PURPOSE: The aim of the study is to evaluate the clinical usefulness of a TWI in the lead aVL of 12-lead ECG for predicting the left ascending artery (LAD) lesion, high risk, and 30-days mortality in patients with acute coronary syndrome (ACS). METHODS: A total of 275 patients who underwent coronary angiography under the diagnosis of ACS were analyzed retrospectively from Jan 2012 to December 2013. RESULTS: A total of 355 patients underwent coronary angiography. Of these, 275 patients (77.5%) were diagnosed with ACS. Of these, 187 patients (68.0%) had a left LAD lesion. Of these, 111 patients (59.3%) had a mid-LAD lesion. Of these, only 23 patients (22.5%) showed a TWI in the aVL lead. However, regarding the prediction of the high risk group, if there is a TWI in the aVL, when compared with patients without a TWI in the aVL, the high risk rate is four times higher in the univariable logistic regression analysis and 2.687 times higher in the multivariable logistic regression analysis. CONCLUSION: A TWI in the lead aVL of ECG of patients with chest pain in the ER was closely associated with high risk of ACS patients.
Acute Coronary Syndrome* ; Arteries ; Chest Pain ; Coronary Angiography ; Diagnosis ; Electrocardiography* ; Humans ; Logistic Models ; Mortality ; Retrospective Studies

Acute aortic dissection is an uncommon disorder which can have fatal results in the event of treatment delay or misdiagnosis. This case examines a 77-year-old woman presenting with chest pain relieved by nitroglycerin. She was referred to the emergency room with clinical suspicion of acute coronary syndrome (ACS). However, she was later diagnosed with acute aortic dissection and an emergency operation was performed with successful recovery. Aortic dissection may manifest in various ways depending on the site involved and may mimic other disorders such as ACS or pulmonary embolism. Therefore, clinicians must always be aware of aortic dissection and its different clinical manifestations must be understood.
Acute Coronary Syndrome ; Aged ; Chest Pain* ; Diagnosis ; Diagnostic Errors ; Emergencies ; Female ; Humans ; Nitroglycerin* ; Pulmonary Embolism ; Thorax*

BACKGROUND/AIMS: Chest pain is an essential symptom in the diagnosis of acute coronary syndrome (ACS). One-third of patients with ACS present atypically, which can influence their receiving timely lifesaving therapy. METHODS: A total of 617 NSTEMI patients from the Korea Acute MI Registry (KAMIR) and the Korea Working Group on MI (KorMI) databases were analyzed. The study population was divided into two groups by symptoms at presentation (typical symptoms group, 128; atypical symptoms groups, 128). RESULTS: In this study population, 23% of patients presented without chest pain. After propensity score matching, the contact-to-device time (2,618 ± 381 minutes vs. 1,739 ± 241 minutes, p = 0.050), the symptoms-to-balloon time (3,426 ± 389 minutes vs. 2,366 ± 255 minutes, p = 0.024), and the door-to-balloon time (2,339 ± 380 minutes vs. 1,544 ± 244 minutes, p = 0.002) were significantly higher in the patients with atypical symptoms than in those with typical symptoms, respectively. Atypical symptoms were an independent predictor for 1-year mortality (hazard ratio, 2.820; 95% confidence interval, 1.058 to 7.515; p = 0.038). The Kaplan-Meier estimates showed higher risk for 12-month mortality in patients with atypical symptoms (p = 0.048) and no significant difference for 12-month major adverse cardiac events (p = 0.487). CONCLUSIONS: Acute myocardial infarction patients with atypical symptoms were not rare in clinical practice and showed a high risk of delayed reperfusion therapy. After imbalance between the groups was minimized by use of propensity score matching, patients who presented atypically had a high mortality rate.
Acute Coronary Syndrome ; Chest Pain ; Diagnosis ; Humans ; Korea ; Mortality ; Myocardial Infarction* ; Propensity Score ; Reperfusion

Takotsubo cardiomyopathy is a reversible cardiac syndrome that occurs subsequently to other medical illnesses such as cerebral hemorrhage, shock, or seizure disorders that are presumed to disturb autonomic regulation. This syndrome is characterized by chest pain, dyspnea, and electrocardiographic changes mimicking an acute coronary syndrome. Mild elevation of cardiac enzymes and transient wall-motion abnormalities of apical akinesia can appear. However, takotsubo cardiomyopathy following epilepsy is not well recognized. We report two cases of takotsubo-cardiomyopathy-related idiopathic status epilepticus presenting with cardiogenic shock.
Acute Coronary Syndrome ; Cerebral Hemorrhage ; Chest Pain ; Dyspnea ; Electrocardiography ; Epilepsy ; Shock ; Shock, Cardiogenic ; Status Epilepticus* ; Takotsubo Cardiomyopathy*

BACKGROUND AND OBJECTIVES: It is well known that coronary spasm can cause acute coronary syndrome (ACS) such as unstable angina or acute myocardial infarction as well as variant angina. But the role of coronary spasm as an initial presentation in ACS is difficult to demonstrate. Therefore we tried to investigate the validity and safety of ergonovine echocardiography in ACS with normal coronary angiogram (CAG) and suspected variant angina. MATERIALS AND METHOD: Since July 1999 to June 2000, 53 consecutive patients were enrolled for this study (mean age 56+/-10, 44 male). Clinical manifestations of the patients are acute myocardial infarction (8), unstable angina (17) and suspected variant angina (28). Ergonovine maleate was administered intravenously (50 microgram at 5 minute intervals up to total cumulative dosage 350 microgram) with continuous echocardiographic monitoring. Positive criteria of this test was reversible regional wall motion abnormality by echocardiography. RESULTS: This test was completed in all patients without major cardiac event or malignant arrhythmia. Forteen patients (14/53, 26%) showed positive test: their clinical diagnosis was AMI in 2, unstable angina in 6, and variant angina in 6. Four cases were positive without chest pain or electrocardiographic change. CONCLUSION: Ergonovine echocardiography is a safe and useful method in diagnosing coronary vasospasm in ACS with normal CAG and suspected variant angina without ST segment change.
Acute Coronary Syndrome* ; Angina, Unstable ; Arrhythmias, Cardiac ; Chest Pain ; Coronary Vasospasm ; Diagnosis ; Echocardiography* ; Electrocardiography ; Ergonovine* ; Humans ; Myocardial Infarction ; Spasm

BACKGROUND AND OBJECTIVES: Identifying symptom clusters of acute myocardial infarction (AMI) and their clinical significance may be useful in guiding treatment seeking behaviors and in planning treatment strategy. The aim of this study was to identify clusters of acute symptoms and their associated factors that manifested in patients with first-time AMI, and to compare clinical outcomes among cluster groups within 1-year of follow-up. SUBJECTS AND METHODS: A total of 391 AMI patients were interviewed individually using a structured questionnaire for acute and associated symptoms between March 2008 and June 2009 in Korea. RESULTS: Among 14 acute symptoms, three distinct clusters were identified by Latent Class Cluster Analysis: typical chest symptom (57.0%), multiple symptom (27.9%), and atypical symptom (15.1%) clusters. The cluster with atypical symptoms was characterized by the least chest pain (3.4%) and moderate frequencies (31-61%) of gastrointestinal symptoms, weakness or fatigue, and shortness of breath; they were more likely to be older, diabetic and to have worse clinical markers at hospital presentation compared with those with other clusters. Cox proportional hazards regression analysis showed that, when age and gender were adjusted for, the atypical symptom cluster significantly predicted a higher risk of 1-year mortality compared to the typical chest pain cluster (hazard ratio 3.288, 95% confidence interval 1.087-9.943, p=0.035). CONCLUSION: Clusters of symptoms can be utilized in guiding a rapid identification of symptom patterns and in detecting higher risk patients. Intensive treatment should be considered for older and diabetic patients with atypical presentation.
Acute Coronary Syndrome ; Biomarkers ; Chest Pain ; Cluster Analysis ; Fatigue ; Humans ; Myocardial Infarction ; Regression Analysis ; Thorax ; Surveys and Questionnaires

This article presents specific examples of delayed diagnosis of acute coronary syndrome, acute aortic dissection, and pulmonary embolism resulting from evaluating patients with nonspecific acute chest pain who did not undergo immediate dedicated coronary CT angiography (CTA) or triple rule-out protocol (TRO). These concrete examples of delayed diagnosis may advance the concept of using cardiac CTA (i.e., dedicated coronary CTA versus TRO) to triage patients with nonspecific acute chest pain. This article also provides an overall understanding of how to choose the most appropriate examination based on the specific clinical situation in the emergency department (i.e., dedicated coronary CTA versus TRO versus dedicated pulmonary or aortic CTA), how to interpret the CTA results, and the pros and cons of biphasic versus triphasic administration of intravenous contrast material during TRO examination. A precise understanding of various cardiac CTA protocols will improve the diagnostic performance of radiologists while minimizing hazards related to radiation exposure and contrast use.
Acute Coronary Syndrome ; Angiography ; Chest Pain ; Delayed Diagnosis ; Emergencies ; Humans ; Pulmonary Embolism ; Thorax ; Tomography, X-Ray Computed ; Triage

PURPOSE: The aim of this study was to investigate the usefulness of several risk scoring systems, such as TIMI, GRACE, HEART, and PERSUIT as predictors for acute coronary syndrome (ACS) in chest pain with an unclear diagnosis. METHODS: This study was conducted as a retrospective and observational study. Enrolled patients were classified into two groups depending on the cause of chest pain: ACS group (CG; N=80) and non-ACS group (NCG; N=42). Clinical variables, including age, gender, past history, characteristics of chest pain, final diagnosis, and risk score were analyzed according to each group. Risk scoring systems for prediction of acute coronary syndrome were compared using receiver operating characteristic curve (ROC) analysis and area under the curve (AUC). RESULTS: Significant differences in age (p<0.001), diabetes mellitus (p=0.049), prior ischemic heart disease (p<0.001), continuous chest pain (p=0.035), and severe chest pain (p=0.001) were observed between the two groups. Results of ROC analysis for each scoring system for prediction of ACS were as follows: HEART (AUC; 0.878, 95% Confidence Interval, CI; 0.806~0.930, cut-off value; 4 points, sensitivity; 90.48%, specificity; 71.25%), TIMI (AUC; 0.839, 95% CI; 0.762~0.899, cut-off value; 1 point, sensitivity 83.33%, specificity 77.50%), PERSUIT (AUC; 0.748, 95% CI; 0.661~0.822, cut-off value; 11 points, sensitivity 61.90%, specificity 77.50%), and GRACE (AUC; 0.698, 95% CI, 0.608~0.778, cut off value 102 points, sensitivity 83.33, specificity 53.75%). CONCLUSION: In comparative analysis of each scoring system, the HEART scoring system was found to be a strong predictor of ACS in chest pain with an unclear diagnosis, followed by the TIMI, PURSUIT, and GRACE scoring systems.
Acute Coronary Syndrome ; Chest Pain ; Diabetes Mellitus ; Electrocardiography ; Emergencies ; Heart ; Humans ; Myocardial Ischemia ; Retrospective Studies ; ROC Curve ; Sensitivity and Specificity ; Thorax

BACKGROUND: We evaluated the clinical utility of TpP in the diagnosis of acute coronary syndrome and changes in the level of TpP and fibrin(ogen) degradation products after low-molecular weight heparin(LMWH) therapy. METHODS: TpP concentration was measured in 12 patients with acute myocardial infarction(AMI), 21 patients with unstable angina(UA), and 9 patients with non-cardiac chest pain and 18 healthy controls. Among them, in 11 patients treated with LMWH(6 patients with deltaparin & 5 patients with enoxaparin), the levels of TpP(American Biogenetic Sciences) and Fibrinostika(R) total degradation product(TDP), fibrinogen degradation product(FgDP) and fibrin degradation product(FbDP, Organon Teknica) was measured from plasma before treatment and at 3, 12, 15 and 24 hours after treatment. RESULTS: TpP was significantly increased in AMI(19.3+/-11.0(microgram/mL) and UA patients(16.8+/-12.4(microgram/mL) compared with the patients with non-cardiac chest pain(7.1+/-5.6(microgram/mL) and healthy controls(2.6+/-1.6(microgram/mL)(P=0.040). The TpP levels was increased in 91.7%(11/12) of AMI patients, 71.4%(15/21) of UA patients and 33.3%(3/9) of the patients with non-cardiac chest pain. TpP was decreased more significantly in enoxaparin treated group than in deltaparin group(P=0.011). No significantly different changes of plasma TDP/FgDP/FbDP levels between enoxaparin and deltaparin treatment. CONCLUSION: TpP, the precursor of thrombus, appears to be a useful index of intravascular thrombotic process. In the treatment with LMWH, enoxaparin reduced TpP more markedly than deltaparin, which may be suggestive of different anti-thrombotic effect of LMWHs on thrombotic process.
Acute Coronary Syndrome* ; Chest Pain ; Diagnosis* ; Enoxaparin ; Fibrin ; Fibrinogen ; Heparin, Low-Molecular-Weight* ; Humans ; Plasma ; Thorax ; Thrombosis

BACKGROUNDS: As Korea has advanced into the aging society, Acute Coronary Syndrome is increased in number, especially elderly age group. The symptoms of acutecoronary syndrome in eldery were presented in atypical feature frequently. We studied the relation of the first symptom and diagnosis of acutecoronary syndrome and distribution of risk factor and coronary angiographic finding in elderly patient of korea society. METHODS: The subjects who were under went coronary angiography between 2002.5 and 2003.8 were dividedunder 65 years old group and over 65 years old group. And each group described diagnosis, risk factor, first symptom and coronary angiographic finding retrospectively. RESULTS: The diagnosis of unstable angina are more higher(46.5% vs. 26.1%, p<0.01) in the over 65 years old group and the first significant symptom of typical chest pain was more higher(57.4% vs. 47.6%, p<0.01) in the under 65 years old group and dyspnea was more higher(22.8% vs. 9.2%, p<0.01) in the over 65 years old group. The number of abnormal vessel were more higher(66.3% vs. 46.9%, p<0.01) in the over 65 years old group. CONCLUSION: Over 65 years old group compared with younger age group were prewented more frequently angina equivalent symptom than typical chest pain. And at the diagnosis of Acute Coronary Syndrome, over 65 years old group showed more severe coronary angiographic finding. Consequently, early stage of diagnostic approach and treatment need scrupulous attention in the elderly patients.
Acute Coronary Syndrome* ; Aged* ; Aging ; Angina, Unstable ; Chest Pain ; Coronary Angiography ; Diagnosis* ; Dyspnea ; Humans ; Korea* ; Retrospective Studies ; Risk Factors