Regional variations in management and outcomes of patients with acute coronary syndrome in China: Evidence from the National Chest Pain Center Program.

Regional variations in acute coronary syndrome (ACS) management and outcomes have been an enormous public health issue. However, studies have yet to explore how to reduce the variations. The National Chest Pain Center Program (NCPCP) is the first nationwide, hospital-based, comprehensive, continuous quality improvement program for improving the quality of care in patients with ACS in China. We evaluated the association of NCPCP and regional variations in ACS healthcare using generalized linear mixed models and interaction analysis. Patients in the Western region had longer onset-to-first medical contact (FMC) time and time stay in non-percutaneous coronary intervention (PCI) hospitals, lower rates of PCI for ST-elevation myocardial infarction (STEMI) patients, and higher rates of medication usage. Patients in Central regions had relatively lower in-hospital mortality and in-hospital heart failure rates. Differences in the door-to-balloon time (DtoB) and in-hospital mortality between Western and Eastern regions were less after accreditation (ß = -8.82, 95% confidence interval (CI) -14.61 to -3.03; OR = 0.79, 95%CI 0.70 to 0.91). Similar results were found in differences in DtoB time, primary PCI rate for STEMI between Central and Eastern regions. The differences in PCI for higher-risk non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients among different regions had been smaller. Additionally, the differences in medication use between Eastern and Western regions were higher after accreditation. Regional variations remained high in this large cohort of patients with ACS from hospitals participating in the NCPCP in China. More comprehensive interventions and hospital internal system optimizations are needed to further reduce regional variations in the management and outcomes of patients with ACS.

Long-term effects and predictors of change of internet-delivered cognitive behavioural therapy on cardiac anxiety in patients with non-cardiac chest pain: a randomized controlled trial.

BACKGROUND: Approximately half of patients who seek care at Emergency Departments due to chest pain are diagnosed with Non-Cardiac Chest Pain (NCCP). Concerns for heart disease and misinterpretation of the symptoms increase cardiac anxiety and have a negative impact on patients' lives. Psychological interventions such as internet-delivered cognitive behavioral therapy (iCBT) are effective in treating psychological conditions such as anxiety, by helping patients to learn how to manage chest pain. AIMS: To evaluate the effects of a nurse-led iCBT program on cardiac anxiety and secondary outcomes, as bodily sensations, depressive symptoms, health-related quality of life and chest pain frequency in patients with NCCP at 6- and 12-month follow-up, and to explore predictors that can have impact on the effects of the iCBT program on psychological distress. METHODS: A longitudinal study of a Randomized Controlled Trial (RCT) evaluating the long-term effects of an iCBT program (n = 54) in patients with NCCP, compared to psychoeducation (n = 55). The primary outcome, cardiac anxiety was measured using the Cardiac Anxiety Questionnaire (CAQ), and the secondary outcomes were measured with The Body Sensations Questionnaire (BSQ), Patient Health Questionnaire-9 (PHQ-9), The EuroQol Visual Analog Scale (EQ-VAS) and a self-developed question to measure chest pain frequency. All measurements were performed before and after the intervention, and 3, 6 and 12 months after the intervention. Linear mixed model was used to test between-group differences in primary and secondary outcomes and multiple regression analysis was used to explore factors that may have an impact on the treatment effect of iCBT on cardiac anxiety. RESULTS: A total of 85% (n = 93/109) participants completed the 12-month follow-up. Mixed model analysis showed no statistically significant interaction effect of time and group between the iCBT and psychoeducation groups regarding cardiac anxiety over the 12-month follow-up. However, there was a statistically significant interaction effect of time and group (p = .009) regarding chest pain frequency favouring the iCBT group. In addition, we found a group effect in health-related quality of life (p = .03) favouring the iCBT group. The regression analysis showed that higher avoidance scores at baseline were associated with improvement in cardiac anxiety at 12-month follow-up. CONCLUSIONS: Cardiac anxiety was reduced in patients with NCCP, but iCBT was not more effective than psychoeducation. Patients with a high tendency to avoid activities or situations that they believe could trigger cardiac symptoms may benefit more from psychological interventions targeting cardiac anxiety. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov NCT03336112 on 08/11/2017.

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.

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.

Acute Coronary Syndrome.

One percent of primary care visits are due to chest pain. It is critical for the primary care physician to have a high index of suspicion for acute coronary syndrome and understand the management of this important condition. This article reviews the outpatient evaluation and management of chest pain and summarizes the key points of inpatient evaluation and treatment of acute coronary syndrome.

Design and implementation of a smart Internet of Things chest pain center based on deep learning.

The data input process for most chest pain centers is not intelligent, requiring a lot of staff to manually input patient information. This leads to problems such as long processing times, high potential for errors, an inability to access patient data in a timely manner and an increasing workload. To address the challenge, an Internet of Things (IoT)-driven chest pain center is designed, which crosses the sensing layer, network layer and application layer. The system enables the construction of intelligent chest pain management through a pre-hospital app, Ultra-Wideband (UWB) positioning, and in-hospital treatment. The pre-hospital app is provided to emergency medical services (EMS) centers, which allows them to record patient information in advance and keep it synchronized with the hospital's database, reducing the time needed for treatment. UWB positioning obtains the patient's hospital information through the zero-dimensional base station and the corresponding calculation engine, and in-hospital treatment involves automatic acquisition of patient information through web and mobile applications. The system also introduces the Bidirectional Long Short-Term Memory (BiLSTM)-Conditional Random Field (CRF)-based algorithm to train electronic medical record information for chest pain patients, extracting the patient's chest pain clinical symptoms. The resulting data are saved in the chest pain patient database and uploaded to the national chest pain center. The system has been used in Liaoning Provincial People's Hospital, and its subsequent assistance to doctors and nurses in collaborative treatment, data feedback and analysis is of great significance.

Dor torácica em pacientes com transtorno do pânico e cardiopatia isquêmica em emergência / Chest pain in patients with panic disorder and ischemic heart path in emergency

Introdução: Dor torácica é um sintoma geralmente presente em ambientes de atendimento emergencial. Objetivo: Verificar as características da dor torácica derivada do transtorno de pânico e da cardiopatia isquêmica, se a equipe multiprofissional acredita que existe diferença entre os sinais e sintomas, se sabem o tratamento, encaminhamento e desfecho dos pacientes. Método: Estudo transversal, com abordagem quantitativa, delineamento descritivo analítico, com correlação entre as variáveis, realizado por meio de questionário com 77 profissionais de uma equipe multiprofissional do Pronto Atendimento da Emergência de um hospital de ensino, no ano de 2022. Resultados: Pacientes com queixa de dor torácica eram atendidos imediatamente seguindo protocolo específico, que envolve repouso absoluto, medicação, oxigenoterapia, eletrocardiograma, monitorização cardíaca e exames laboratoriais. A maioria dos profissionais relatou que existe diferença entre os sinais e sintomas da dor decorrente de pânico e da cardiopatia isquêmica, mas destacou que há pontos comuns, e o conjunto de sintomas físicos e psicológicos confunde a equipe e dificulta o diagnóstico. A maioria conhecia o fluxo, encaminhamento e tratamento dos pacientes coronariopatas, mas não sabiam o tratamento e encaminhamento para aqueles com transtorno do pânico, pois recebiam alta hospitalar da emergência para casa, sem avaliação de um especialista e sem orientações sobre o problema. Destacaram que a comunicação efetiva auxilia na detecção tanto de problemas físicos, como de sofrimentos emocionais, sendo crucial para o tratamento e a assistência. Conclusão: Os participantes do estudo demonstraram conhecimento e preparo para atender as condições da dor torácica dos pacientes, independente da origem, acreditam que há diferença na apresentação da dor, relacionada a irradiação para braço e pescoço, mas se confundem, o que dificulta o diagnóstico e o tratamento, especialmente quando é pânico. O serviço e a equipe carecem de profissionais especializados em saúde mental e psiquiatria para tratamento e encaminhamento adequado dos acometidos pelo transtorno de pânico.

Introduction: Chest pain is a symptom generally present in emergency care environments. Objective: To verify the characteristics of chest pain resulting from panic disorder and ischemic heart disease, whether the multidisciplinary team believes that there is a difference between signs and symptoms, whether they know the treatment, referral and outcome of patients. Method: Cross-sectional study, with a quantitative approach, analytical descriptive design, with correlation between variables, carried out through a questionnaire with 77 professionals from a multidisciplinary team from the Emergency Department of a teaching hospital, in the year 2022. Results: Patients with complaints of chest pain were treated immediately following a specific protocol, which involves absolute rest, medication, oxygen therapy, electrocardiogram, cardiac monitoring and laboratory tests. Most professionals reported that there is a difference between the signs and symptoms of pain resulting from panic and ischemic heart disease, but highlighted that there are common points, and the set of physical and psychological symptoms confuses the team and makes diagnosis difficult. The majority knew the flow, referral and treatment of patients with coronary artery disease, but they did not know the treatment and referral for those with panic disorder, as they were discharged from the emergency room to home, without evaluation by a specialist and without guidance on the problem. They highlighted that effective communication helps to detect both physical problems and emotional suffering, being crucial for treatment and assistance. Conclusion: The study participants demonstrated knowledge and preparation to deal with the conditions of patients' chest pain, regardless of the origin, they believe that there is a difference in the presentation of pain, related to irradiation to the arm and neck, but it is confused, which makes diagnosis difficult and treatment, especially when it is panic. The service and team lack professionals specialized in mental health and psychiatry for treatment and appropriate referral of those affected by panic disorder

Introducción: El dolor torácico es un síntoma generalmente presente en ambientes de atención de emergencia. Objetivo: Verificar las características del dolor torácico derivado del trastorno de pánico y de la cardiopatía isquémica, si el equipo multidisciplinario cree que existe diferencia entre signos y síntomas, si conoce el tratamiento, derivación y evolución de los pacientes. Método: Estudio transversal, con enfoque cuantitativo, diseño analítico descriptivo, con correlación entre variables, realizado a través de un cuestionario a 77 profesionales de un equipo multidisciplinario del Servicio de Emergencia de un hospital universitario, en el año 2022. Resultados: Los pacientes con quejas de dolor torácico fueron tratados inmediatamente siguiendo un protocolo específico, que incluye reposo absoluto, medicación, oxigenoterapia, electrocardiograma, monitorización cardíaca y pruebas de laboratorio. La mayoría de los profesionales informaron que existe diferencia entre los signos y síntomas del dolor por pánico y la cardiopatía isquémica, pero resaltaron que hay puntos en común, y el conjunto de síntomas físicos y psicológicos confunde al equipo y dificulta el diagnóstico. La mayoría conocía el flujo, derivación y tratamiento de los pacientes con enfermedad coronaria, pero desconocía el tratamiento y derivación de aquellos con trastorno de pánico, ya que eran dados de alta de urgencia a su domicilio, sin evaluación de un especialista y sin orientación sobre el problema. Destacaron que la comunicación efectiva ayuda a detectar tanto problemas físicos como sufrimiento emocional, siendo crucial para el tratamiento y asistencia. Conclusión: Los participantes del estudio demostraron conocimiento y preparación para afrontar las condiciones de dolor torácico de los pacientes, independientemente del origen, creen que existe diferencia en la presentación del dolor, relacionado con la irradiación al brazo y cuello, pero pero obtienen confuso, lo que dificulta el diagnóstico y el tratamiento, especialmente cuando se trata de pánico. El servicio y el equipo carecen de profesionales especializados en salud mental y psiquiatría para el tratamiento y derivación adecuada de los afectados por el trastorno de pánico

Transitions in health care settings for frequent and infrequent users of emergency departments: a population-based retrospective cohort study.

BACKGROUND: Efforts to reduce emergency department (ED) volumes often target frequent users. We examined transitions in care across ED, hospital, and community settings, and in-hospital death, for high system users (HSUs) compared to controls. METHODS: Population-based databases provided ED visits and hospitalizations in Alberta and Ontario, Canada. The retrospective cohort included the top 10% of all the ED users during 2015/2016 (termed HSUs) and a random sample of controls (4 per each HSU) from the bottom 90% per province. Rates of transitions among ED, hospitalization, community settings, and in-hospital mortality were adjusted for sociodemographic and ED variables in a multistate statistical model. RESULTS: There were 2,684,924 patients and 579,230 (21.6%) were HSUs. Patient characteristics associated with shorter community to ED transition times for HSUs included Alberta residence (ratio of hazard ratio [RHR] = 1.11, 95% confidence interval [CI] 1.11,1.12), living in areas in the lower income quintile (RHR = 1.06, 95%CI 1.06,1.06), and Ontario residents without a primary health care provider (RHR = 1.13, 95%CI 1.13,1.14). Once at the ED, characteristics associated with shorter ED to hospital transition times for HSUs included higher acuity (e.g., RHR = 1.70, 95% CI 1.61, 1.81 for emergent), and for many diagnoses including chest pain (RHR = 1.71, 95%CI 1.65,1.76) and gastrointestinal (RHR = 1.66, 95%CI 1.62,1.71). Once admitted to hospital, HSUs did not necessarily have longer stays except for conditions such as chest pain (RHR = 0.90, 95% CI 0.86, 0.95). HSUs had shorter times to death in the ED if they presented for cancer (RHR = 2.51), congestive heart failure (RHR = 1.93), myocardial infarction (RHR = 1.53), and stroke (RHR = 1.84), and shorter times to death in-hospital if they presented with cancer (RHR = 1.29). CONCLUSIONS: Differences between HSUs and controls in predictors of transitions among care settings were identified. Co-morbidities and limitations in access to primary care are associated with more rapid transitions from community to ED and hospital among HSUs. Interventions targeting these challenges may better serve patients across health systems.. TRIAL REGISTRATION: Not applicable.

Updating a Healthcare System-wide Clinical Pathway for Managing Chest Pain and Acute Coronary Syndromes.

Clinical pathways are useful tools for conveying and reinforcing best practices to standardize care and optimize patient outcomes across myriad conditions. The NewYork-Presbyterian Healthcare System has utilized a clinical chest pain pathway for more than 20 years to facilitate the timely recognition and management of patients presenting with chest pain syndromes and acute coronary syndromes. This chest pain pathway is regularly updated by an expanding group of key stakeholders, which has extended from the Columbia University Irving Medical Center to encompass the entire regional healthcare system, which includes 8 hospitals. In this 2023 update of the NewYork-Presbyterian clinical chest pain pathway, we present the key changes to the healthcare system-wide clinical chest pain pathway.

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.

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 .

Initial Evaluation and Management of Patients Presenting with Acute Chest Pain in the Emergency Department.

PURPOSE OF THE REVIEW: To review the initial evaluation of chest pain in the emergency department (ED), with a focus on coronary artery disease (CAD) and acute coronary syndromes (ACS), using consensus statements from major cardiovascular disease organizations. RECENT FINDINGS: Major cardiovascular organizations have released consensus statements on this topic, notably the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain and the 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department. Also, recent studies have evaluated the use of high sensitivity troponin (hs-cTn) to safely rule out myocardial infarction (MI), with the development of rule-out pathways designed to be utilized in the ED. This review highlights the comprehensive differential diagnoses of chest pain in the ED and urgent management of these etiologies, with a focus on cardiovascular etiologies. There exist a few rule-out pathways recommended by major cardiovascular organizations, notably the high-STEACS and the ESC 0/1 and 0/2 pathways that can safely and quickly discharge patients with low risk of MI.

Investigation of the Effects of Acupuncture on Post-Operative Chest Pain after Open Heart Surgery.

Background: Coronary artery bypass grafting (CABG) accounts for more than half of all adult cardiac surgeries worldwide. Post-operative chest pain is a common CABG complication and can cause significant discomfort. Objectives: Because taking large amounts of analgesics can have many side effects, we evaluated whether acupuncture effectively reduces pain and the use of analgesics by CABG patients. Methods: In this clinical trial, 30 patients who had recently undergone CABG were randomly allocated to two groups. For both groups, exercise therapy and routine analgesics were recommended. The intervention group underwent bilateral acupuncture in distinct acupoints, including the HT3, HT4, HT5, HT6, HT7, PC3, PC5, PC6, and PC7 for 10 daily sessions constantly. Visual analog scale (VAS) and analgesic use were evaluated in both groups at baseline and after completing the 10-day treatment. Results: Our analysis revealed significant decreases in the mean VAS scores in both the intervention and the control group, and that the reduction was more significant in the acupuncture group (p < 0.001). Moreover, analgesic use was significantly lower in the acupuncture group when compared with the control group (p < 0.001). Conclusion: Our findings highlight acupuncture as an alternative method of controlling CABG-associated post-operative chest pain and reducing the use of analgesics, which might have many side effects.

Rapid access chest pain clinics in Australia and New Zealand.

Chest pain is the second most common reason for adult emergency department presentations. Most patients have low or intermediate risk chest pain, which historically has led to inpatient admission for further evaluation. Rapid access chest pain clinics represent an innovative outpatient pathway for these low and intermediate risk patients, and have been shown to be safe and reduce hospital costs. Despite variations in rapid access chest pain clinic models, there are limited data to determine the most effective approach. Developing a national framework could be beneficial to provide sites with evidence, possible models, and business cases. Multicentre data analysis could enhance understanding and monitoring of the service.

Emergency Department Observation Unit Patients Want Evaluation and Treatment for Hypercholesterolemia: A Health Belief Model Study.

BACKGROUND: Hypercholesterolemia (HCL) is common among emergency department (ED) and ED observation unit (EDOU) patients with chest pain but is not typically addressed in these settings. The objective of this study was to assess patient attitudes towards EDOU-based HCL care using the Health Belief Model. METHODS: We conducted a cross-sectional survey study among 100 EDOU patients ≥18 years-old evaluated for chest pain in the EDOU of a tertiary care center from September 1, 2020, to November 01, 2021. Five-point Likert-scale surveys were used to assess each Health Belief Model domain: Cues to Action, Perceived Susceptibility, Perceived Barriers, Perceived Self-Efficacy, and Perceived Benefits. Responses were categorized as agree or do not agree. RESULTS: The participants were 49.0% (49/100) female, 39.0% (39/100) non-white, and had a mean age of 59.0 ± 12.4 years. Most (83.0% [83/100, 95% confidence interval (CI), 74.2%-89.8%]) agreed the EDOU is an appropriate place for HCL education and 52.0% (52/100, 95% CI, 41.8%-62.1%) were interested in talking with their EDOU care team about HCL. Regarding Perceived Susceptibility, 88.0% (88/100, 95% CI, 80.0%-93.6%) believed HCL to be bad for their health, while 41.0% (41/100, 95% CI, 31.3%-51.3%) believed medication costs could be a barrier. For Perceived Self-Efficacy, 76.0% (76/100, 95% CI, 66.4%-84.0%) were receptive to taking medications. Overall, 95.0% (95/100, 95% CI, 88.7%-98.4%) believed managing HCL would benefit their health. CONCLUSIONS: This Health Belief Model-based survey indicates high patient interest in EDOU-initiated HCL care. Patients reported high rates of Perceived Susceptibility, Self-Efficacy, and Benefits and a minority found HCL therapy costs a barrier.

Prehospital Chest Pain Management: Disparity Based on Homeless Status.

BACKGROUND: People experiencing homelessness may use emergency medical services to access health care. We sought to examine the relationship between homelessness and prehospital evaluation and treatment of chest pain. METHODS: We obtained 2019 data of all emergency medical services activations from a single 9-1-1 provider in San Francisco, California with a clinician's primary impression of chest pain. Using chart review, we categorized patients as experiencing homelessness or not and determined treatment rates between the two groups based on local chest pain/acute coronary syndrome protocol. We then stratified the two groups based on primary impression subcategories: "chest pain-not cardiac" and "chest-pain-cardiac/STEMI"; ST elevation myocardial infarction (STEMI). RESULTS: A total of 601 chest pain calls were analyzed after excluding non-transports and pediatric patients. 120 incidents (20%) involved patients experiencing homelessness. Across all chest pain impressions, people experiencing homelessness were less likely to receive aspirin (35% vs 53%; p < 0.001), intravenous access (38% vs 62%; p < 0.001), and nitroglycerin (21% vs 39%; p < 0.001). No patients experiencing homelessness received analgesic medication, though only 4% of other patients received this intervention (0% vs 4%; p = 0.020). People experiencing homelessness were more likely to receive a clinical impression of "chest pain-not cardiac" compared to "chest pain-cardiac/STEMI" (68% vs 32%; p < 0.001). Results were less significant in most fields when adjusted for impression sub categorizations: "chest pain-not cardiac" versus "chest pain-cardiac/STEMI." Greater than 97% of all patients received 12 lead electrocardiograms. CONCLUSIONS: Significant disparities were observed between patients experiencing and not experiencing homelessness in the prehospital treatment of chest pain. Larger scale evaluations are needed to further assess potential disparities in care for people experiencing homelessness in the prehospital setting. Using prehospital clinician impression as a proxy for acuity may mask existing bias and disparity; however, 12-lead ECG acquisition, the key diagnostic tool, was appropriately performed in more than 97% of all chest pain patients.

Recurrent myocardial infarction and emergency department visits: a retrospective study on the Stockholm Area Chest Pain Cohort.

BACKGROUND: Patients who experience acute myocardial infarction (AMI) are at risk of recurrent AMI. Contemporary data on recurrent AMI and its association with return emergency department (ED) visits for chest pain are needed. METHODS: This Swedish retrospective cohort study linked patient-level data from six participating hospitals to four national registers to construct the Stockholm Area Chest Pain Cohort (SACPC). The AMI cohort included SACPC participants visiting the ED for chest pain diagnosed with AMI and discharged alive (first primary diagnosis of AMI during the study period not necessarily the patient's first AMI). The rate and timing of recurrent AMI events, return ED visits for chest pain and all-cause mortality were determined during the year following index AMI discharge. RESULTS: Among 1 37 706 patients presenting to the ED with chest pain as principal complaint from 2011 to 2016, 5.5% (7579/137 706) were hospitalised with AMI. In total, 98.5% (7467/7579) of patients were discharged alive. In the year following index AMI discharge, 5.8% (432/7467) of AMI patients experienced ≥1 recurrent AMI event. Return ED visits for chest pain occurred in 27.0% (2017/7467) of index AMI survivors. During a return ED visit, recurrent AMI was diagnosed in 13.6% (274/2017) of patients. One-year all-cause mortality was 3.1% in the AMI cohort and 11.6% in the recurrent AMI cohort. CONCLUSIONS: In this AMI population, 3 in 10 AMI survivors returned to the ED for chest pain in the year following AMI discharge. Furthermore, over 10% of patients with return ED visits were diagnosed with recurrent AMI during that visit. This study confirms the high residual ischaemic risk and associated mortality among AMI survivors.

Construction and validation of simulated scenarios in the emergency care of patients with chest pain.

OBJECTIVE: To construct and validate clinical simulation scenarios for emergency care for patients with chest pain. METHODS: A methodological study carried out in two stages: construction and validity. The construction took place through the survey of evidence from national and international literature. The validity stage took place through instrument assessment by judges, according to the Content Validity Index and application of a pilot test with the target audience. Fifteen judges with expertise in simulation, teaching and/or care participated in the research, in addition to 18 nursing students, in the pilot test. RESULTS: Two scenarios of clinical simulation were constructed, and all the assessed items obtained a value above 0.80, showing evidence of validity, being considered instruments suitable for application. CONCLUSION: The research contributed to the development and validity of instruments that can be applied for teaching, assessment and training in clinical simulation in emergency care for patients with chest pain.

[Painful left bundle branch block syndrome: an uncommon but treatable chest pain condition]. / Smärtsamt skänkelblocksyndrom.

Painful left bundle branch block syndrome is an uncommon chest pain condition, which is caused by rate-dependent left bundle branch block in the absence of myocardial ischemia. The onset and resolution of the chest pain follows that of the left bundle branch block aberrancy, with an intensity ranging from mild to incapacitating, and it can be treated by pacemaker implantation (preferably with so-called conduction system pacing, since dyssynchronous myocardial contraction is thought to be the culprit). To date, roughly 70 case reports of painful left bundle branch block syndrome have been published in the literature (with none of them originating from Sweden). In this case report, we present ECG findings from repeated exercise tests in a patient who was diagnosed with painful left bundle branch block syndrome and successfully treated by pacemaker implantation.