Acute prevention of a heart attack : Early identification of prodromal symptoms as the Rosetta Stone in decoding the heart attack problem.

Chest discomfort before severe chest pain represents a marker of clinical ischemia and indicates live myocardium in jeopardy and often precedes cardiac arrest or acute myocardial infarction (MI). The intermittent or "stuttering" symptoms that precede MI are referred to as "prodromal symptoms." These symptoms have been shown to correlate with cyclic ST changes and repeated episodes of spontaneous reperfusion and occlusion, occurring during a period of hours or days before the acute ischemia proceeds to death or heart damage. These symptoms of premonitory angina have been associated with improved outcomes due to ischemic pre-conditioning or opening of collateral vascular channels around the area of ischemia. Acute prevention of an MI through recognition of prodromal symptoms represents an opportunity to significantly reduce heart attack deaths. The Early Heart Attack Care (EHAC) program puts emphasis on prodromal symptom recognition and allows for a shift in time backward to prevent the ischemic process from proceeding to MI. This strategy has been shown to detect the 15% of patients with ischemia in the low-probability group and to reduce inappropriate admissions to hospital as well as to reduce the number of patients with missed MI being sent home from the emergency department.

Paclitaxel-eluting versus bare-metal stents in acute ST elevation myocardial infarction (STEMI).

INTRODUCTION: Data comparing efficacy and safety of drug eluting stents (DES), particularly paclitaxel stent with bare metal stents (BMS) in the setting of acute ST elevation myocardial infarction (STEMI) is limited and inconclusive. The aim of our study is to compare the efficacy and safety of paclitaxel stent with bare metal stent in acute STEMI. METHODS: A retrospective cohort study was performed on patients from our single community hospital who participated in the C-PORT trial from January 2003 to May 2005. One hundred forty-three patients treated exclusively with either BMS or paclitaxel DES were included (79 with paclitaxel DES and 64 with BMS) and were followed at 1, 3, and 6 months. The primary outcome was occurrence of major adverse cardiac events defined as cardiac death, STEMI or NSTEMI or the need for target vessel revascularization. Variables were compared using appropriate statistics and event free survival curves were estimated. RESULTS: Baseline clinical characteristics in BMS and paclitaxel DES groups were well matched. No statistical difference between BMS and DES groups in the rate of cardiac death (6% vs. 9%, P = 0.56), STEMI or NSEMI (1.6% vs. 1.3% respectively, P = 0.88) and composite end point (13% vs. 10%, P = 0.65) was observed while a significant reduction in target vessel revascularization was seen in DES group (6% vs. 0% respectively, P = 0.02) was noticed. CONCLUSION: In our patient group with acute STEMI, the use of paclitaxel DES did not show significant decrease in cumulative end points, cardiac mortality and recurrent STEMI or NSTEMI compared with BMS over a 6-month follow-up period. However, a significant reduction in revascularization of target vessel was seen.

Maryland's first inpatient chest pain short stay unit as an alternative to emergency room-based observation unit.

INTRODUCTION: Approximately 8 million people in the United States visit emergency rooms (ERs) annually for chest pain but only about 1.2 million were ultimately diagnosed with acute myocardial infarction. Of concern, up to 4% to 5% of patients with acute myocardial infarction are those inappropriately discharged from the ER. ER-based observation units (EROU) were developed to enable safe, expedited, and effective management of these patients with negative initial workup. In the state of Maryland, the unique reimbursement system serves as a disincentive to operate EROU. The inpatient chest pain short stay unit (CPSSU) at St. Agnes hospital is the first in Maryland dedicated to evaluating patients with chest pain. We study the performance of CPSSU as compared with that of EROU. METHODS: The project is a prospective observational study that involved consecutive patients presenting to St. Agnes ER with the primary complaint of chest pain between June 1, 2005 and November 30, 2005. After negative initial electrocardiograms and cardiac enzymes, the patients were further evaluated using a standard CPSSU protocol in ER or CPSSU. Primary outcome variables were myocardial infarction or death. RESULTS: A total of 332 patients were enrolled among which 202 were worked up in ER and 130 in CPSSU. There were no deaths and only 1 patient with significant coronary artery disease, representing 0.3% of study population was missed. Thirteen patients (3.9%) were detected with significant coronary artery disease. Severe 3 vessel disease was found in 4 (1.2%) patients. Median cost (and revenue) of evaluation in ER and CPSSU was $978.323 ($1203.533) and $1543.287 ($2947.85), respectively. CONCLUSION: Inpatient CPSSU initiative is an effective alternative to EROU for evaluating chest pain patients with negative initial workup. Furthermore, this is achieved with net profit gain of $1744.37 over that of EROU evaluation.

A formal, standardized and evidence-based approach to Chest Pain Center development and process improvement: the Society of Chest Pain Centers and Providers accreditation process.

The notion of a Chest Pain Center has continued to develop over the past twenty years. The designation of "Chest Pain Center" now applies to the entire facility, much the same as that of "Trauma Center." The Chest Pain Center model incorporates both operational and clinical considerations required to develop proper Acute Coronary Syndrome (ACS) care in the context of a complex health-care system. The Society of Chest Pain Centers and Providers has launched a Chest Pain Center Accreditation initiative that provides an organizational road map for success in approaching the care for patients with ACS.

Usefulness of prodromal unstable angina pectoris in predicting better survival and smaller infarct size in acute myocardial infarction (The InTIME-II Prodromal Symptoms Substudy).

Prodromal unstable angina on presentation is a significant predictor of smaller infarct size, reflected by smaller creatine kinase-MB and creatine kinase total measurements and lower 30-day, 6-month, and 5-year mortality. These findings suggest that prodromal unstable angina is an important physiologic marker that should be routinely collected for risk stratification.