Patterns of acute chest pain at two tertiary centres in Accra, Ghana.

Objective: To assess the clinical presentation and evaluation of acute life-threatening chest pain in Accra, Ghana. Design: This was a cross-sectional study at the emergency departments of two leading tertiary hospitals in Accra. Settings: The study was conducted at the Korle-Bu Teaching Hospital and the 37 Military Hospital in Accra. Participants: The study participants comprised adult patients aged 18 years and above who presented with acute chest pain at the emergency departments between April and June 2018. Main Outcome: Acute coronary syndrome is the leading life-threatening cause of chest pain with poor pre- and in-hospital care. Results: 232 patients with chest pain were enrolled as respondents aged 18 to 94 years. The prevalence of life-threatening conditions causing chest pain was 31.9% of those who presented with acute chest pain. These included acute coronary syndrome (82.4%), pulmonary embolism (14.9%), and acute chest syndrome (2.7%). A few (6.6%) with life-threatening conditions such as acute coronary syndrome were transported by ambulances, and 44.3% reported to the facility within 2 to 9 days after the onset of chest pain. None of the patients with pulmonary embolism and acute chest syndrome had computer tomography pulmonary angiogram (CTPA) and echocardiogram done, respectively. Conclusion: Our study found that life-threatening conditions amongst patients presenting with acute chest pains are common; however, there is a need to improve pre-hospital care and in-hospital assessment of these cases. Funding: The study was partly funded by the Medtronic Foundation.

Patients With Nonobstructive Coronary Artery Disease and Chest Pain: Impact of Obesity and Depressive Symptoms.

BACKGROUND: Chest pain (CP) in patients with nonobstructive coronary artery disease is a therapeutic challenge affecting morbidity and mortality. We aimed to identify clinical factors associated with CP in this population, hypothesizing that obesity and depressive symptoms are associated with CP. METHODS AND RESULTS: In 814 patients with angiographically confirmed nonobstructive coronary artery disease, we measured sociodemographic variables, clinical risk factors, medications, and Patient Health Questionnaire 9 scores for depressive symptoms. We assessed CP frequency and prevalence by using all items from the Seattle Angina Questionnaire angina frequency domain to generate an angina frequency composite score. In the overall sample (58.8±11.7 years old, 52.6% female), 42.8% had obesity, and 71.5% had CP, with an angina frequency composite score (SD) score of 76.4 (22.1). Compared with individuals without obesity, individuals with obesity had a higher prevalence (77.6% versus 67%, P<0.001) and more frequent CP (angina frequency composite score, 74.9 [SD, 22.2] versus 78.3 [SD, 21.9], P=0.02). Obesity was independently associated with CP occurrence (odds ratio [OR], 1.7 [95% CI, 1-2.9], P=0.04). Obesity's connection with CP was only in men: men with obesity had more frequent CP (angina frequency composite score, 75.8 [SD, 20.1] versus 82.1 [SD, 19.9], P=0.002) and more prevalent CP (79.5% versus 58.2%, P<0.001) than their counterparts insofar as men with obesity had similar CP to women. Patient Health Questionnaire 9 score (OR, 1.07 [95% CI, 1.01-1.13], P=0.03) was independently associated with CP and partly mediated the association between obesity and CP. CONCLUSIONS: Obesity and depressive symptoms were independently associated with CP in individuals with nonobstructive coronary artery disease, particularly in men, and depressive symptoms partly mediated this association.

The association of triglyceride-glucose index and combined obesity indicators with chest pain and risk of cardiovascular disease in American population with pre-diabetes or diabetes.

Aim: To investigate the correlation of the triglyceride-glucose (TyG) index and its combined obesity indicators with chest pain and cardiovascular disease (CVD) in the pre-diabetes and diabetes population. Methods: This cross-sectional investigation encompassed 6488 participants with diabetes and pre-diabetes who participated in the National Health and Nutrition Examination Survey (NHANES) between 2007 and 2016. The association of the TyG and combined obesity index with chest pain and CVD was investigated using weighted logistic regression models and restricted cubic spline (RCS) analysis. The receiver operating characteristic (ROC) curve analysis was performed to compare different indicators. Results: In multivariate logistic regression fully adjusted for confounding variables, our analyses revealed significant associations between TyG, TyG-BMI, TyG-WC, and TyG-WHtR and chest pain, with adjusted ORs (95% CI) of 1.21 (1.05, 1.39), 1.06 (1.01, 1.11), 1.08 (1.04, 1.14), and 1.27 (1.08, 1.48), respectively. For total-CVD, the adjusted ORs (95% CI) were 1.32 (1.08, 1.61), 1.10 (1.03, 1.17), 1.13 (1.06, 1.19), and 1.63 (1.35, 1.97), respectively, among which TyG, TyG-WC, and TyG-WHtR present curvilinear associations in RCS analysis (all P-nonlinear < 0.05). Furthermore, the ROC curve showed that TyG-WC had the most robust predictive efficacy for total-CVD, coronary heart disease (CHD), and myocardial infarction (MI), while TyG-WHtR had the best predictive ability for angina and heart failure. Conclusion: There are significant associations of TyG and its related indicators with chest pain and total-CVD among the pathoglycemia population. TyG-WC and TyG-WHtR demonstrated superior predictive capability for the incidence of cardiovascular events.

Diagnosis, Risk Stratification, and Treatment of Pericarditis: A Review.

Importance: Pericarditis accounts for up to 5% of emergency department visits for nonischemic chest pain in North America and Western Europe. With appropriate treatment, 70% to 85% of these patients have a benign course. In acute pericarditis, the development of constrictive pericarditis (<0.5%) and pericardial tamponade (<3%) can be life-threatening. Observations: Acute pericarditis is diagnosed with presence of 2 or more of the following: sharp, pleuritic chest pain that worsens when supine (≈90%); new widespread electrocardiographic ST-segment elevation and PR depression (≈25%-50%); a new or increased pericardial effusion that is most often small (≈60%); or a pericardial friction rub (<30%). In North America and Western Europe, the most common causes of acute pericarditis are idiopathic or viral, followed by pericarditis after cardiac procedures or operations. Tuberculosis is the most common cause in endemic areas and is treated with antituberculosis therapy, with corticosteroids considered for associated constrictive pericarditis. Treatment of acute idiopathic and pericarditis after cardiac procedures or operations involves use of high-dose nonsteroidal anti-inflammatory drugs (NSAIDs), with doses tapered once chest pain has resolved and C-reactive protein level has normalized, typically over several weeks. These patients should receive a 3-month course of colchicine to relieve symptoms and reduce the risk of recurrence (37.5% vs 16.7%; absolute risk reduction, 20.8%). With a first recurrence of pericarditis, colchicine should be continued for at least 6 months. Corticosteroids are often used if pericarditis does not improve with NSAIDs and colchicine. In certain patients with multiple recurrences, which can occur for several years, interleukin 1 (IL-1) blockers have demonstrated efficacy and may be preferred to corticosteroids. Conclusions: Acute pericarditis is a common cause of nonischemic chest pain. Tuberculosis is the leading cause of pericarditis in endemic areas and is treated with antitubercular therapy. In North America and Western Europe, pericarditis is typically idiopathic, develops after a viral infection, or develops following cardiac procedures or surgery. Treatment with NSAIDs and colchicine leads to a favorable prognosis in most patients, although 15% to 30% of patients develop recurrence. Patients with multiple recurrent pericarditis can have a disease duration of several years or more, are often treated with corticosteroids, and IL-1 blockers may be used for selected patients as steroid-sparing therapy.

Screening significance of systemic immune-inflammation index (SII) and systemic inflammation response index (SIRI) in coronary heart disease of symptomatic youth.

BACKGROUND: The incidence of coronary heart disease (CHD) in youth is rapidly increasing but difficultly recognized in the early stage. METHODS AND RESULTS: In this retrospective study, 194 CHD patients under the age of 45 who previously experienced chest pain symptoms and 170 non-CHD patients were included and demographic data were collected. Systemic inflammation index (SII) and systemic inflammation response index (SIRI) were increased in young CHD patients (p < 001). Spearman's correlation analysis showed that both SII and SIRI were negatively correlated with HDL and positively correlated with hypertension, Gensini score, and hsTnI. Logistic regression analysis indicated that SII and SIRI were independently associated with the presence of CHD in youth with chest pain symptoms. The area under the ROC curve (AUC) of the SII model for young CHD patients was 0.805 (0.728-0.869), and the sensitivity and specificity were 0.65 and 0.823, respectively. Meanwhile, the AUC for the SIRI model was 0.812 (0.739-0.872), and the sensitivity and specificity were 0.673 and 0.8022. The calibration curves of both SII and SIRI models are in good agreement with the actual curves. And the decision curves of both models indicated their clinical practicality. CONCLUSION: SII and SIRI are independent risk factors for CHD in young adults, which can quickly and effectively identify CHD patients among young adults who have previously experienced chest pain symptoms.

Prevalence of classic and non-classic pain sites of coronary artery disease: a cross-sectional study.

STUDY OBJECTIVE: This study aims to assess the prevalence of both classic and non-classic pain sites in patients with ischemic heart disease, emphasizing the importance of recognizing and not disregarding non-classic symptoms. METHODS: This cross-sectional study included 100 patients diagnosed with coronary artery disease (CAD) who were admitted to two major hospitals in Syria. classic pain was identified as pain located in the precordial area, with or without radiation to the neck, jaw, left shoulder or arm. Patients' demographics and previous medical history were documented to investigate any potential associations with non-classic pain. RESULTS: 62% of the patients experienced non-classic pain, while 12% had no precordial pain. For those without precordial pain, the most common pain site was the left chest (66.7%). Non-classic pain was significantly associated with smoking, with 72.2% of smokers experiencing non-classic pain compared to 35.7% non-smokers (p = 0.001). Additionally, patients with previous heart disease were more likely to have non-classic pain (71.7%), compared with patients with no history of heart disease (51.1%) (p = 0.03). Other factors such as age, sex, and diabetes were not statistically significant. CONCLUSION: Non-classic pain is common, affecting 62% of individuals, primarily in the right shoulder, right arm, and back. This type of pain could be associated with smoking and prior heart disease. Misdiagnosing coronary artery disease can have serious consequences, as patients with non-classic symptoms may miss important pre-hospital procedures like ECG.

Long-term prognosis of low high-sensitivity cardiac troponin T in the emergency department compared with the general population.

BACKGROUND: Long-term prognosis associated with low-high-sensitivity cardiac troponin T (hs-cTnT) concentrations in patients with chest pain is unknown. We investigated these prognostic implications compared with the general population. METHODS: All first visits to seven emergency departments (ED)s in Sweden were included from 9 December 2010 to 31 August, 2017 by patients presenting with chest pain and at least one hs-cTnT measured. Patients with myocardial injury (any hs-cTnT >14 ng/L), including patients with myocardial infarction (MI) were excluded. Standardised mortality ratios (SMRs) and standardised incidence ratios (SIRs) were calculated as the ratio of the number of observed to expected events. The expected number was computed by multiplying the 1-year calendar period-specific, age-specific and sex-specific follow-up time in the cohort with the corresponding incidence in the general population. HRs were calculated for all-cause mortality and major adverse cardiovascular events (MACE), defined as acute MI, heart failure hospitalisation, cerebrovascular stroke or cardiovascular death, between patients with undetectable (<5 ng/L) and low (5-14 ng/L) hs-cTnT. RESULTS: A total of 1 11 916 patients were included, of whom 69 090 (62%) and 42 826 (38%) had peak hs-cTnT concentrations of <5 and 5-14 ng/L. Patients with undetectable peak hs-cTnT had a lower mortality risk compared with the general Swedish population (SMR 0.83, 95% CI 0.79 to 0.87), with lower risks observed in all patients ≥65 years of age, but a slightly higher risk of being diagnosed with a future MI (SIR 1.39, 95% CI 1.32 to 1.47). The adjusted risk of a first MACE associated with low versus undetectable peak hs-cTnT was 1.6-fold (HR 1.61, 95% CI 1.53 to 1.70). CONCLUSION: Patients with chest pain and undetectable hs-cTnT have an overall lower risk of death compared with the general population, with risks being highly age dependent. Detectable hs-cTnT concentrations are still associated with increased long-term cardiovascular risks.

Diabetes and risk of acute coronary syndrome in callers with chest discomfort: Cross-sectional study in out-of-hours primary care.

AIMS: We investigated the differences in prevalence of acute coronary syndrome (ACS) by presence versus absence of diabetes in males and females with chest discomfort who called out-of-hours primary care (OHS-PC). METHODS: A cross-sectional study performed in the Netherlands. Patients who called the OHS-PC in the Utrecht region, the Netherlands between 2014 and 2017 with acute chest discomfort were included. We compared those with diabetes with those without diabetes. Multivariable logistic regression was used to determine the relation between diabetes and (i) high urgency allocation and (ii) ACS. RESULTS: Of the 2,195 callers with acute chest discomfort, 180 (8.2%) reported having diabetes. ACS was present in 15.3% of males (22.0% in those with diabetes) and 8.4% of females (18.8% in those with diabetes). Callers with diabetes did not receive a high urgency more frequently (74.4% vs. 67.8% (OR: 1.38; 95% CI 0.98-1.96). However, such callers had a higher odds for ACS (OR: 2.17; 95% CI 1.47-3.19). These differences were similar for females and males. CONCLUSIONS: Diabetes holds promise as diagnostic factor in callers to OHS-PC with chest discomfort. It might help triage in this setting given the increased risk of ACS in those with diabetes.

Reported Physical Symptoms During Screening Echocardiography Are Not Associated With Presence of Suspected Hypertrophic Cardiomyopathy.

BACKGROUND: The prevalence of hypertrophic cardiomyopathy (HCM) can be silent and can present with sudden death as the first manifestation of this disease. The goal of this study was to evaluate any association between reported physical symptoms with the presence of suspected HCM. METHOD: The Anthony Bates Foundation has been performing screening echocardiography across the United States for prevention of sudden death since 2001. A total of 4120 subjects between the ages of 4 and 79 underwent echocardiographic screening. We evaluated any association between various symptoms and suspected HCM defined as any left ventricular wall thickness³ ≥15 mm. RESULTS: The total prevalence of suspected HCM in the entire study population was 1.1%. The presence of physical symptoms was not associated with HCM (chest pain in 4.3% of participants with HCM vs. 9.9% of the control, P = 0.19, palpitation in 4.3% of participants with HCM vs. 7.3% of the control, P = 0.41, shortness of breath in 6.4% of participant with HCM vs. 11.7% of the control, P = 0.26, lightheadedness in 4.3% of participant with HCM vs. 13.1% of the control, P = 0.07, ankle swelling in 2.1% of participant with HCM vs. 4.0% of the control, P = 0.52, dizziness in 8.5% of participant with HCM vs. 12.2% of the control, P = 0.44). CONCLUSIONS: Echocardiographic presence of suspected HCM is not associated with a higher prevalence of physical symptoms in the participants undergoing screening echocardiography.

Very long-term effects of conservatively treated blunt thoracic trauma: A retrospective analysis.

INTRODUCTION: Despite the high incidence of blunt thoracic trauma and frequently performed conservative treatment, studies on very long-term consequences for these patients remain sparse in current literature. In this study, we identify prevalence of long-term morbidity such as chronic chest pain, shortness of breath, and analyze the effect on overall quality of life and health-related quality of life. METHODS: Questionnaires were send to patients admitted for blunt thoracic trauma at our institution and who were conservatively treated between 1997 and 2019. We evaluated the presences of currently existing chest pain, persistence of shortness of breath after their trauma, the perceived overall quality of life, and health-related quality of life. Furthermore, we analyzed the effect of pain and shortness of breath on overall quality of life and health-related quality of life. RESULTS: The study population consisted of 185 trauma patients with blunt thoracic trauma who were admitted between 1997 and 2019, with a median long term follow up of 11 years. 60 percent still experienced chronic pain all these years after trauma, with 40,7 percent reporting mild pain, 12,1 percent reporting moderate pain, and with 7,7 percent showing severe pain. 18 percent still experienced shortness of breath during exercise. Both pain and shortness of breath showed no improvement in this period. Pain and shortness of breath due to thoracic trauma were associated with a lower overall quality of life and health-related quality of life. CONCLUSION: Chronic pain and shortness of breath may be relatively common long after blunt thoracic trauma, and are of influence on quality of life and health-related quality of life in patients with conservatively treated blunt thoracic trauma.

Sex- and gender-related disparities in chest pain syndromes: the feminine mystique of chest pain.

Chest pain syndromes encompass a wide range of different clinical conditions, being coronary artery disease one of the most important and feared aetiology. Sex and gender disparities have been reported in pathophysiology, clinical presentations, diagnostic work-up and outcomes of patients admitted for chest pain. Biological differences in sexual hormones and neurological pain procession pathways have been proposed as contributors to disparities between men and women; however, gender-related disparities in socio-economic and psychological status have emerged as additional factors involved in these conditions. A better understanding of gender- and sex-related disparities will lead to improved clinical care and management of chest pain syndromes in both men and women. In this comprehensive review, we describe the existing knowledge regarding sex and gender-based differences in management and outcomes of chest pain syndromes in order to stimulate and promote the development of a more sex- and gender-oriented approach to these conditions.

Factors influencing the indication of coronary angiography in patients presenting with chest pain unspecified: an analysis of two decades (1994-2014).

Guidelines for cardiac catheterization in patients with non-specific chest pain (NSCP) provide significant room for provider discretion, which has resulted in variability in the utilization of invasive coronary angiograms (CAs) and a high rate of normal angiograms. The overutilization of CAs in patients with NSCP and discharged without a diagnosis of coronary artery disease is an important issue in medical care quality. As a result, we sought to identify patient demographic, socioeconomic, and geographic factors that influenced the performance of a CA in patients with NSCP who were discharged without a diagnosis of coronary artery disease. We intended to establish reference data points for gauging the success of new initiatives for the evaluation of this patient population. In this 20-year retrospective cohort study (1994-2014), we examined 107 796 patients with NSCP from the Myocardial Infarction Data Acquisition System, a large statewide validated database that contains discharge data for all patients with cardiovascular disease admitted to every non-federal hospital in NJ. Patients were partitioned into two groups: those offered a CA (CA group; n = 12 541) and those that were not (No-CA group; n = 95 255). Geographic, demographic, and socioeconomic variables were compared between the two groups using multivariable logistic regression, which determined the predictive value of each categorical variable on the odds of receiving a CA. Whites were more likely than Blacks and other racial counterparts (19.7% vs. 5.6% and 16.5%, respectively; P < .001) to receive a CA. Geographically, patients who received a CA were more likely admitted to a large hospital compared to small- or medium-sized ones (12.5% vs. 8.9% and 9.7%, respectively; P < .05), a primary teaching institution rather than a teaching affiliate or community center (16.1 % vs. 14.3% and 9.1%, respectively; P < .001), and at a non-rural facility compared to a rural one (12.1% vs. 6.5%; P < .001). Lastly from a socioeconomic standpoint, patients with commercial insurance more often received a CA compared to those having Medicare or Medicaid/self-pay (13.7% vs. 9.5% and 6.0%, respectively; P < .001). The utilization of CA in patients with NSCP discharged without a diagnosis of coronary artery disease in NJ during the study period may be explained by differences in geographic, demographic, and socioeconomic factors. Patients with NSCP should be well scrutinized for CA eligibility, and reliable strategies are needed to reduce discretionary medical decisions and improve quality of care.

Long-term prognostic factors for cardiovascular events in patients with chest pain without diabetes mellitus nor significant coronary stenosis.

Chest pain is the most common symptom of coronary artery disease (CAD) and diabetes mellitus (DM) is a well-known single strongest risk factor for cardiovascular diseases. Thus, the impact of CAD nor DM on long-term clinical effects is reported widely, but the prognostic factors of non-DM patients presenting with chest pain without significant CAD are limited. A total of 1,046 patients with chest pain without DM and significant CAD who underwent coronary angiography (CAG) and acetylcholine (ACH) provocation tests were finally enrolled. Propensity score matching and multivariate Cox-proportional hazard ratio analysis were performed to adjust for baseline potential confounders. Major adverse cardiac and cerebrovascular events (MACCE) were defined as the composite of total death, myocardial infarction (MI), revascularization, stroke, and recurrent angina. This study aimed to evaluate the long-term prognostic factors for MACCE in patients with chest pain without DM and CAD up to 5 years. Coronary artery spasm (CAS) was the most common cause of chest pain. However, long-term MACCE of CAS was not worse than those of patients with chest pain without CAS when patients with CAS had subsequent optimal antianginal medication therapy. However, a recurrent chest pain remains a problem even with continuous antianginal medication therapy. Up to 5 years, the incidence of MACCE was in 7.3%, including recurrent angina 6.9%. Dyslipidemia (HR: 2.010, 95% CI 1.166-3.466, P = 0.012), mild-moderate (30-70%) coronary stenosis (HR: 2.369, 95% CI 1.118-5.018, P = 0.024), the use of aspirin (HR: 2.885, 95% CI 1.588-5.238, P < 0.001), and the use of nitrates (HR: 1.938, 95% CI 1.094-3.433, P = 0.023) were independent risk factors for MACCE. Among the patients with chest pain without DM and significant CAD, the incidence of MACE were rare, but recurrent angina was still a challenging problem who had treated with antianginal medications.

Injury to the Muscle Layer and Risk of Non-cardiac Chest Pain after Endoscopic Submucosal Dissection for Esophageal Cancer.

BACKGROUND AND AIMS: Non-cardiac chest pain (NCCP) is a frequent complication of endoscopic submucosal dissection (ESD) for early-stage esophageal cancer. However, little is known about relationships between ESD findings and NCCP. This study aims to evaluate the risk factors for NCCP, including ESD findings related to injury to the muscle layer. METHODS: We enrolled a total of 296 lesions from 270 patients with esophageal squamous cell carcinoma (ESCC), who underwent ESD in our center. The grade of injury to the muscle layer caused by ESD was categorized as follows: grade 0: no exposure of muscularis propria; grade 1: muscularis propria exposure and/or whitish color change by the electrocoagulation; grade 2: torn muscularis propria with whitish color change by the electrocoagulation; and grade 3, esophageal perforation. The risk factors for NCCP, including ESD findings, were analyzed by univariate and multivariate analyses. RESULTS: NCCP occurred in 89 patients (33.0%) after esophageal ESD. Multivariate analysis demonstrated that younger age [odds ratio (OR) 0.95, 95% confidence interval (95%CI) 0.92-0.98, p=0.003), postoperative fever (>= 38°C) (OR=25.9, 95%CI: 2.89-232.10, p=0.004), ESD findings (grade 1: OR=3.99, 95%CI: 1.63-9.75, p=0.003 and grade 2: OR=3.18, 95%CI: 1.54-6.57, p=0.002) were independently associated with the incidence of post ESD NCCP. CONCLUSIONS: ESD findings relate to slight Injury to the muscle layer, such as muscularis propria exposure and whitish color change by the electrocoagulation were identified as risk factor for post ESD NCCP. We should therefore perform esophageal ESD carefully to avoid injuring the muscle layers.

Elderly patients with non-specific complaints at the emergency department have a high risk for admission and 30-days mortality.

BACKGROUND: Older adults have complex medical needs that causes increased use of resources at the emergency department (ED). The prevalence of non-specific complaint (NSC) as a chief-complaint in the ED is common among older adults and is not prioritized even though possibly having worse clinical outcome. The objective was to study hospital admission and mortality for older adults visiting the ED with NSC compared to specific complaints such as dyspnea, chest pain and abdominal pain. METHODS: A retrospective observational study of older adults visiting the ED with NSC and specific complaints; dyspnea, chest pain and abdominal pain was performed. Chief-complaint were collected from electronic medical records. Fatigue, confusion, non-specific complaints, generalized weakness and risk of falling were defined as non-specific complaint (NSC) when registered as chief-complaint at the ED. Admission rate and 30-days mortality were the primary outcomes. RESULTS: A total of 4927 patients were included in the study based on chief-complaint; patients with chest pain 1599 (32%), dyspnea 1343 (27%), abdominal pain 1460 (30%) and NSC 525 (11%). Patients with dyspnea and NSC had the highest hospital admission rate 79% vs 70% compared to patients with chest pain (63%) and abdominal pain (61%) (p = < 0.001). Patients with NSC had a mean LOS 4.7 h at the ED which was significantly higher compared to chest pain, dyspnea and abdominal pain. Mean bed-days for the whole population was 4.2 days compared to patients with NSC who had a mean LOS of 5.6 days. NSC and dyspnea were both associated with the highest 30-day mortality. CONCLUSION: Older patients who present with NSC at the ED are associated with a high risk for admission and 30-days mortality. In addition, patients with NSC have a longer LOS at the ED, a high admission rate and the highest number of bed-days once admitted. This study indicates that ED staff should be more vigilant when an elderly patient presents with NSC at the ED. Further studies and guidelines are needed to improve the management of these individuals.

Investigation of the presence of atopy in children visiting the paediatric cardiology department due to chest pain.

BACKGROUND: The cases of chest pain in children are usually not of cardiac origin. OBJECTIVES: To investigate asthma and other atopic diseases in children with chest pain not of cardiac origin. PATIENTS AND METHODS: Children aged 6-18 years who were seen for chest pain were included in the study. Haematologic parameters, pulmonary function tests, and skin prick tests were performed. Atopic diseases and environmental factors were investigated. RESULTS: The non-cardiac chest pain group (Group 1) included 88 children (female: 53.4%) with a mean age of 11.9 ± 3.4 years; the control group (Group 2) included 29 children (female: 53.8%) with a mean age of 11.4±2 years (p > 0.05). A family history of atopy (22.7%) and skin prick test positivity (28.4%) was more common in Group 1 than Group 2 (p = 0.006 and p = 0.017, respectively). The rate of presence of all environmental factors except stove use and mould was significantly higher in Group 1 (54.5%) than Group 2 (3.4%) (p < 0.001). Asthma was diagnosed in 44.3% and allergic rhinitis in 9.1% of patients in Group 1. Idiopathic chest pain, musculoskeletal system disorders, gastroesophageal reflux, and pneumonia were identified in 23.9%, 11.4%, 8%, and 3.4% of patients in Group 1, respectively. CONCLUSIONS: In this study, the most common cause of non-cardiac chest pain was asthma. The local prevalence of asthma is higher than normal, and this may have affected the results of this study. A detailed history and physical examination will accurately establish the cause of chest pain in most children.

The sternal brace: a novel osteopathic diagnostic screening tool to rule out cardiac chest pain in the emergency department.

CONTEXT: Chest pain is one of the most common emergency medicine complaints in the United States, yet no reliable physical examination finding exists to help differentiate cardiac chest pain (CCP) from noncardiac chest pain (non-CCP). OBJECTIVES: This is a diagnostic accuracy study of the sternal brace, a novel physical examination maneuver to rule out cardiac-related chest pain from non-CCP. METHODS: We performed this double-blind prospective diagnostic accuracy pilot study on 34 adults in the Newark Beth Israel emergency department with a chief complaint of chest pain. We utilized the Numerical Rating Scale 0-10 (NRS) to quantify chest pain severity before and after the maneuver. Eligible for inclusion were adults over 18 years old who were able to provide written informed consent. We performed the sternal brace on all consenting adults meeting these criteria, and the researchers were blinded between test results and final diagnosis. Cardiac ischemia in the US with a disease prevalence of 0.029 was utilized. RESULTS: A total of 34 patients were included, of whom 11 had a final diagnosis of cardiac-related chest pain. The cutoff value was a decrease in pain severity of 2 or greater between pretest and posttest. Sensitivity was 81.8 % (95 % confidence interval [CI], 48.2-97.7 %); specificity 34.8 % (95 % CI, 16.4-57.3 %), the positive predictive value was 3.6 % (95 % CI, 0.1-20.3 %), and the negative predictive value was 98.4 % (95 % CI, 66.8-100.0 %). CONCLUSIONS: The sternal brace is a good screening test because if a person with chest pain has an NRS that decreases by 2 or more with the maneuver, then there is a 98.5 % chance that the chest pain is noncardiac, given the prevalence of cardia ischemia. In addition, if the disease is present, then it is 81.8 % likely that their NRS will not decrease by more than 2.

Musculoskeletal chest pain prevalence in emergency department presentations: A retrospective case notes review.

OBJECTIVE: Musculoskeletal (MSK) causes of chest pain are considered common in emergency care, yet management is limited, reported outcomes are poor and prevalence data in New Zealand are lacking. The present study aims to estimate the prevalence of MSK chest pain in New Zealand EDs and describe the characteristics of MSK chest pain cases. METHODS: A retrospective chart review was conducted based on de-identified clinical notes extracted from four hospitals within the South Island of New Zealand from 3 months spanning 1 March to 31 May 2021. Individual cases were categorised to the single best-fitting cause of chest pain using systems-based categorisation, based primarily on the doctors' documented final impression. RESULTS: A total of 1344 cases were categorised in the present study. MSK chest pain had a prevalence of 15% (range 11-31%) of chest pain presentations across all study sites. This represented the second most common system responsible for chest pain, after the cardiovascular system. The mean age of MSK chest pain cases was 46.9 (standard deviation [SD] 19.1) years, compared to 55.5 (SD 19.7) years in all cases. Age and gender-specific data, data from rural hospitals and MSK sub-type data are presented. CONCLUSIONS: These data provide a conservative estimate of MSK chest pain prevalence in EDs within the South Island of New Zealand. The findings highlight MSK chest pain as common in emergency care, providing a basis and justification for further research to improve management and outcomes for people with MSK chest pain.

Predictors of major adverse cardiac events among patients with chest pain and low HEART score in the emergency department.

AIM: For patients who present to the emergency departments (ED) with undifferentiated chest pain, the risk of major adverse cardiac events (MACE) may be underestimated in low-HEART score patients. We aimed to identify characteristics of patients who were classified as low risk by HEART score but subsequently developed MACE at 6 weeks. METHODS: We studied a multiethnic cohort of patients who presented with chest pain arousing suspicion of acute coronary syndrome to EDs in the Netherlands and Singapore. Patients were risk-stratified using HEART score and followed up for MACE at 6 weeks. Risk factors of developing MACE despite low HEART scores (scores 0-3) were identified using logistic and Cox regression models. RESULTS: Among 1376 (39.8%) patients with low HEART scores, 63 (4.6%) developed MACE at 6 weeks. More males (53/806, 6.6%) than females (10/570, 2.8%) with low HEART score developed MACE. There was no difference in outcomes between ethnic groups. Among low-HEART score patients with 2 points for history, 21% developed MACE. Among low-HEART score patients with 1 point for troponin, 50% developed MACE, while 100% of those with 2 points for troponin developed MACE. After adjusting for HEART score and potential confounders, male sex was independently associated with increased odds (OR 4.12, 95%CI 2.14-8.78) and hazards (HR 3.93, 95%CI 1.98-7.79) of developing MACE despite low HEART score. CONCLUSION: Male sex, highly suspicious history and elevated troponin were disproportionately associated with MACE. These characteristics should prompt clinicians to consider further investigation before discharge.

Determining factors of service priority in the risk classification of patients with chest pain.

OBJECTIVE: To verify the determining factors of high priority in the risk classification and the outcomes of the care provided to adult patients with chest pain. METHOD: Retrospective study, conducted at an emergency referral service of a public hospital in the interior of São Paulo State, analyzing the records of care performed in the risk classification in 181 medical records of patients with the symptom of chest pain, between August and November 2020. RESULTS: Individuals were most males 98 (54.1%), with moderate pain 133 (73.5), high priority for care 135 (74.5%) and who sought the service spontaneously 139 (76.8%). Of those classified as high priority, 47 (34.8%) were referred to the emergency room and, of these, 27 (17.0%) remained hospitalized. Female gender (p=0.0198; OR=0.40; CI=0.189-0.866) was independently associated with high priority of care. CONCLUSION: Despite the priority classification, few participants were referred to the emergency room and required hospitalization. Female gender was a protective factor in the risk classification as high priority.