Chest pain in pediatric patients in the emergency department- Presentation, risk factors and outcomes-A systematic review and meta-analysis.

OBJECTIVE: This study aimed to assess and determine the presentation, risk factors, and outcomes of pediatric patients who were admitted for cardiac-related chest pain. BACKGROUND: Although chest pain is common in children, most cases are due to non-cardiac etiology. The risk of misdiagnosis and the pressure of potentially adverse outcomes can lead to unnecessary diagnostic testing and overall poorer patient experiences. Additionally, this can lead to a depletion of resources that could be better allocated towards patients who are truly suffering from cardiac-related pathology. METHODS: This review was conducted per PRISMA guidelines. This systematic review used several databases including MEDLINE, Embase, Scopus, and Web of Science to obtain its articles for review. RESULTS: A total of 6,520 articles were identified, and 11 articles were included in the study. 2.5% of our study population was found to have cardiac-related chest pain (prevalence = 0.025, 95% CI [0.013, 0.038]). The most commonly reported location of pain was retrosternal chest pain. 97.5% of the study population had a non-cardiac cause of chest pain, with musculoskeletal pain being identified as the most common cause (prevalence = 0.357, 95% CI [0.202, 0.512]), followed by idiopathic (prevalence = 0.352, 95% CI [0.258, 0.446]) and then gastrointestinal causes (prevalence = 0.053, 95% CI [0.039, 0.067]). CONCLUSIONS: The overwhelming majority of pediatric chest pain cases stem from benign origins. This comprehensive analysis found musculoskeletal pain as the predominant culprit behind chest discomfort in children. Scrutinizing our study cohort revealed that retrosternal chest pain stands as the unequivocal epicenter of this affliction. Thorough evaluation of pediatric patients manifesting with chest pain is paramount for the delivery of unparalleled care, especially in the context of potential cardiac risks in the emergency department.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Dolor torácico secundario al consumo de drogas atendido en urgencias hospitalarias en España / Chest pain secondary to drug use treated in hospital emergency departments in Spain

Objetivo Conocer las características de los pacientes con dolor torácico (DT) asociado al consumo reciente de drogas. Método Estudio de los casos del Registro REUrHE atendidos en urgencias de 11 hospitales españoles por DT tras el consumo de drogas de uso recreacional. Resultados El DT supuso el 8,97% de las asistencias (varones 82,9%, p<0,001). La cocaína estaba presente en el 70% de los casos, seguida del cannabis (35,7%) y las anfetaminas y derivados (21,4%). La clínica inicial más frecuente fue: palpitaciones (45,5%, p<0,001), ansiedad (42,5%, p<0,001), hipertensión (13,6%, p<0,001) y arritmias (5,9%, p<0,001). Recibieron más tratamiento los pacientes con DT (81,9% vs. 74,1%; p<0,001), aunque ingresaron menos (7,6%, p=0,0), sin diferencias en cuanto a maniobras de reanimación cardiopulmonar, sedación, intubación, o ingreso en cuidados intensivos (1,9%). Conclusiones En el DT tras una intoxicación aguda por drogas predomina el uso de la cocaína, aunque aumentan los casos por consumo de cannabis (AU)

Objective To determine the characteristics of patients with chest pain (CP) associated with recent drug use. Methods Study of cases from the REUrHE registry attended in the emergency department of 11 Spanish hospitals for CP following recreational drug use. Results CP accounted for 8.97% of attendances (males 82.9%, P<.001). Cocaine was present in 70% of cases, followed by cannabis (35.7%) and amphetamines and derivatives (21.4%). The most frequent initial symptoms were: palpitations (45.5%, P<.001), anxiety (42.5%, P<.001), hypertension (13.6%, P<.001) and arrhythmias (5.9%, P<.001). Patients with TD received more treatment (81.9% vs. 74.1%; P<.001), although they were admitted less (7.6%, P=.0), with no differences in terms of CPR manoeuvres, sedation, intubation, or admission to intensive care (1.9%). Conclusions In CP following acute drug intoxication, cocaine use predominates, although cases of cannabis use are increasing (AU)

Effect of a national awareness campaign on ambulance attendances for chest pain and out-of-hospital cardiac arrest.

AIM: Awareness of heart attack symptoms may enhance health-seeking behaviour and prevent premature deaths from out-of-hospital cardiac arrest (OHCA). We sought to investigate the impact of a national awareness campaign on emergency medical service (EMS) attendances for chest pain and OHCA. METHODS: Between January 2005 and December 2017, we included registry data for 97,860 EMS-attended OHCA cases from 3 Australian regions and dispatch data for 1,631,217 EMS attendances for chest pain across 5 Australian regions. Regions were exposed to between 11 and 28 months of television, radio, and print media activity. Multivariable negative binomial models were used to explore the effect of campaign activity on the monthly incidence of EMS attendances for chest pain and OHCA. RESULTS: Months with campaign activity were associated with an 8.8% (IRR 1.09, 95% CI: 1.07, 1.11) increase in the incidence of EMS attendances for chest pain and a 5.6% (IRR 0.94, 95% CI: 0.92, 0.97) reduction in OHCA attendances. Larger intervention effects were associated with increasing months of campaign activity, increasing monthly media spending and media exposure in 2013. In stratified analyses of OHCA cases, the largest reduction in incidence during campaign months was observed for unwitnessed arrests (IRR 0.93, 95% CI: 0.90, 0.96), initial non-shockable arrests (IRR 0.93, 95% CI: 0.90, 0.97) and arrests occurring in private residences (IRR 0.95, 95% CI: 0.91, 0.98). CONCLUSION: A national awareness campaign targeting knowledge of heart attack symptoms was associated with an increase in EMS use for chest pain and a reduction in OHCA incidence and may serve as an effective primary prevention strategy for OHCA.

Decline in typical angina among patients referred for cardiac stress testing.

OBJECTIVE: To evaluate temporal trends in the prevalence of typical angina and its clinical correlates among patients referred for stress/rest SPECT myocardial perfusion imaging (MPI). PATIENTS AND METHODS: We evaluated the prevalence of chest pain symptoms and their relationship to inducible myocardial ischemia among 61,717 patients undergoing stress/rest SPECT-MPI between January 2, 1991 and December 31, 2017. We also assessed the relationship between chest pain symptom and angiographic findings among 6,579 patients undergoing coronary CT angiography between 2011 and 2017. RESULTS: The prevalence of typical angina among SPECT-MPI patients declined from 16.2% between 1991 and 1997 to 3.1% between 2011 and 2017, while the prevalence of dyspnea without any chest pain increased from 5.9 to 14.5% over the same period. The frequency of inducible myocardial ischemia declined over time within all symptom groups, but its frequency among current patients (2011-2017) with typical angina was approximately three-fold higher versus other symptom groups (28.4% versus 8.6%, p < 0.001). Overall, patients with typical angina had a higher prevalence of obstructive CAD on CCTA than those with other clinical symptoms, but 33.3% of typical angina patients had no coronary stenoses, 31.1% had 1-49% stenoses, and 35.4% had ≥ 50% stenoses. CONCLUSIONS: The prevalence of typical angina has declined to a very low level among contemporary patients referred for noninvasive cardiac tests. The angiographic findings among current typical angina patients are now quite heterogeneous, with one-third of such patients having normal coronary angiograms. However, typical angina remains associated with a substantially higher frequency of inducible myocardial ischemia compared to patients with other cardiac symptoms.

Clinical presentations of acute pulmonary embolism: A retrospective cohort study.

We aimed to investigate whether the unusual clinical presentation of pulmonary embolism (PE) varies by the type of provocation. In this retrospective cohort study, we examined the electronic health records (EHR) records of all patients diagnosed with PE (upon presentation or during hospitalization) presented to our tertiary hospital during 2014 to 2019. Inclusion criteria were the diagnosis of acute PE and age above 18 years. Excluded were all patients to whom complete EHR were not available. The primary outcome was the main presenting symptom, categorized by a multidisciplinary consensus expert committee as either typical or atypical of PE. Comorbidities, vital signs, medications and laboratory results on presentations were recorded. 591 patients were included in the final analysis. Dyspnea was significantly less common and hemoptysis and chest pain more common in the unprovoked PE group (35%, 5%, and 25%, respectively) compared with nonmalignant (42.6%, 0%, and 16.3%) and malignancy-associated (47.7%, 0.9%, and 8.2%) PE (Pv = 0.02, 0.002 and 0.001, respectively). No recorded symptoms were the third most common presentation overall, accounting for a significantly (Pv < 0.001) higher proportion of PE patients with malignancy (19%) whereas atypical presentation was the hallmark of patients with nonmalignant provokation (19.7%) (Pv = 0.005). Accounting for multiple potential confounders, the risk of atypical or asymptomatic presentation was higher with lower heart rates (RR = 0.974 95%C.I. [0.957-0.990]) and higher pulse oximetry saturation (RR = 1.114 95%CI [1.034-1.201]). The clinical presentation of PE varies with different types of provoking factors, with atypical presentation most common in nonmalignant provocation and asymptomatic presentation most prevalent in patients with underlying malignancy. Further studies are needed to determine the effect of said variance on long term clinical outcomes.

Unstable angina in the context of high-sensitive troponins: Still a marker of high risk? A comparison of outcomes with adjudicated type 1 myocardial infarction.

BACKGROUND: Unstable angina (UA), considered historically a marker of high risk, has rarely been studied in the high sensitive troponin era. We sought to characterise this population and determine short- and medium-term outcomes for UA and compared this to both patients with musculoskeletal chest pain and adjudicated type 1 MI (NSTEMI). METHOD: We conducted a post-hoc analysis of 2 prospective cohort studies of suspected acute coronary syndrome in 2 hospitals in the northwest of England. (n = 3018) We used a dedicated symptom score to diagnose unstable angina. Type 1 MI (NSTEMI) was diagnosed by independent physician adjudication according to 3rd universal definition of MI. Follow-up was 100% complete for all patients to 1 year. RESULTS: 185 (6.1%) and 249 (8.3%) were adjudicated as suffering from UA and NSTEMI respectively. We restricted our analysis of UA to 158 (5.2%) patients with UA with high sensitive troponin T (Roche Elecsys) ≤14 ng/L (≤99th percentile). Compared to the NSTEMI population, the UA cohort were younger (59 vs 74, p < 0.002), had a lower incidence of hypertension (56.3% vs 69.1%, p = 0.009), had significantly lower composite risk scores and had fewer ECG abnormalities (ST depression >1 mm, 5.1% vs 15.6%, p = 0.001, T wave flattened, biphasic or inverted 24.1% vs 47.8%, p < 0.0001). Subsequent Type 1 MI to 30 days and 1 year in the UA cohort was 1.9% and 1.9% respectively compared to 0.8% and 2.4% in the index type 1 MI (NSTEMI cohort) respectively. However, compared to patients presenting with musculoskeletal chest pain (n = 468) there was a significantly greater incidence of subsequent MI and coronary revascularisation in patients with unstable angina. All cause death at 30 days and 1 year was 0.0% and 0.6% (n = 1) for UA patients and 2.8% (n = 7) and 16.1% (n = 40) for the NSTEMI cohort respectively. CONCLUSION: UA, defined objectively by a symptom score and absence of myocyte necrosis, is still prevalent as an entity, with a risk of subsequent MI and urgent or emergency coronary revascularisation. However, mortality is >10-fold lower when compared to NSTEMI, indicating a less severe pathology in terms of atherosclerosis or plaque burden, and implying the need for a different management strategy to that of NSTEMI.

Chest pain in cardiac amyloidosis: occurrence, causes and prognostic significance.

BACKGROUND: Chest pain is experienced by patients with cardiac amyloidosis (CA), but a systematic investigation of its frequency, underlying etiologies and clinical significance is lacking. METHODS: Clinical, echocardiographic, laboratory characteristics, available coronary arteries imaging and endomyocardial biopsy (EMB) findings of 174 patients with CA (n = 104 with transthyretin, ATTR; n = 70 with light chains, AL) were analyzed. RESULTS: Chest pain was reported in 66 (38%) CA patients. Compared to those without, patients with chest pain had more frequently a history of coronary artery disease (CAD) (27% vs 15%, p = 0.048) and heart failure (HF) symptoms (62% vs 43%, p = 0.015), higher high sensitivity troponin I (hs-cTnI, 101 vs 65 ng/L, p = 0.032) and higher brain natriuretic peptide (597 vs 407 ng/L, p = 0.024). Among CA patients with chest pain undergoing coronary arteries imaging (n = 37), obstructive CAD was detected in 14 (38%), 13 of whom with ATTR-CA. Of these 37 patients, EMB was available in 10 and vascular/perivascular amyloid deposition was detected in 4/5 (80%) of AL-CA patients and 1/5 ATTR-CA. Among patients with suspected acute coronary syndrome (n = 22), obstructive CAD was detected in 9/17 (53%) ATTR-CA and 0/5 AL-CA; hs-cTnI levels were similar between those with and without obstructive CAD. During a follow-up of 17 (8-34) months, chest pain was a significant predictor of HF hospitalization (HR1.86, 95% CI 1.02-3.39, p = 0.042), even after adjustment for CA subtype and CAD. CONCLUSION: Chest pain is a common symptom in patients with CA, reflects a more advanced cardiac impairment and predicts future HF hospitalization. The etiology of chest pain seems to differ, with obstructive CAD more frequent in ATTR-CA whilst amyloid vascular/perivascular involvement more common in AL-CA.

The long-term effects of the Covid-19 infection on cardiac symptoms.

BACKGROUND: Besides the lungs, coronavirus disease 2019 (COVID-19) can affect the cardiovascular, digestive, urinary, hepatic, and central nervous systems. Other than its short-term effects, COVID-19 may also cause long-term complications. In this study, we assessed long-term COVID-19 cardiovascular symptoms among patients in a cardiovascular clinic. METHOD: A retrospective cohort was conducted between October 2020 to May 2021 on patients at an outpatient cardiovascular clinic in Shiraz, Iran. Patients with a history of COVID-19 at least one year before their referral were included. Baseline information was extracted from the clinic's database. Data were collected regarding symptoms like dyspnea, chest pain, fatigue, and palpitations after a year of COVID-19. We also noted any major adverse cardiac events (MACE). RESULTS: Most common symptoms after a year of COVID-19 were exertional dyspnea (51.2%), dyspnea at rest (41.6%), fatigue (39%), and chest pain (27.1%). The symptoms were more prevalent in hospitalized patients than in non-hospitalized patients. The prevalence of MACE was about 6.1% during the 12-month follow-up, with this rate being higher in those with a history of hospitalization or comorbid diseases. CONCLUSION: The prevalence of cardiovascular symptoms was fairly high in patients at our clinic a year after COVID-19, and the most common symptom was dyspnea. Hospitalized patients had more MACE. (Clinicaltrial.gov number: NCT05715879)(04/02/2023).

Rarely tested or treated but highly prevalent: Hypercholesterolemia in ED observation unit patients with chest pain.

BACKGROUND: Hypercholesterolemia (HCL) is common among Emergency Department (ED) patients with chest pain but is typically not addressed in this setting. This study aims to determine whether a missed opportunity for Emergency Department Observation Unit (EDOU) HCL testing and treatment exists. METHODS: We conducted a retrospective observational cohort study of patients ≥18 years old evaluated for chest pain in an EDOU from 3/1/2019-2/28/2020. The electronic health record was used to determine demographics and if HCL testing or treatment occurred. HCL was defined by self-report or clinician diagnosis. Proportions of patients receiving HCL testing or treatment at 1-year following their ED visit were calculated. HCL testing and treatment rates at 1-year were compared between white vs. non-white and male vs. female patients using multivariable logistic regression models including age, sex, and race. RESULTS: Among 649 EDOU patients with chest pain, 55.8% (362/649) had known HCL. Among patients without known HCL, 5.9% (17/287, 95% CI 3.5-9.3%) had a lipid panel during their index ED/EDOU visit and 26.5% (76/287, 95% CI 21.5-32.0%) had a lipid panel within 1-year of their initial ED/EDOU visit. Among patients with known or newly diagnosed HCL, 54.0% (229/424, 95% CI 49.1-58.8%) were on treatment within 1-year. After adjustment, testing rates were similar among white vs. non-white patients (aOR 0.71, 95% CI 0.37-1.38) and men vs. women (aOR 1.32, 95% CI 0.69-2.57). Treatment rates were similar among white vs. non-white (aOR 0.74, 95% CI 0.53-1.03) and male vs. female (aOR 1.08, 95% CI 0.77-1.51) patients. CONCLUSIONS: Few patients were evaluated for HCL in the ED/EDOU or outpatient setting after their ED/EDOU encounter and only 54% of patients with HCL were on treatment during the 1-year follow-up period after the index ED/EDOU visit. These findings suggest a missed opportunity to reduce cardiovascular disease risk exists by evaluating and treating HCL in the ED or EDOU.