis In Myocardial Infarction Risk Score in Emergency Department Patients With Chest Pain and Possible Acute Coronary SyndromeACADEMIC EMERGENCY MEDICINE, Issue 4 2010Erik P. Hess MD Abstract Objectives:, This study attempted to prospectively validate a modified Thrombolysis In Myocardial Infarction (TIMI) risk score that classifies patients with either ST-segment deviation or cardiac troponin elevation as high risk. The objectives were to determine the ability of the modified score to risk-stratify emergency department (ED) patients with chest pain and to identify patients safe for early discharge. Methods:, This was a prospective cohort study in an urban academic ED over a 9-month period. Patients over 24 years of age with a primary complaint of chest pain were enrolled. On-duty physicians completed standardized data collection forms prior to diagnostic testing. Cardiac troponin T-values of >99th percentile (,0.01 ng/mL) were considered elevated. The primary outcome was acute myocardial infarction (AMI), revascularization, or death within 30 days. The overall diagnostic accuracy of the risk scores was compared by generating receiver operating characteristic (ROC) curves and comparing the area under the curve. The performance of the risk scores at potential decision thresholds was assessed by calculating the sensitivity and specificity at each potential cut-point. Results:, The study enrolled 1,017 patients with the following characteristics: mean (±SD) age 59.3 (±13.8) years, 60.6% male, 17.9% with a history of diabetes, and 22.4% with a history of myocardial infarction. A total of 117 (11.5%) experienced a cardiac event within 30 days (6.6% AMI, 8.9% revascularization, 0.2% death of cardiac or unknown cause). The modified TIMI risk score outperformed the original with regard to overall diagnostic accuracy (area under the ROC curve = 0.83 vs. 0.79; p = 0.030; absolute difference 0.037; 95% confidence interval [CI] = 0.004 to 0.071). The specificity of the modified score was lower at all cut-points of >0. Sensitivity and specificity at potential decision thresholds were: >0 = sensitivity 96.6%, specificity 23.7%; >1 = sensitivity 91.5%, specificity 54.2%; and >2 = sensitivity 80.3%, specificity 73.4%. The lowest cut-point (TIMI/modified TIMI >0) was the only cut-point to predict cardiac events with sufficient sensitivity to consider early discharge. The sensitivity and specificity of the modified and original TIMI risk scores at this cut-point were identical. Conclusions:, The modified TIMI risk score outperformed the original with regard to overall diagnostic accuracy. However, it had lower specificity at all cut-points of >0, suggesting suboptimal risk stratification in high-risk patients. It also lacked sufficient sensitivity and specificity to safely guide patient disposition. Both scores are insufficiently sensitive and specific to recommend as the sole means of determining disposition in ED chest pain patients. ACADEMIC EMERGENCY MEDICINE,2010; 17:368,375 © 2010 by the Society for Academic Emergency Medicine [source] Impact of Chest Pain on Cost of Migraine Treatment With Almotriptan and SumatriptanHEADACHE, Issue 2002Joseph T. Wang MS Chest-related symptoms occur with all triptans; up to 41% of patients with migraine who receive sumatriptan experience chest symptoms, and 10% of patients discontinue treatment. Thus, the cost of chest pain-related care was estimated in migraineurs receiving almotriptan 12.5 mg versus sumatriptan 50 mg. A population-based, retrospective cohort study used data to quantify the incidence and costs of chest pain-related diagnoses and procedures. An economic model was constructed to estimate annual cost savings per 1000 patients receiving almotriptan versus sumatriptan based on the reported rates of chest pain. Annual direct medical cost avoided was calculated for a hypothetical health plan covering 1 million lives. Among a cohort of 1390 patients, the incidence of chest pain-related diagnoses increased significantly by 43.6% with sumatriptan (P=.003). Aggregate costs for chest pain-related diagnoses and procedures increased from $22 713 to $30 234. Payments for inpatient hospital services, costs for primary care visits, and costs for outpatient hospital visits increased by over 100%, 53.1%, and 14.4%, respectively. The model predicted $11 215 in direct medical cost savings annually per 1000 patients treated with almotriptan versus sumatriptan. Annual direct medical costs avoided totaled $194 358, and when applied to recent estimates of 86 million lives currently covered by almotriptan treatment, translates into an annual cost savings of just under $17 million for chest pain and associated care. Thus, using almotriptan in place of sumatriptan will likely reduce the cost of chest pain-related care. [source] Culturally Competent Care of Patients with Acute Chest PainJOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS, Issue 9 2005Mary Sobralske PhD Purpose To inform nurse practitioners (NPs) about the influence of culture on patients' responses to pain using the example of acute chest pain. Data sources Selected clinical and research articles on pain and culture and the authors' clinical experiences providing care across a variety of cultures. Conclusions There is very little written and even fewer studies on the connection of culture and the response to acute chest pain. This topic needs more attention by nurse researchers. Implications for practice If NPs are not aware that some patients may not demonstrate behavior typically expected in acute myocardial infarction, they may miss the diagnosis and fail to treat or refer these patients for immediate treatment. [source] Influence of Sex on the Out-of-hospital Management of Chest PainACADEMIC EMERGENCY MEDICINE, Issue 1 2010Zachary F. Meisel MD Abstract Background:, Sex disparities in the diagnosis and treatment of chest pain or suspected angina have been demonstrated in multiple clinical settings. Out-of-hospital (OOH) care for chest pain is protocol-driven and may be less likely to demonstrate differences between men and women. Objectives:, The objectives were to investigate the relationship between sex and the OOH treatment of patients with chest pain. The authors sought to test the hypothesis that OOH care for chest pain patients would differ by sex. Methods:, A 1-year retrospective cohort study of 683 emergency medical services (EMS) patients with a complaint of chest pain was conducted. Included were patients taken to any one of three hospitals (all cardiac referral centers) by a single municipal EMS system. Excluded were patients transported by basic life support (BLS) units, those younger than 30 years, and patients with known contraindications to any of the outcome measures. Multivariable regression was used to adjust for potential confounders. The main outcome was adherence to state EMS protocols for treatment of patients over age 30 years with undifferentiated chest pain. Rates of administration of aspirin, nitroglycerin, and oxygen; establishment of intravenous (IV) access; and cardiac monitoring were measured. Results:, A total of 342 women and 341 men were included. Women were less likely than men to receive aspirin (relative risk [RR] = 0.76; 95% confidence interval [CI] = 0.59 to 0.96), nitroglycerin (RR = 0.76; 95% CI = 0.60 to 0.96), or an IV (RR 0.86; 95% CI = 0.77 to 0.96). These differences persisted after adjustment for demographics and emergency department (ED) evaluation for acute coronary syndrome (ACS) as a blunt marker for cardiac risk. Women were also less likely to receive these treatments among the small subgroup of patients who were later diagnosed with acute myocardial infarction (AMI). Conclusions:, For OOH patients with chest pain, sex disparities in treatment are significant and do not appear to be explained by differences in patient age, race, or underlying cardiac risk. ACADEMIC EMERGENCY MEDICINE 2010; 17:80,87 © 2010 by the Society for Academic Emergency Medicine [source] Women With Chest Pain and Normal Coronary Angiograms: No Longer a Benign Syndrome?PREVENTIVE CARDIOLOGY, Issue 4 2006Melissa Robinson MD No abstract is available for this article. [source] Racial and Sex Differences in Emergency Department Triage Assessment and Test Ordering for Chest Pain, 1997,2006ACADEMIC EMERGENCY MEDICINE, Issue 8 2010Lenny López MD ACADEMIC EMERGENCY MEDICINE 2010; 17:801,808 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, This study assessed whether sociodemographic differences exist in triage assignment and whether these differences affect initial diagnostic testing in the emergency department (ED) for patients presenting with chest pain. Methods:,A nationally representative ED data sample for all adults (,18 years) was obtained from the National Hospital Ambulatory Health Care Survey of EDs for 1997,2006. Weighted logistic regression was used to examine the associations between race and presenting symptom, triage assignment, and test ordering, adjusting for patient and hospital characteristics. Results:, Over 10 years, an estimated 78 million visits to the ED presented with a complaint of chest pain. Of those presenting with chest pain, African Americans (odds ratio [OR] = 0.70; 99% confidence interval [CI] = 0.53 to 0.92), Hispanics (OR = 0.74; 99% CI = 0.51to 0.99), Medicaid patients (OR = 0.72; 99% CI = 0.54 to 0.94), and uninsured patients (OR = 0.65; 99% CI = 0.51 to 0.84) were less likely to be triaged emergently. African Americans (OR = 0.86; 99% CI = 0.70 to 0.99), Medicaid patients (OR = 0.70; 99% CI = 0.55 to 0.88), and uninsured patients (OR = 0.70; 99% CI = 0.55 to 0.89) were less likely to have an electrocardiogram (ECG) ordered. African Americans (OR = 0.69; 99% CI = 0.49 to 0.97), Medicaid patients (OR = 0.67; 99% CI = 0.47 to 0.95), and uninsured patients (OR = 0.66; 99% CI = 0.44 to 0.96) were less likely to have cardiac enzymes ordered. Similarly, African Americans and Hispanics were less likely to have a cardiac monitor and pulse oximetry ordered, and Medicaid and uninsured patients were less likely to have a cardiac monitor ordered. Conclusions:, Persistent racial, sex, and insurance differences in triage categorization and basic cardiac testing exist. Eliminating triage disparities may affect "downstream" clinical care and help eliminate observed disparities in cardiac outcomes. [source] The Association Between Emergency Department Crowding and Adverse Cardiovascular Outcomes in Patients with Chest PainACADEMIC EMERGENCY MEDICINE, Issue 7 2009Jesse M. Pines MD Abstract Objectives:, While emergency department (ED) crowding is a worldwide problem, few studies have demonstrated associations between crowding and outcomes. The authors examined whether ED crowding was associated with adverse cardiovascular outcomes in patients with chest pain syndromes (chest pain or related complaints of possible cardiac origin). Methods:, A retrospective analysis was performed for patients ,30 years of age with chest pain syndrome admitted to a tertiary care academic hospital from 1999 through 2006. The authors compared rates of inpatient adverse outcomes from ED triage to hospital discharge, defined as delayed acute myocardial infarction (AMI), heart failure, hypotension, dysrhythmias, and cardiac arrest, which occurred after ED arrival using five separate crowding measures. Results:, Among 4,574 patients, 251 (4%) patients developed adverse outcomes after ED arrival; 803 (18%) had documented acute coronary syndrome (ACS), and of those, 273 (34%) had AMI. Compared to less crowded times, ACS patients experienced more adverse outcomes at the highest waiting room census (odds ratio [OR] = 3.7, 95% confidence interval [CI] = 1.3 to 11.0) and patient-hours (OR = 5.2, 95% CI = 2.0 to 13.6) and trended toward more adverse outcomes during time of high ED occupancy (OR = 3.1, 95% CI = 1.0 to 9.3). Adverse outcomes were not significantly more frequent during times with the highest number of admitted patients (OR = 1.6, 95% CI = 0.6 to 4.1) or the highest trailing mean length of stay (LOS) for admitted patients transferred to inpatient beds within 6 hours (OR = 1.5, 95% CI = 0.5 to 4.0). Patients with non-ACS chest pain experienced more adverse outcomes during the highest waiting room census (OR = 3.5, 95% CI = 1.4 to 8.4) and patient-hours (OR = 4.3, 95% CI = 2.6 to 7.3), but not occupancy (OR = 1.8, 95% CI = 0.9 to 3.3), number of admitted patients (OR = 0.6, 95% CI 0.4 to 1.1), or trailing LOS for admitted patients (OR = 1.2, 95% CI = 0.6 to 2.0). Conclusions:, There was an association between some measures of ED crowding and a higher risk of adverse cardiovascular outcomes in patients with both ACS-related and non,ACS-related chest pain syndrome. [source] Frequency of Acute Coronary Syndrome in Patients with Normal Electrocardiogram Performed during Presence or Absence of Chest PainACADEMIC EMERGENCY MEDICINE, Issue 6 2009Samuel D. Turnipseed MD Abstract Objectives:, The authors hypothesized that patients with active chest pain at the time of a normal electrocardiogram (ECG) have a lower frequency of acute coronary syndrome (ACS) than patients being evaluated for chest pain but with no active chest pain at the time of a normal ECG. The study objective was to describe the association between chest pain in patients with a normal ECG and the diagnosis of ACS. Methods:, This was a prospective observational study of emergency department (ED) patients with a chief complaint of chest pain and an initial normal ECG admitted to the hospital for chest pain evaluation over a 1-year period. Two groups were identified: patients with chest pain during the ECG and patients without chest pain during the ECG. Normal ECG criteria were as follow: 1) normal sinus rhythm with heart rate of 55,105 beats/min, 2) normal QRS interval and ST segment, and 3) normal T-wave morphology or T-wave flattening. "Normal" excludes pathologic Q waves, left ventricular hypertrophy, nonspecific ST-T wave abnormalities, any ST depression, and discrepancies in the axis between the T wave and the QRS. Patients' initial ED ECGs were interpreted as normal or abnormal by two emergency physicians (EPs); differences in interpretation were resolved by a cardiologist. ACS was defined as follows: 1) elevation and characteristic evolution of troponin I level, 2) coronary angiography demonstrating >70% stenosis in a major coronary artery, or 3) positive noninvasive cardiac stress test. Chi-square analysis was performed and odds ratios (ORs) are presented. Results:, A total of 1,741 patients were admitted with cardiopulmonary symptoms; 387 met study criteria. The study group comprised 199 males (51%) and 188 females (49%), mean age was 56 years (range, 25,90 years), and 106 (27%) had known coronary artery disease (CAD). A total of 261 (67%) patients experienced chest pain during ECG; 126 (33%) patients experienced no chest pain during ECG. There was no difference between the two groups in age, sex, cardiac risk factors, or known CAD. The frequency of ACS for the total study group was 17% (67/387). There was no difference in prevalence of ACS based on the presence or absence of chest pain (16% or 42/261 vs. 20% or 25/126; OR = 0.77, 95% confidence interval = 0.45 to 1.33, p = 0.4). Conclusions:, Contrary to our hypothesis concerning patients who presented to the ED with a chief complaint of chest pain, our study demonstrated no difference in the frequency of acute coronary syndrome between patients with chest pain at the time of acquisition of a normal electrocardiogram and those without chest pain during acquisition of a normal electrocardiogram. [source] Sixty-four,slice Computed Tomography of the Coronary Arteries: Cost,Effectiveness Analysis of Patients Presenting to the Emergency Department with Low-risk Chest PainACADEMIC EMERGENCY MEDICINE, Issue 7 2008Rahul K. Khare MD Abstract Objectives:, The aim was to use a computer model to estimate the cost,effectiveness of 64-slice multidetector computed tomography (MDCT) of the coronary arteries in the emergency department (ED) compared to an observation unit (OU) stay plus stress electrocardiogram (ECG) or stress echocardiography for the evaluation of low-risk chest pain patients presenting to the ED. Methods:, A decision analytic model was developed to compare health outcomes and costs that result from three different risk stratification strategies for low-risk chest pain patients in the ED: stress ECG testing after OU care, stress echocardiography after OU care, and MDCT with no OU care. Three patient populations were modeled with the prevalence of symptomatic coronary artery disease (CAD) being very low risk, 2%; low risk, 6% (base case); and moderate risk, 10%. Outcomes were measured as quality-adjusted life years (QALYs). Incremental cost,effectiveness ratios (ICERs), the ratio of change in costs of one test over another to the change in QALY, were calculated for comparisons between each strategy. Sensitivity analyses were conducted to test the robustness of the results to assumptions regarding the characteristics of the risk stratification strategies, costs, utility weights, and likelihood of events. Results:, In the base case, the mean (±standard deviation [SD]) costs and QALYs for each risk stratification strategy were MDCT arm $2,684 (±$1,773 to $4,418) and 24.69 (±24.54 to 24.76) QALYs, stress echocardiography arm $3,265 (±$2,383 to $4,836) and 24.63 (±24.28 to 24.74) QALYs, and stress ECG arm $3,461 (±$2,533 to $4,996) and 24.59 (±24.21 to 24.75) QALYs. The MDCT dominated (less costly and more effective) both OU plus stress echocardiography and OU plus stress ECG. This resulted in an ICER where the MDCT arm dominated the stress echocardiography arm (95% confidence interval [CI] = dominant to $29,738) and where MDCT dominated the ECG arm (95% CI = dominant to $7,332). The MDCT risk stratification arm also dominated stress echocardiography and stress ECG in the 2 and 10% prevalence scenarios, which demonstrated the same ICER trends as the 6% prevalence CAD base case. The thresholds where the MDCT arm remained a cost-saving strategy compared to the other risk stratification strategies were cost of MDCT, <$2,097; cost of OU care, >$1,092; prevalence of CAD, <70%; MDCT specificity, >65%; and a MDCT indeterminate rate, <30%. Conclusions:, In this computer-based model analysis, the MDCT risk stratification strategy is less costly and more effective than both OU-based stress echocardiography and stress ECG risk stratification strategies in chest pain patients presenting to the ED with low to moderate prevalence of CAD. [source] Relationship between a Clear-cut Alternative Noncardiac Diagnosis and 30-day Outcome in Emergency Department Patients with Chest PainACADEMIC EMERGENCY MEDICINE, Issue 3 2007Judd E. Hollander MD Background: Accurate identification of patients with acute coronary syndromes (ACSs) in the emergency department (ED) remains problematic. Studies have not been able to identify a cohort of patients that are safe for immediate ED discharge; however, prior studies have not examined the utility of a clear-cut alternative noncardiac diagnosis. Objectives: To compare the 30-day event rate in ED chest pain patients who were diagnosed with a clear-cut alternative noncardiac diagnosis with the 30-day event rate in the cohort of patients in whom a definitive diagnosis could not be made in the ED. Methods: This was a prospective cohort study of consecutive ED patients with potential ACS. Data included demographics, medical and cardiac history, laboratory and electrocardiogram results, and whether or not the treating physician ascribed the condition to a clear-cut alternative noncardiac diagnosis. The main outcome was death, acute myocardial infarction (AMI), or revascularization within 30 days, as determined by phone follow-up or medical record review. Results: The investigators enrolled 1,995 patients in the ED who had potential ACSs. Overall, 77 had a final hospital diagnosis of AMI (4%). Within 30 days, 73 patients received revascularization (4%), and 26 died (1%). There were 599 (30%) patients given a clear-cut alternative noncardiac diagnosis. Comparing the patients with a clear-cut alternative noncardiac diagnosis with those without an obvious noncardiac diagnosis, the presence of a clear-cut alternative noncardiac diagnosis was associated with a reduced risk of an in-hospital triple-composite endpoint (death, MI, and revascularization), with a risk ratio of 0.32 (95% confidence interval [CI] = 0.19 to 0.55) and 30-day triple-composite endpoint with a risk ratio of 0.45 (95% CI = 0.29 to 0.69); however, patients with a clear-cut alternative noncardiac diagnosis still had a 4% event rate at 30 days (95% CI = 2.4% to 5.6%). Conclusions: In the ED chest pain patient, the presence of a clear-cut alternative noncardiac diagnosis reduces the likelihood of a composite outcome of death and cardiovascular events within 30 days. However, it does not reduce the event rate to an acceptable level to allow ED discharge of these patients. [source] Resting Chest Pain, Negative Treadmill Excercise Electrocardiogram, and Reverse Redistribution in Dipyridamole Myocardial Perfusion Scintigraphy Might Be the Features of Coronary Artery SpasmCLINICAL CARDIOLOGY, Issue 3 2009Tsung O. Cheng MD No abstract is available for this article. [source] Electrocardiogram in Women with Chest PainACADEMIC EMERGENCY MEDICINE, Issue 3 2007David C. Lee MD No abstract is available for this article. [source] Heart-Focused Anxiety and Chest Pain: A Conceptual and Clinical ReviewCLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE, Issue 4 2000Georg H. Eifert This article reviews the concept of heart-focused anxiety that may occur in response to cardiac-related stimuli and sensations. Our aim was to examine the relation between chest pain, panic, and heart-focused anxiety in persons with and without heart disease. We identify a preoccupation with the heart and its functioning based on the belief that it will lead to negative consequences (e.g., death, pain) as an important psychological variable in the production of anxious and fearful responding. We then discuss heart-focused anxiety in relation to other clinically relevant variables in anxiety-related problems such as hypochondriacal concerns, including physical symptoms, disease fear, disease conviction, and safety-seeking behavior. Finally, we briefly discuss the clinical importance of heart-focused anxiety in the assessment and treatment of certain anxiety and cardiac-related problems. [source] Retrospective Review: The Incidence of Non-ST Segment Elevation MI in Emergency Department Patients Presenting With Decompensated Heart FailureCONGESTIVE HEART FAILURE, Issue 6 2003W. Frank Peacock MD The authors performed a 6-month review of heart failure patients presenting to a teaching hospital emergency department to determine the rate of positive serum myocardial infarction markers. All patients with an emergency department discharge diagnosis of heart failure were included; those with a creatinine level >2.0 mg/dL were excluded. There were 151 patients who met the entry criteria, with a mean age of 68.6±13.6 years, and 84 (56%) were men. The mean ejection fraction was 32%, and the mean Framingham score was 3.8±1.6. Twenty (14%) had positive markers. Troponin T was positive in 17 (11%), and creatine kinase was positive in nine (6%). Both markers were positive in six (4%). Chest pain was absent in 70% of the positive marker group. The authors conclude that elevated cardiac markers are not rare in decompensated heart failure. These pilot data suggest these tests should be routinely obtained on heart failure patients. [source] Laparoscopic Heller myotomy with Dor fundoplication for achalasia: long-term outcomes and effect on chest painDISEASES OF THE ESOPHAGUS, Issue 4 2010A. Sasaki SUMMARY The aim of the present study was to evaluate the long-term outcomes of laparoscopic Heller myotomy with Dor fundoplication (LHD) and its effect on chest pain. Between June 1995 and August 2009, a total of 35 patients with achalasia underwent an LHD. The symptom scores were calculated by combining the frequency and the severity. Pre- and postoperative evaluations included symptom score, radiology, manometry, and 24-hour pH manometry. Median total symptom score was significantly lower than the preoperative score (19 vs 4, P < 0.001) at a median follow-up of 94 months. Among the 35 patients, 18 (51%) had chest pain. The frequency of chest pain was similar for the pre- and postoperative scores, but the severity tended to be less. Median esophageal diameter (5.4 cm vs 3.5 cm, P < 0.001) and lower esophageal sphincter pressure (41 mmHg vs 8.9 mmHg, P < 0.001) were significantly reduced after surgery. Median age, duration of symptoms, esophageal diameter, and lower esophageal sphincter pressure were similar between patients with and without chest pain prior to surgery. No significant differences were observed between the two groups in terms of amplitude, duration, and frequency of contractions from the findings of postoperative 24-hour esophageal manometry. Chest pain resolved in three patients (17%) and improved in seven patients (39%) after surgery. LHD can durably relieve achalasic symptoms of both dysphagia and regurgitation, and it can be considered the surgical procedure of choice. However, achalasic chest pain does not always seem to be related with patient characteristics and manometric findings. [source] Chest pain is inversely associated with blood pressure during exercise among individuals being assessed for coronary heart diseasePSYCHOPHYSIOLOGY, Issue 2 2007Blaine Ditto Abstract Acute and chronic increases in blood pressure have been related to decreases in pain perception. This phenomenon has been studied primarily using acute experimental pain stimuli. To extend the literature to naturalistic pain and in particular the problem of silent cardiac ischemia, this study examined the relationship between blood pressure and chest pain during exercise stress testing. Nine hundred seven (425 men, 482 women) individuals undergoing exercise stress testing for diagnosis of possible myocardial ischemia completed the McGill Pain Questionnaire (MPQ) immediately afterward and other questionnaires before and after testing. Blood pressure was measured before, during, and after exercise. Systolic blood pressure at the end of exercise was inversely related to a number of measures of pain such as total score on the MPQ. The relationship could not be explained by individual differences in exercise duration, medication use, sex, or other measured variable. In sum, the inverse relationship between blood pressure and sensitivity to pain that has been observed in other populations in experimental and naturalistic conditions was observed for chest pain during exercise. Blood pressure may contribute to episodes of silent ischemia. [source] The causes of haemoptysis in Malaysian patients aged over 60 and the diagnostic yield of different investigationsRESPIROLOGY, Issue 1 2003Catherine Mee-Ming WONG Objective: In southeast Asia, pulmonary tuberculosis (TB) is the most frequently presumed diagnosis for haemoptysis. This study was designed to assess the causes of haemoptysis, the diagnostic yield of causes in different diagnostic modalities and the distribution of older patients. Methods: All patients presenting to the University of Malaya Medical Centre, Kuala Lumpur, Malaysia with haemoptysis were recruited prospectively and evaluated. Results: One hundred and sixty patients were evaluated for haemoptysis; 71 (44.4%) were aged 60 years or more. Significantly more patients smoked in the older age group (P = 0.002). The main causes of haemoptysis in the older patients were bronchogenic carcinoma (49.3%), pneumonia (11.3%), bronchiectasis (8.6%), cryptogenic (5.6%) and active TB (4.2%). Significantly more older patients had carcinoma (P < 0.001), while the younger patients more often had TB (P < 0.001). Chest pain was significantly more common in the older patients (P = 0.025), particularly in patients with carcinoma. Bronchoscopy alone or combined with CT of the thorax was significantly more diagnostic in the older patient (P = 0.006). Conclusion: Bronchogenic carcinoma is the commonest cause of haemoptysis in patients aged 60 years and above. Presumptive anti-TB therapy should not be encouraged despite the regional high prevalence of TB. [source] The Elder Patient with Suspected Acute Coronary Syndromes in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 8 2007Jin H. Han MD ObjectivesTo describe the evaluation and outcomes of elder patients with suspected acute coronary syndromes (ACS) presenting to the emergency department (ED). MethodsThis was a post hoc analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i,trACS) registry, which had 17,713 ED visits for suspected ACS. First visits from the United States with nonmissing patient demographics, 12-lead electrocardiogram results, and clinical history were included in the analysis. Those who used cocaine or amphetamines or left the ED against medical advice were excluded. Elder was defined as age 75 years or older. ACS was defined by 30-day revascularization, Diagnosis-related Group codes, or death within 30 days with positive cardiac biomarkers at index hospitalization. Multivariable logistic regression analyses were performed to determine the association between being elder and 1) 30-day all-cause mortality, 2) ACS, 3) diagnostic tests ordered, and 4) disposition. Multivariable logistic regression was also performed to determine which clinical variables were associated with ACS in elder and nonelder patients. ResultsA total of 10,126 patients with suspected ACS presenting to the ED were analyzed. For patients presenting to the ED, being elder was independently associated with ACS and all-cause 30-day mortality, with adjusted odds ratios of 1.8 (95% confidence interval [CI] = 1.5 to 2.2) and 2.6 (95% CI = 1.6 to 4.3), respectively. Elder patients were more likely to be admitted to the hospital (adjusted odds ratio, 2.2; 95% CI = 1.8 to 2.6), but there were no differences in the rates of cardiac catheterization and noninvasive stress cardiac imaging. Different clinical variables were associated with ACS in elder and nonelder patients. Chest pain as chief complaint, typical chest pain, and previous history of coronary artery disease were significantly associated with ACS in nonelder patients but were not associated with ACS in elder patients. Male gender and left arm pain were associated with ACS in both elder and nonelder patients. ConclusionsElder patients who present to the ED with suspected ACS represent a population at high risk for ACS and 30-day mortality. Elders are more likely to be admitted to the hospital, but despite an increased risk for adverse events, they have similar odds of receiving a diagnostic test, such as stress cardiac imaging or cardiac catheterization, compared with nonelder patients. Different clinical variables are associated with ACS, and clinical prediction rules utilizing presenting symptoms should consider the effect modification of age. [source] Chest pain in a 15-year-old girl (Case Presentation)ACTA PAEDIATRICA, Issue 10 2009B Heinzl No abstract is available for this article. [source] Chest pain in a 15-year-old girl (Discussion and Diagnosis)ACTA PAEDIATRICA, Issue 10 2009B Heinzl No abstract is available for this article. [source] Female Gender and the Risk of Rupture of Congenital Aneurysmal Fistula in AdultsCONGENITAL HEART DISEASE, Issue 1 2008Salah A.M. Said MD ABSTRACT Aims., To delineate the risk factors for rupture of congenital aneurysmal fistulas in adult patients. Methods., We conducted a literature search of the Medline database using Pubmed search interface to identify reports dealing with rupture of congenital aneurysmal fistulas in an adult population. The search included the English and non-English languages between 1963 and 2005. Results., Fourteen adult patients (12 females) with serious and life-threatening complications secondary to aneurysmal fistulas were reported. Mean age was 62.9 years. The ethnic origins of these 14 patients were 9 Asian and 5 Caucasian. Most patients have had no other cardiac malformations. Five patients had a history of hypertension. One patient was asymptomatic. In 13 symptomatic patients, the clinical presentation was cardiac tamponade, pericardial effusion, syncope, heart failure, chest pain, dyspnea, fatigue, distal thromboembolic events with infarction, shock, and/or sudden death. Aneurysmal fistulas were identified in 10 patients; of these 6 were of the saccular type. Rupture occurred in 9 patients (8 females and 1 male). Eleven patients were treated surgically with 1 late death. Two male subjects experienced sudden unexpected cardiac death. Conclusion., Rupture of congenital aneurysmal fistulas occurred more often in females. Identified risk factors for rupture, hemopericardium, tamponade, and death were among others saccular aneurysm, Asian ethnic race, origin of the aneurysmal fistulas from the left coronary artery and a history of hypertension may play a role. In this article, we present a literature review of congenital aneurysmal fistulas associated with or without rupture and a case report of a woman with unruptured aneurysmal fistula. [source] Left Coronary Artery Arteriovenous Malformation Presenting as a Diastolic Murmur with Exercise Intolerance in a Child with a Suspected Familial Vascular Malformation SyndromeCONGENITAL HEART DISEASE, Issue 3 2007Valerie A. Schroeder MD Abstract Objective., Intracardiac arteriovenous malformations are rare and may be associated with sudden death in adults. This case report describes an intracardiac left coronary arteriovenous malformation in a 7-year-old boy with a suspected familial cutaneous vascular malformation syndrome. The patient presented with a diastolic murmur, exercise intolerance, chest pain, and a left ventricular mass. Methods., The left ventricular mass was initially identified by echocardiography. Subsequently, a computed tomography scan revealed the vascular nature of the lesion. We hypothesized that the lesion represented either an arteriovenous malformation (AVM) or a hemangioma. These lesions are thought to cause coronary steal and myocardial dysfunction. Skin biopsies of the patient's cutaneous lesions revealed capillary hyperplasia, which was not consistent with either hemangioma or AVM. Thus, a surgical biopsy and partial resection of the mass was performed. Results., The surgical pathology of the cardiac mass was consistent with an AVM. Within 6 months following partial resection of the mass, the patient unexpectedly developed a left ventricular pseudoaneurysm at the resection site and required re-operation. Although a portion of the mass remains, both the patient's chest pain and exercise tolerance have improved subjectively. Conclusion., Patients with cutaneous vascular malformations and diastolic murmurs, as well as cardiac symptoms, should undergo echocardiography or alternative imaging modalities to screen for treatable pathological myocardial vascular malformations. [source] P43 Acute urticaria to infliximabCONTACT DERMATITIS, Issue 3 2004Ana Giménez-Arnau Infliximab is a chimeric antitumor necrosis factor-alpha monoclonal antibody used to treat Crohn's disease and rheumatoid arthritis. Acute infusion reactions, headache, fever, chills, urticaria and chest pain were seen in 17% of patients with infliximab compared with 7% of those receiving placebo. Other adverse cutaneous reactions are fungal dermatitis, eczema, seborrhoea, hordeolum, bullous eruption, furunculosis, periorbital oedema, hyperkeratosis, rosacea, verruca, skin pigmentation, alopecia, leukocytoclastic vasculitis, lichenoid drug eruption, erythema multiforme, perniosis-like eruption, granuloma annulare and acute folliculitis. Any pathogenic mechanism has been suggested. Patch test with infliximab can induce flare-up of lesions, nausea and malaise and suggest a percutaneous absortion. A sixty years-old man with atopy background and rheumatoid arthritis treated with Remicare®, infliximab who developed a severe acute urticaria with angioedema is presented. The lesions appearance after previous endovenous administrations and the worsening spreading wheals days after the injection clinically suggested an hypersensitivity mechanism. The protocolized study drug hypersensitivity performed showed only the Prick Test positivity with infliximab at 30/60 minutes. Patch test with infliximab was negative and any adverse event was reported. Actually the patient is treated with etanercept and this drug is well tolerated. This result suggested a type I hypersensitivity mediated reaction. Urticaria could be induced as immunologic reaction of the host against the murine part of infliximab, just as it hapens with other antichimeric antibodies. [source] Electrocardiogram Differentiation of Benign Early Repolarization Versus Acute Myocardial Infarction by Emergency Physicians and CardiologistsACADEMIC EMERGENCY MEDICINE, Issue 9 2006Samuel D. Turnipseed MD Abstract Objectives: ST-segment elevation (STE) related to benign early repolarization (BER), a common normal variant, can be difficult to distinguish from acute myocardial infarction (AMI). The authors compared the electrocardiogram (ECG) interpretations of these two entities by emergency physicians (EPs) and cardiologists. Methods: Twenty-five cases (13 BER, 12 AMI) of patients presenting to the emergency department with chest pain were identified. Criteria for BER required four of the following: 1) widespread STE (precordial greater than limb leads), 2) J-point elevation, 3) concavity of initial up-sloping portion of ST segment, 4) notching or irregular contour of J point, and 5) prominent, concordant T waves. Additional BER criteria were 1) stable ECG pattern, 2) negative cardiac injury markers, and 3) normal cardiac stress test or angiography. AMI criteria were 1) regional STE, 2) positive cardiac injury markers, and 3) identification of culprit coronary artery by angiography in less than eight hours of presentation. The 25 ECGs were distributed to 12 EPs and 12 cardiologists (four in academic medicine, four in community practice, and four in community academics [health maintenance organization] in each physician group). The physicians were informed of the patients' age, gender, and race, and they then interpreted the ECGs as BER or AMI. Undercalls (AMI misdiagnosed as BER) and overcalls (BER misdiagnosed as AMI) were calculated for each physician group. Results: Cardiologists correctly interpreted 90% of ECGs, and EPs correctly interpreted 81% of ECGs. The proportion of undercalls (missed AMI/total AMI) was 2.8% for cardiologists (95% confidence interval [CI] = 0.09% to 5.5%) compared with 9.7% for EPs (95% CI = 4.8% to 14.6%) (p = 0.02). The proportion of overcalls (missed BER/total BER) was 17.3% for cardiologists (95% CI = 11.4% to 23.3%) versus 27.6% for EPs (95% CI = 20.6% to 34.6%) (p = 0.03). The mean number of years in practice was 19.8 for cardiologists (95% CI = 19 to 20.5) and 11 years for EPs (95% CI = 10.5 to 12.0) (p < 0.001). Conclusions: Although correct interpretation was high in both groups, cardiologists, who had significantly more years of practice, had fewer misinterpretations than EPs in distinguishing BER from AMI electrocardiographically. [source] A Community Intervention by Firefighters to Increase 911 Calls and Aspirin Use for Chest PainACADEMIC EMERGENCY MEDICINE, Issue 4 2006Hendrika Meischke PhD Abstract Objectives: To test the effectiveness of an intervention, delivered face-to-face by local firefighters, designed to increase utilization of 911 and self-administration of aspirin for seniors experiencing chest pain. Methods: King County, Washington was divided into 126 geographically distinct areas that were randomized to intervention and control areas. A mailing list identified households of seniors within these areas. More than 20,000 homes in the intervention areas were contacted by local firefighters. Data on all 911 calls for chest pain and self-administration of aspirin were collected from the medical incident report form (MIRF). The unit of analysis was the area. Firefighters delivered a heart attack survival kit (that included an aspirin) and counseled participants on the importance of aspirin and 911 use for chest pain. Main outcome measures were 911 calls for chest pain and aspirin ingestion for a chest pain event, obtained from the MIRFs that are collected by emergency medical services personnel for 2 years after the intervention. Results: There were significantly more calls (16%) among seniors on the mailing list in the intervention than control areas in the first year after the intervention. Among the seniors who were not on the mailing list, there was little difference in the intervention and control areas. The results were somewhat sensitive to the analytical model used and to an outlier in the treatment group. Conclusions: A community-based firefighter intervention can be effective in increasing appropriate response to symptoms of a heart attack among elders. [source] Fine-needle aspiration biopsy of metastatic malignant melanoma resembling a malignant peripheral nerve sheath tumorDIAGNOSTIC CYTOPATHOLOGY, Issue 10 2008Svetoslav Bardarov M.D. Abstract We report a case of metastatic malignant melanoma resembling a malignant peripheral sheath tumor, which posed a significant diagnostic challenge. The patient is a 76-year-old male, who presented in the emergency room with bilateral chest pain exacerbated by inspiration. The pain was present for 3 week and was not exacerbated by physical exercise. The diagnostic workup revealed bilateral parenchymal pulmonary infiltrates. The CT-scan guided fine-needle aspiration and the core biopsies of the largest pulmonary lesion revealed high-grade spindle cell neoplasm with individual cell apoptosis and necrosis. The immunohistochemical profile on the cell block showed that the cells are positive for Vimentin. The S-100 stain showed only focal positivity. The immunohistochemical stains for HMB45, Melan A, pancytokeratin, and smooth muscle actin were negative. Five years ago the patient was diagnosed with melanoma on the back with Clark level of IV. The melanoma was excised with clear margins and sentinel lymph nodes were negative. Careful examination of patient's previous slides revealed an area of spindle cell melanoma adjacent to a nodular type melanoma. Based on the patient's previous history, current clinico-pathologic presentation and immunohistochemical profile, the diagnosis of metastatic malignant melanoma resembling peripheral nerve sheath tumor was favored over the diagnosis of metastatic malignant spindle cell neoplasm of unknown primary site, which by itself is very rare clinical scenario. Diagn. Cytopathol. 2008;36:754,757. © 2008 Wiley-Liss, Inc. 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