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1.
Aust J Gen Pract ; 53(7): 437-442, 2024 Jul.
Article in English | MEDLINE | ID: mdl-38957056

ABSTRACT

BACKGROUND: Chest pain is a common symptom in the community, with underlying causes ranging from benign musculoskeletal pain to life-threatening cardiac events. It is a challenging presentation for healthcare providers, because the aetiology is not always immediately apparent. Chest pain can also cause significant anxiety for patients, leading to increased healthcare utilisation and costs. OBJECTIVE: The objective of this discussion is to emphasise the importance of accurately describing the nature of chest discomfort and using appropriate terminology to facilitate an appropriate diagnostic work-up. The discussion also highlights the differences between typical and atypical chest pain and provides information about the aetiology of chest pain and management in the community. DISCUSSION: Accurately describing the nature of chest discomfort by using appropriate terminology is crucial in identifying the underlying cause of the symptom. Healthcare providers should be aware of the different terms patients might use to describe their chest discomfort and use precise and informative terms to describe the potential underlying cause of the chest pain. Atypical chest pain is often used to describe non-cardiac chest pain, but it lacks specificity. Using the terms 'cardiac,' 'possibly cardiac' or 'non-cardiac' is the preferred terminology.


Subject(s)
Chest Pain , Humans , Chest Pain/etiology , Chest Pain/diagnosis , Chest Pain/physiopathology , Diagnosis, Differential
2.
Arq Bras Cardiol ; 121(6): e20230700, 2024.
Article in Portuguese, English | MEDLINE | ID: mdl-38985080

ABSTRACT

BACKGROUND: Gamma cameras with cadmium-zinc telluride (CZT) detectors allowed the quantification of myocardial flow reserve (MBF), which can increase the accuracy of myocardial perfusion scintigraphy (MPS) to detect the cause of chest discomfort. OBJECTIVE: To assess the clinical impact of MBF to detect the cause of chest discomfort. METHODS: 171 patients with chest discomfort who underwent coronary angiography or coronary CT angiography also underwent MPS and MBF in a time interval of <30 days. The acquisitions of dynamic imaging of rest and stress were initiated simultaneously with the 99mTc injection sestamibi (10 and 30mCi, respectively), both lasting eleven minutes, followed by immediately acquiring perfusion images for 5 minutes. The stress was performed with dipyridamole. A global or per coronary territory MBF <2.0 was classified as abnormal. RESULTS: The average age was 65.9±10 years (60% female). The anatomical evaluation showed that 115 (67.3%) patients had coronary obstruction significant, with 69 having abnormal MPs and 91 having abnormal MBF (60.0% vs 79.1%, p<0.01). Among patients without obstruction (56 - 32.7%), 7 had abnormal MPS, and 23 had reduced global MBF. Performing MBF identified the etiology of the chest discomfort in 114 patients while MPS identified it in 76 (66.7% vs 44.4%, p<0.001). CONCLUSION: MBF is a quantifiable physiological measure that increases the clinical impact of MPS in detecting the cause of chest discomfort through greater accuracy for detecting obstructive CAD, and it also makes it possible to identify the presence of the microvascular disease.


FUNDAMENTO: Gama-câmaras com detectores de telureto-cádmio-zinco (CZT) permitiram a quantificação da reserva de fluxo miocárdico (RFM), podendo aumentar a acurácia da cintilografia miocárdica de perfusão (CMP) para detectar a causa do desconforto torácico. OBJETIVO: Avaliar o impacto clínico da RFM para detectar a causa do desconforto torácico. MÉTODOS: 171 pacientes com desconforto torácico que foram submetidos a coronariografia ou angiotomografia de coronárias também realizaram CMP e RFM num intervalo de tempo <30 dias. As aquisições das imagens dinâmicas de repouso e estresse foram iniciadas simultaneamente à injeção de 99mTc sestamibi (10 e 30mCi, respectivamente), ambas com duração de onze minutos, seguidas imediatamente pela aquisição das imagens de perfusão durante 5 minutos. O estresse foi realizado com dipiridamol. Uma RFM global ou por território coronariano <2,0 foi classificada como anormal. RESULTADOS: A idade média foi de 65,9±10 anos (60% do sexo feminino). A avaliação anatômica mostrou que 115 (67,3%) pacientes apresentavam obstrução coronariana significativa, sendo que, 69 apresentavam CMP anormal e 91 apresentavam RFM anormal (60,0% vs. 79,1%, p<0,01). Dentre os pacientes sem obstrução (56 ­ 32,7%), 7 tinham CMP anormais e 23 tinham RFM global reduzida. A realização da RFM identificou a etiologia do desconforto torácico em 114 pacientes enquanto a CMP identificou em 76 (66,7% vs. 44,4%, p<0,001). CONCLUSÃO: A RFM é uma medida fisiológica quantificável que aumenta o impacto clínico da CMP na detecção da causa do desconforto torácico através de uma maior acurácia para detecção de DAC obstrutiva e ainda possibilita identificar a presença de doença microvascular.


Subject(s)
Chest Pain , Coronary Angiography , Fractional Flow Reserve, Myocardial , Myocardial Perfusion Imaging , Technetium Tc 99m Sestamibi , Humans , Female , Male , Aged , Myocardial Perfusion Imaging/methods , Middle Aged , Fractional Flow Reserve, Myocardial/physiology , Chest Pain/diagnostic imaging , Chest Pain/etiology , Chest Pain/physiopathology , Radiopharmaceuticals , Reproducibility of Results , Tellurium , Zinc , Cadmium , Dipyridamole , Computed Tomography Angiography/methods , Reference Values
3.
Sci Rep ; 14(1): 16977, 2024 07 23.
Article in English | MEDLINE | ID: mdl-39043796

ABSTRACT

Chest pain, a common initial symptom in hypertrophic cardiomyopathy (HCM) patients, is closely linked to myocardial ischemia, despite the absence of significant coronary artery stenosis. This study explored microvascular dysfunction in HCM patients by employing angiography-derived microcirculatory resistance (AMR) as a novel tool for comprehensive assessment. This retrospective analysis included HCM patients with chest pain as the primary symptom and control patients without cardiac hypertrophy during the same period. The AMR was computed through angiography, providing a wire-free and adenosine-free index for evaluating microcirculatory function. Propensity score matching ensured balanced demographics between groups. This study also investigated the correlation between the AMR and clinical outcomes by utilizing echocardiography and follow-up data. After matching, 76 HCM patients and 152 controls were analyzed. While there was no significant difference in the incidence of epicardial coronary stenosis, the AMR of three epicardial coronary arteries was markedly greater in HCM patients. The criterion of an AMR ≥ 250 mmHg*s/m was that 65.7% of HCM patients experienced coronary microvascular dysfunction (CMD). Independent risk factors for CMD included increased left ventricular (LV) wall thickness (OR = 1.209, 95% CI 1.013-1.443, p = 0.036). Furthermore, an AMR_LAD ≥ 250 mmHg*s/m had an increased cumulative risk of the endpoint (log-rank p = 0.023) and was an independent risk factor for the endpoint (HR = 11.64, 95% CI 1.13-120.03, p = 0.039), providing valuable prognostic insights.


Subject(s)
Cardiomyopathy, Hypertrophic , Chest Pain , Microcirculation , Humans , Cardiomyopathy, Hypertrophic/diagnostic imaging , Cardiomyopathy, Hypertrophic/physiopathology , Cardiomyopathy, Hypertrophic/complications , Male , Female , Middle Aged , Chest Pain/physiopathology , Chest Pain/diagnostic imaging , Chest Pain/etiology , Retrospective Studies , Coronary Angiography/methods , Vascular Resistance , Adult , Aged , Echocardiography/methods , Coronary Vessels/diagnostic imaging , Coronary Vessels/physiopathology , Risk Factors
6.
Am J Cardiol ; 163: 8-12, 2022 01 15.
Article in English | MEDLINE | ID: mdl-34785035

ABSTRACT

This study aimed to assess long-term resource utilization and outcomes in patients with acute chest pain who underwent coronary computed tomography angiography (CCTA) and stress echocardiography (SE). This was a retrospective, propensity-matched analysis of health insurance claims data for a national sample of privately insured patients over the period January 1, 2011, to December 31, 2014. There were 3,816 patients matched 1:1 who received either CCTA (n = 1,908) or SE (n = 1,908). Patients were seen in the emergency department (ED) between January 1, 2011, and December 31, 2011 with a primary diagnosis of chest pain and received either CCTA or SE within 72 hours as the first noninvasive test and maintained continuous enrollment in the database from the time of the ED encounter through December 31, 2014. All individual patient data were censored at 3 years. Compared with SE, CCTA was associated with higher odds of downstream cardiac catheterization (9.9% vs 7.7%, adjusted odds ratio [AOR] 1.28, 95% confidence interval (CI) 1.00 to 1.63), future noninvasive testing (27.7% vs 22.3%, AOR 1.22, 95% CI 1.05 to 1.42), and return ED visits or hospitalization for chest pain at 3 years (33.1% vs 24.2%, AOR 1.37, 95% CI 1.19 to 1.59). There were no statistically significant differences in new statin use (15.5% vs 14.9%, AOR 1.04, 95% CI 0.85 to 1.28), coronary revascularization (2.7% vs 2.2%, AOR 1.25, 95% CI 0.77 to 2.01) or hospitalization for acute myocardial infarction (0.9% vs 0.9%, AOR 0.96, 95% CI 0.47 to 1.99). In conclusion, in patients who present to the ED with chest pain, CCTA is associated with increased downstream resource utilization compared with SE with no differences in long-term cardiovascular outcomes.


Subject(s)
Cardiac Catheterization/statistics & numerical data , Chest Pain/physiopathology , Computed Tomography Angiography/methods , Coronary Artery Disease/diagnosis , Echocardiography, Stress/methods , Myocardial Infarction/epidemiology , Myocardial Revascularization/statistics & numerical data , Patient Readmission/statistics & numerical data , Chest Pain/etiology , Coronary Angiography , Coronary Artery Disease/complications , Emergency Service, Hospital , Female , Follow-Up Studies , Health Resources , Hospitalization , Humans , Logistic Models , Male , Middle Aged , Odds Ratio , Propensity Score , Retrospective Studies
7.
Am J Cardiol ; 163: 38-42, 2022 01 15.
Article in English | MEDLINE | ID: mdl-34763825

ABSTRACT

Limited and inconsistent data are present regarding the importance of the time delay between symptom onset and balloon inflation in ST-segment elevation myocardial infarction (STEMI) patients. We aimed to investigate the possible influence of prolonging pain-to-balloon times (PBT) on in-hospital outcomes and mortality in a large cohort of patients with STEMI undergoing primary percutaneous coronary intervention. We retrospectively studied 2,345 STEMI patients (age 61 ± 13 years, 82% men) who underwent primary percutaneous coronary intervention. Patients were stratified according to PBT into 3 groups: ≤120 minutes, 121 to 360 minutes, and >360 minutes. Patients' records were assessed for the occurrence of in-hospital complications, 30-day, and 1-year mortality. Of the 2,345 study patients, 36% had PBT time ≤120 minutes, 40% had PBT of 121 to 360 minutes and 24% had PBT time >360 minutes. The major part of the total PBT (average 358 minutes) was caused by the time interval from symptom onset to hospital arrival, namely, pain-to-door time (average 312 minutes) in all 3 groups. Longer PBT was associated with a lower left ventricular ejection fraction, higher incidence of in-hospital complications, and higher 30-day mortality. In 2 multivariate cox regression models, a per-hour increase in PBT (hazard ratio 1.03 [95% confidence interval 1.00 to 1.06], p = 0.039) as well as PBT >360 minutes (hazard ratio 1.6 [95% confidence interval 1.1 to 2.5], p = 0.04) were both independently associated with an increased risk for 1-year mortality. In conclusion, PBT may be an accurate and independent marker for adverse events, pointing to the importance of coronary reperfusion as early as possible based on the onset of pain.


Subject(s)
Chest Pain/physiopathology , Mortality , Percutaneous Coronary Intervention/statistics & numerical data , ST Elevation Myocardial Infarction/surgery , Time-to-Treatment/statistics & numerical data , Aged , Female , Humans , Male , Middle Aged , ST Elevation Myocardial Infarction/physiopathology
9.
Circulation ; 144(22): e368-e454, 2021 11 30.
Article in English | MEDLINE | ID: mdl-34709879

ABSTRACT

AIM: This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS: A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.


Subject(s)
Algorithms , Chest Pain , Registries , American Heart Association , Chest Pain/diagnosis , Chest Pain/physiopathology , Chest Pain/therapy , Humans , Observational Studies as Topic , Randomized Controlled Trials as Topic , United States
10.
Circulation ; 144(22): e368-e454, 2021 11 30.
Article in English | MEDLINE | ID: mdl-34709928

ABSTRACT

AIM: This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS: A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.


Subject(s)
Algorithms , Chest Pain , Registries , American Heart Association , Chest Pain/diagnosis , Chest Pain/physiopathology , Chest Pain/therapy , Humans , Observational Studies as Topic , Practice Guidelines as Topic , Randomized Controlled Trials as Topic , United States
12.
PLoS One ; 16(8): e0252612, 2021.
Article in English | MEDLINE | ID: mdl-34428208

ABSTRACT

BACKGROUND: Chest pain is amongst the most common reason for presentation to the emergency department (ED). There are many causes of chest pain, and it is important for the emergency physician to quickly and accurately diagnose life threatening causes such as acute myocardial infarction (AMI). Multiple clinical decision tools have been developed to assist clinicians in risk stratifying patients with chest. There is growing recognition that machine learning (ML) will have a significant impact on the practice of medicine in the near future and may assist with diagnosis and risk stratification. This systematic review aims to evaluate how ML has been applied to adults presenting to the ED with undifferentiated chest pain and assess if ML models show improved performance when compared to physicians or current risk stratification techniques. METHODS AND FINDINGS: We conducted a systematic review of journal articles that applied a ML technique to an adult patient presenting to an emergency department with undifferentiated chest pain. Multiple databases were searched from inception through to November 2020. In total, 3361 articles were screened, and 23 articles were included. We did not conduct a metanalysis due to a high level of heterogeneity between studies in both their methods, and reporting. The most common primary outcomes assessed were diagnosis of acute myocardial infarction (AMI) (12 studies), and prognosis of major adverse cardiovascular event (MACE) (6 studies). There were 14 retrospective studies and 5 prospective studies. Four studies reported the development of a machine learning model retrospectively then tested it prospectively. The most common machine learning methods used were artificial neural networks (14 studies), random forest (6 studies), support vector machine (5 studies), and gradient boosting (2 studies). Multiple studies achieved high accuracy in both the diagnosis of AMI in the ED setting, and in predicting mortality and composite outcomes over various timeframes. ML outperformed existing risk stratification scores in all cases, and physicians in three out of four cases. The majority of studies were single centre, retrospective, and without prospective or external validation. There were only 3 studies that were considered low risk of bias and had low applicability concerns. Two studies reported integrating the ML model into clinical practice. CONCLUSIONS: Research on applications of ML for undifferentiated chest pain in the ED has been ongoing for decades. ML has been reported to outperform emergency physicians and current risk stratification tools to diagnose AMI and predict MACE but has rarely been integrated into practice. Many studies assessing the use of ML in undifferentiated chest pain in the ED have a high risk of bias. It is important that future studies make use of recently developed standardised ML reporting guidelines, register their protocols, and share their datasets and code. Future work is required to assess the impact of ML model implementation on clinical decision making, patient orientated outcomes, and patient and physician acceptability. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews registration number: CRD42020184977.


Subject(s)
Chest Pain/diagnosis , Diagnosis, Computer-Assisted , Emergency Service, Hospital , Machine Learning , Myocardial Infarction/diagnosis , Chest Pain/physiopathology , Humans , Myocardial Infarction/physiopathology , Predictive Value of Tests , Risk Factors
13.
Am Heart J ; 241: 83-86, 2021 11.
Article in English | MEDLINE | ID: mdl-34302751

ABSTRACT

SARS-CoV-2 infection has been associated with cardiovascular disease in children, but which children need cardiac evaluation is unclear. We describe our experience evaluating 206 children for cardiac disease following SARS-CoV-2 infection (one of whom had ventricular ectopy) and propose a new guideline for management of these children. Routine cardiac screening after SARS-CoV-2 infection in children without any cardiac signs or symptoms does not appear to be high yield.


Subject(s)
Aftercare , COVID-19/physiopathology , Heart Diseases/diagnosis , Referral and Consultation , Adolescent , Ambulatory Care , Atrioventricular Block/diagnosis , Atrioventricular Block/etiology , Atrioventricular Block/physiopathology , Bradycardia/diagnosis , Bradycardia/etiology , Bradycardia/physiopathology , COVID-19/complications , Cardiology , Chest Pain/physiopathology , Child , Child, Preschool , Dyspnea/physiopathology , Echocardiography , Electrocardiography , Fatigue/physiopathology , Female , Heart Diseases/etiology , Heart Diseases/physiopathology , Humans , Hypertrophy, Left Ventricular/diagnosis , Hypertrophy, Left Ventricular/etiology , Hypertrophy, Left Ventricular/physiopathology , Hypertrophy, Right Ventricular/diagnosis , Hypertrophy, Right Ventricular/etiology , Hypertrophy, Right Ventricular/physiopathology , Implementation Science , Male , Pediatrics , Practice Guidelines as Topic , SARS-CoV-2 , Severity of Illness Index , Syncope/physiopathology , Ventricular Premature Complexes/diagnosis , Ventricular Premature Complexes/etiology , Ventricular Premature Complexes/physiopathology , Young Adult
14.
Am J Emerg Med ; 48: 165-169, 2021 Oct.
Article in English | MEDLINE | ID: mdl-33957340

ABSTRACT

BACKGROUND: Coronary risk scores (CRS) including History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) score and Emergency Department Assessment of Chest pain Score (EDACS) can help identify patients at low risk of major adverse cardiac events. In the emergency department (ED), there are wide variations in hospital admission rates among patients with chest pain. OBJECTIVE: This study aimed to evaluate the impact of CRS on the disposition of patients with symptoms suggestive of acute coronary syndrome in the ED. METHODS: This retrospective cohort study included 3660 adult patients who presented to the ED with chest pain between January and July in 2019. Study inclusion criteria were age > 18 years and a primary position International Statistical Classification of Diseases and Related Health Problems-10th revision coded diagnosis of angina pectoris (I20.0-I20.9) or chronic ischemic heart disease (I25.0-I25.9) by the treating ED physician. If the treating ED physician completed the electronic structured variables for CRS calculation to assist disposition planning, then the patient would be classified as the CRS group; otherwise, the patient was included in the control group. RESULTS: Among the 2676 patients, 746 were classified into the CRS group, whereas the other 1930 were classified into the control group. There was no significant difference in sex, age, initial vital signs, and ED length of stay between the two groups. The coronary risk factors were similar between the two groups, except for a higher incidence of smokers in the CRS group (19.6% vs. 16.1%, p = 0.031). Compared with the control group, significantly more patients were discharged (70.1% vs. 64.6%) directly from the ED, while fewer patients who were hospitalized (25.9% vs. 29.7%) or against-advise discharge (AAD) (2.6% vs. 4.0%) in the CRS group. Major adverse cardiac events and mortality at 60 days between the two groups were not significantly different. CONCLUSIONS: A higher ED discharge rate of the group using CRS may indicate that ED physicians have more confidence in discharging low-risk patients based on CRS.


Subject(s)
Acute Coronary Syndrome/diagnosis , Angina Pectoris/diagnosis , Chest Pain/physiopathology , Clinical Decision-Making , Emergency Service, Hospital , Hospitalization/statistics & numerical data , Myocardial Ischemia/diagnosis , Patient Discharge/statistics & numerical data , Acute Coronary Syndrome/complications , Age Factors , Aged , Angina Pectoris/complications , Chest Pain/blood , Chest Pain/epidemiology , Chest Pain/etiology , Cohort Studies , Coronary Artery Disease/epidemiology , Electrocardiography , Female , Heart Disease Risk Factors , Humans , Male , Middle Aged , Myocardial Ischemia/complications , Patient Transfer , Retrospective Studies , Sweating , Troponin/blood
15.
Sci Rep ; 11(1): 10513, 2021 05 18.
Article in English | MEDLINE | ID: mdl-34006974

ABSTRACT

Identification of obstructive coronary artery disease (OCAD) in patients with chest pain is a clinical challenge. The value of corrected QT interval (QTc) for the prediction of OCAD has yet to be established. We consecutively enrolled 1741 patients with suspected angina. The presence of obstructive OCAD was defined as ≥ 50% diameter stenosis by coronary angiography. The pre-test probability was evaluated by combining QTc prolongation with the CAD Consortium clinical score (CAD2) and the updated Diamond-Forrester (UDF) score. OCAD was detected in 661 patients (38.0%). QTc was longer in patients with OCAD compared with those without OCAD (444 ± 34 vs. 429 ± 28 ms, p < 0.001). QTc was increased by the severity of OCAD (P < 0.001). QTc prolongation was associated with OCAD (odds ratio (OR), 2.27; 95% confidence interval (CI), 1.81-2.85). With QTc, the C-statistics increased significantly from 0.68 (95% CI 0.66-0.71) to 0.76 (95% CI 0.74-0.78) in the CAD2 and from 0.64 (95% CI 0.62-0.67) to 0.74 (95% CI 0.72-0.77) in the UDF score, respectively. QT prolongation predicted the presence of OCAD and the QTc improved model performance to predict OCAD compared with CAD2 or UDF scores in patients with suspected angina.


Subject(s)
Chest Pain/physiopathology , Coronary Artery Disease/physiopathology , Adult , Coronary Artery Disease/diagnostic imaging , Electrocardiography , Female , Humans , Long QT Syndrome/diagnostic imaging , Long QT Syndrome/physiopathology , Male , Middle Aged
17.
Eur J Clin Invest ; 51(11): e13602, 2021 Nov.
Article in English | MEDLINE | ID: mdl-34050527

ABSTRACT

BACKGROUND: Currently, we remain uncertain about which patients are at increased risk for recurrent pericarditis. We developed a risk score for pericarditis recurrence in patients with acute pericarditis. MATERIALS AND METHODS: We prospectively recruited 262 patients with a first episode of acute pericarditis. Baseline patients' demographics, clinical, imaging and laboratory data were collected. Patients were followed up for a median of 51 months (interquartile range 21-71) for recurrence. Variables with <10% missingness were entered into multivariable logistic regression models with stepwise elimination to explore independent predictors of recurrence. The final model performance was assessed by the c-index whereas model's calibration and optimism-corrected c-index were evaluated after 10-fold cross-validation. RESULTS: We identified six independent predictors for pericarditis recurrence, that is age, effusion size, platelet count (negative predictors) and reduced inferior vena cava collapse, in-hospital use of corticosteroids and heart rate (positive predictors). The final model had good performance for recurrence, c-index 0.783 (95% CI 0.725-0.842), while the optimism-corrected c-index after cross-validation was 0.752. Based on these variables, we developed a risk score point system for recurrence (0-22 points) with equally good performance (c-index 0.740, 95% CI 0.677-0.803). Patients with a low score (0-7 points) had 21.3% risk for recurrence, while those with high score (≥12 points) had a 69.8% risk for recurrence. The score was predictive of recurrence among most patient subgroups. CONCLUSIONS: A simple risk score point system based on 6 variables can be used to predict the individualized risk for pericarditis recurrence among patients with a first episode of acute pericarditis.


Subject(s)
Anti-Inflammatory Agents, Non-Steroidal/therapeutic use , Glucocorticoids/therapeutic use , Pericardiocentesis , Pericarditis/therapy , Adult , Age Factors , Aged , Aspirin/therapeutic use , Chest Pain/physiopathology , Colchicine/therapeutic use , Female , Fever/physiopathology , Heart Rate/physiology , Humans , Ibuprofen/therapeutic use , Male , Middle Aged , Pericarditis/blood , Pericarditis/physiopathology , Platelet Count , Recurrence , Risk Assessment , Risk Factors
18.
Circ Genom Precis Med ; 14(3): e003298, 2021 06.
Article in English | MEDLINE | ID: mdl-34032468

ABSTRACT

BACKGROUND: Polygenic risk scores (PRSs) are associated with coronary artery disease (CAD), but the clinical potential of using PRSs at the single-patient level for risk stratification has yet to be established. We investigated whether adding a PRS to clinical risk factors (CRFs) improves risk stratification in patients referred to coronary computed tomography angiography on a suspicion of obstructive CAD. METHODS: In this prespecified diagnostic substudy of the Dan-NICAD trial (Danish study of Non-Invasive testing in Coronary Artery Disease), we included 1617 consecutive patients with stable chest symptoms and no history of CAD referred for coronary computed tomography angiography. CRFs used for risk stratification were age, sex, symptoms, prior or active smoking, antihypertensive treatment, lipid-lowering treatment, and diabetes. In addition, patients were genotyped, and their PRSs were calculated. All patients underwent coronary computed tomography angiography. Patients with a suspected ≥50% stenosis also underwent invasive coronary angiography with fractional flow reserve. A combined end point of obstructive CAD was defined as a visual invasive coronary angiography stenosis >90%, fractional flow reserve <0.80, or a quantitative coronary analysis stenosis >50% if fractional flow reserve measurements were not feasible. RESULTS: The PRS was associated with obstructive CAD independent of CRFs (adjusted odds ratio, 1.8 [95% CI, 1.5-2.2] per SD). The PRS had an area under the curve of 0.63 (0.59-0.68), which was similar to that for age and sex. Combining the PRS with CRFs led to a CRF+PRS model with area under the curve of 0.75 (0.71-0.79), which was 0.04 more than the CRF model (P=0.0029). By using pretest probability (pretest probability) cutoffs at 5% and 15%, a net reclassification improvement of 15.8% (P=3.1×10-4) was obtained, with a down-classification of risk in 24% of patients (211 of 862) in whom the pretest probability was 5% to 15% based on CRFs alone. CONCLUSIONS: Adding a PRS improved risk stratification of obstructive CAD beyond CRFs, suggesting a modest clinical potential of using PRSs to guide diagnostic testing in the contemporary clinical setting. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02264717.


Subject(s)
Chest Pain , Computed Tomography Angiography , Coronary Angiography , Coronary Artery Disease , Coronary Stenosis , Chest Pain/diagnostic imaging , Chest Pain/genetics , Chest Pain/physiopathology , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/genetics , Coronary Artery Disease/physiopathology , Coronary Stenosis/diagnostic imaging , Coronary Stenosis/genetics , Coronary Stenosis/physiopathology , Female , Humans , Male , Middle Aged , Risk Assessment
19.
Am J Cardiol ; 149: 16-20, 2021 06 15.
Article in English | MEDLINE | ID: mdl-33757786

ABSTRACT

Despite the increasing use of Coronary Artery Calcium (CAC) scoring for cardiovascular risk stratification in asymptomatic patients, the gender differences in CAC among symptomatic patients have not been well evaluated. We analyzed patients presenting to the emergency department (ED) with chest pain suggesting possible coronary artery disease (CAD) who received coronary computed tomography angiography (CCTA). Ordinal logistic regression was used to determine the odds ratio for the association of traditional cardiovascular risk factors and CAC. Patients with a CAC score ≥ 100 were followed for cardiovascular events or changes in medical management. Our cohort included 542 individuals (263 male, 279 female). Ordinal logistic regression model showed that among traditional cardiovascular risk factors, male sex had the highest odds ratio (OR) of 3.04 (p < 0.001, 95% CI [2.01, 4.59]) for the presence of CAC. Also, males had more diffuse distribution of coronary atherosclerosis (p=0.01). Subgroup analysis revealed that obesity was a bigger risk factor in male patients (OR 2.16), while smoking showed the greatest effect (OR 4.27) on CAC in women. Of patients who had CAC > 100 with an average follow-up of 346 days, there was an increase in both aspirin and statin use, yet significant sex differences were observed especially in patients with non-obstructive lesions on CCTA. Among male patients with non-obstructive lesions, 68.2% were on aspirin and 86.4% were on statin therapy after the CCTA compared to 27.3% and 45.5% respectively in their female counterparts. In conclusion, sex not only is the most powerful predictor for higher CAC among traditional cardiovascular risk factors in symptomatic patients but also influences the contribution of various traditional risk factors to elevated CAC. Furthermore, the discovery of CAD led to the initiation of medical therapy in male patients more frequently than in female patients, even after adjusting for the degree of luminal stenosis detected on coronary CT angiography.


Subject(s)
Chest Pain/physiopathology , Coronary Artery Disease/epidemiology , Coronary Stenosis/epidemiology , Obesity/epidemiology , Smoking/epidemiology , Vascular Calcification/epidemiology , Adult , Aspirin/therapeutic use , Cohort Studies , Computed Tomography Angiography , Coronary Angiography , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/physiopathology , Coronary Stenosis/diagnostic imaging , Coronary Stenosis/physiopathology , Female , Heart Disease Risk Factors , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Logistic Models , Male , Middle Aged , Platelet Aggregation Inhibitors/therapeutic use , Retrospective Studies , Sex Factors , Vascular Calcification/diagnostic imaging , Vascular Calcification/physiopathology
20.
Curr Pain Headache Rep ; 25(5): 32, 2021 Mar 24.
Article in English | MEDLINE | ID: mdl-33760994

ABSTRACT

PURPOSE OF REVIEW: Chest pain is a very common presenting complaint among patients in the hospital, a large proportion of whom have non-cardiac chest pain (NCCP). Neurological causes of NCCP have not been previously reviewed although several causes have been identified. RECENT FINDINGS: Chest pain has been reported as a symptom of multiple neurological conditions such as migraine, epilepsy, and multiple sclerosis, with varying clinical presentations. The affected patients are often not formally diagnosed for long periods of time due to difficulties in recognizing the symptoms as part of neurological disease processes. This paper will briefly summarize well-known etiologies of chest pain and, then, review neurological causes of NCCP, providing an overview of current literature and possible pathophysiologic mechanisms.


Subject(s)
Chest Pain/etiology , Nervous System Diseases/complications , Central Nervous System Sensitization , Chest Pain/physiopathology , Complex Regional Pain Syndromes/complications , Complex Regional Pain Syndromes/physiopathology , Epilepsy/complications , Epilepsy/physiopathology , Guillain-Barre Syndrome/complications , Guillain-Barre Syndrome/physiopathology , Herpes Zoster/complications , Herpes Zoster/physiopathology , Humans , Migraine Disorders/complications , Migraine Disorders/physiopathology , Nervous System Diseases/physiopathology , Neuralgia, Postherpetic/complications , Neuralgia, Postherpetic/physiopathology , Polyradiculoneuropathy, Chronic Inflammatory Demyelinating/complications , Polyradiculoneuropathy, Chronic Inflammatory Demyelinating/physiopathology , Radiculopathy/complications , Radiculopathy/physiopathology , Spinal Nerve Roots , Stiff-Person Syndrome/complications , Stiff-Person Syndrome/physiopathology , Stroke/complications , Stroke/physiopathology
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