INTRODUCTION: Elevated troponin, while essential for diagnosing myocardial infarction, can also be present in non-myocardial infarction conditions. The myocardial-ischaemic-injury-index (MI3) algorithm is a machine learning algorithm that considers age, sex and cardiac troponin I (TnI) results to risk-stratify patients for type 1 myocardial infarction. METHOD: Patients aged ≥25 years who presented to the emergency department (ED) of Singapore General Hospital with symptoms suggestive of acute coronary syndrome with no diagnostic 12-lead electrocardiogram (ECG) changes were included. Participants had serial ECGs and high-sensitivity troponin assays performed at 0, 2 and 7 hours. The primary outcome was the adjudicated diagnosis of type 1 myocardial infarction at 30 days. We compared the performance of MI3 in predicting the primary outcome with the European Society of Cardiology (ESC) 0/2-hour algorithm as well as the 99th percentile upper reference limit (URL) for TnI. RESULTS: There were 1351 patients included (66.7% male, mean age 56 years), 902 (66.8%) of whom had only 0-hour troponin results and 449 (33.2%) with serial (both 0 and 2-hour) troponin results available. MI3 ruled out type 1 myocardial infarction with a higher sensitivity (98.9, 95% confidence interval [CI] 93.4-99.9%) and similar negative predictive value (NPV) 99.8% (95% CI 98.6-100%) as compared to the ESC strategy. The 99th percentile cut-off strategy had the lowest sensitivity, specificity, positive predictive value and NPV. CONCLUSION The MI3 algorithm was accurate in risk stratifying ED patients for myocardial infarction. The 99th percentile URL cut-off was the least accurate in ruling in and out myocardial infarction compared to the other strategies.
Humans ; Male ; Female ; Emergency Service, Hospital ; Middle Aged ; Electrocardiography ; Machine Learning ; Singapore ; Chest Pain/blood* ; Troponin I/blood* ; Myocardial Infarction/blood* ; Risk Assessment/methods* ; Aged ; Algorithms ; Acute Coronary Syndrome/blood* ; Adult ; Sensitivity and Specificity

Acute myocardial infarction (AMI) is a fatal cardiovascular disease, and mortality is relatively high; therefore, integrated assessment is necessary for its management. There are several risk predictive models, but treatment trends have changed due to newly introduced medications and the universal use of percutaneous coronary intervention (PCI). The author aimed to find out predictive factors of in-hospital mortality in Korean patients with AMI. A group of 13,104 patients with AMI enrolled in the Korea Acute Myocardial Infarction Registry-National Institute of Health (KAMIR-NIH) registry were divided into two groups. One was a derivation group for evaluating mortality prediction; the other was a validation group for the application of risk prediction. In-hospital mortality was 4.2% (n=552). With hierarchical and stepwise multivariate analyses, nine factors were shown to predict in-hospital mortality for Korean patients with AMI. These were 1) being over 65 years of age, 2) high Killip class over II, 3) hyperglycemia over 180 mg/dl, 4) tachycardia over 100/min, 5) serum creatinine over 1.5 mg/dl, 6) atypical chest pain, 7) low systolic blood pressure under 90 mmHg, 8) low Thrombolysis In Myocardial Infarction (TIMI) flow (TIMI 0-II) before PCI and 9) low TIMI flow (TIMI 0-II) after PCI. The validation group showed a predictive power of 88.3%. Old age, high Killip class, hyperglycemia, tachycardia, renal dysfunction, atypical chest pain, low systolic blood pressure, and low TIMI flow are important risk factors of in-hospital mortality in Korean patients with AMI.
Blood Pressure ; Cardiovascular Diseases ; Chest Pain ; Creatinine ; Hospital Mortality* ; Humans ; Hyperglycemia ; Korea ; Mortality ; Multivariate Analysis ; Myocardial Infarction* ; Percutaneous Coronary Intervention ; Prognosis ; Risk Factors ; Tachycardia

Postinfectious glomerulonephritis (PIGN) is most commonly caused by Streptococcus pyogenes in children, but PIGN associated with other pathogens has been described in the literature. A previously healthy 6-year-old boy was admitted with complaints of cough, fever, and right chest pain. The patient was diagnosed with pneumococcal bacteremia and influenza A virus infection and treated with antibiotics and antiviral agent. During hospitalization, generalized edema, hematuria, proteinuria, and increased blood pressure were observed; therefore, we started administering diuretics. The boy was discharged with gross hematuria, and even microscopic hematuria disappeared 14 weeks after discharge. We report a case of PIGN associated with bacteremic pneumococcal pneumonia and influenza A virus infection in children. A urine test and blood pressure measurement should be considered for the early detection of PIGN in children with pneumococcal or influenza A virus infection when they present with nephritic symptoms.
Anti-Bacterial Agents ; Bacteremia ; Blood Pressure ; Chest Pain ; Child ; Cough ; Diuretics ; Edema ; Fever ; Glomerulonephritis ; Hematuria ; Hospitalization ; Humans ; Influenza A virus ; Influenza, Human ; Male ; Pneumonia ; Pneumonia, Pneumococcal ; Proteinuria ; Streptococcus pneumoniae ; Streptococcus pyogenes

PURPOSE: Coronary artery spasm (CAS) and diabetes mellitus (DM) are implicated in endothelial dysfunction, and insulin resistance (IR) is a major etiological cause of type 2 DM. However, the association between CAS and IR in non-diabetic individuals has not been elucidated. The aim of the present study was to evaluate the impact of IR on CAS in patients without DM. MATERIALS AND METHODS: A total of 330 eligible patients without DM and coronary artery disease who underwent acetylcholine (Ach) provocation test were enrolled in this study. Inclusion criteria included both hemoglobin A1c < 6.0% and fasting glucose level < 110 mg/dL without type 2 DM. Patients were divided into quartile groups according the level of homeostasis model assessment of insulin resistance (HOMA-IR): 1Q (n=82; HOMA-IR < 1.35), 2Q (n=82; 1.35≤HOMA-IR < 1.93), 3Q (n=83; 1.93≤HOMA-IR < 2.73), and 4Q (n=83; HOMA-IR≥2.73). RESULTS: In the present study, the higher HOMA-IR group (3Q and 4Q) was older and had higher body mass index, fasting blood glucose, serum insulin, hemoglobin A1c, total cholesterol, and triglyceride levels than the lower HOMA-IR group (1Q). Also, poor IR (3Q and 4Q) was considerably associated with frequent CAS. Compared with Q1, the hazard ratios for Q3 and Q4 were 3.55 (95% CI: 1.79–7.03, p < 0.001) and 2.12 (95% CI: 1.07–4.21, p=0.031), respectively, after adjustment of baseline risk confounders. Also, diffuse spasm and accompanying chest pain during Ach test were more strongly associated with IR patients with CAS. CONCLUSION: HOMA-IR was significantly negatively correlated with reference diameter measured after nitroglycerin and significantly positively correlated with diffuse spasm and chest pain.
Acetylcholine ; Blood Glucose ; Body Mass Index ; Chest Pain ; Cholesterol ; Coronary Artery Disease ; Coronary Vessels* ; Diabetes Mellitus ; Fasting ; Glucose ; Homeostasis ; Humans ; Insulin Resistance* ; Insulin* ; Nitroglycerin ; Spasm* ; Triglycerides

Mid-ventricular obstruction (MVO) rarely occurs in patients without hypertrophic cardiomyopathy. Increased cardiac contractility may play an important role in causing MVO. We experienced a case of severe chest pain and MVO in a 50-year-old female patient. She had hypertension, diabetes, stroke and peripheral artery disease. Her blood pressure was very high (222/122 mmHg) with severe fluctuation. The transthoracic echocardiography revealed MVO accompanied by hyper-dynamic left ventricular systolic function. We regarded her chest pain and MVO as secondary findings related to other diseases. Coronary angiography and several tests for uncontrolled hypertension were performed, and those evaluations revealed that she had coronary artery disease and hyperthyroidism. We considered that the increase in the myocardial oxygen demand in response to the increase in cardiac contractility and workload associated with hyperthyroidism aggravated her symptoms and MVO. She was treated with methimazole and beta blockers and her symptoms dramatically improved.
Blood Pressure ; Cardiomyopathy, Hypertrophic ; Chest Pain* ; Coronary Angiography ; Coronary Artery Disease ; Echocardiography ; Female ; Humans ; Hypertension ; Hyperthyroidism* ; Methimazole ; Middle Aged ; Oxygen ; Peripheral Arterial Disease ; Stroke ; Thorax* ; Ventricular Function

Mid-ventricular obstruction (MVO) rarely occurs in patients without hypertrophic cardiomyopathy. Increased cardiac contractility may play an important role in causing MVO. We experienced a case of severe chest pain and MVO in a 50-year-old female patient. She had hypertension, diabetes, stroke and peripheral artery disease. Her blood pressure was very high (222/122 mmHg) with severe fluctuation. The transthoracic echocardiography revealed MVO accompanied by hyper-dynamic left ventricular systolic function. We regarded her chest pain and MVO as secondary findings related to other diseases. Coronary angiography and several tests for uncontrolled hypertension were performed, and those evaluations revealed that she had coronary artery disease and hyperthyroidism. We considered that the increase in the myocardial oxygen demand in response to the increase in cardiac contractility and workload associated with hyperthyroidism aggravated her symptoms and MVO. She was treated with methimazole and beta blockers and her symptoms dramatically improved.
Blood Pressure ; Cardiomyopathy, Hypertrophic ; Chest Pain ; Coronary Angiography ; Coronary Artery Disease ; Echocardiography ; Female ; Humans ; Hypertension ; Hyperthyroidism ; Methimazole ; Middle Aged ; Oxygen ; Peripheral Arterial Disease ; Stroke ; Thorax ; Ventricular Function

BACKGROUND: Acute heart failure negatively affects short-term outcomes of patients with acute coronary syndrome (ACS). Therefore, reliable and non-invasive assessment of pulmonary congestion is needed to select patients requiring more intensive monitoring and therapy. Since plasma levels of natriuretic peptides are influenced by myocardial ischemia, they might not reliably reflect congestion in the context of ACS. The novel endothelial biomarker, soluble CD146 (sCD146), presents discriminative power for detecting the cardiac origin of acute dyspnea similar to that of natriuretic peptides and is associated with systemic congestion. We evaluated the performance of sCD146 for the assessment of pulmonary congestion in the early phase of ACS. METHODS: One thousand twenty-one consecutive patients with ACS were prospectively enrolled. Plasma levels of sCD146, brain natriuretic peptide (BNP), and high-sensitive troponin T were measured within 24 hr after the onset of chest pain. Pulmonary congestion on chest radiography was determined and classified in three groups according to the degree of congestion. RESULTS: Nine hundred twenty-seven patients with ACS were analyzed. Ninety-two (10%) patients showed signs of pulmonary edema on chest radiography. Plasma levels of sCD146 reflected the radiological severity of pulmonary congestion. Higher plasma levels of sCD146 were associated with the worse degree of pulmonary congestion. In contrast to BNP, sCD146 levels were not affected by the level of troponin T. CONCLUSIONS: The novel endothelial biomarker, sCD146, correlates with radiological severity of pulmonary congestion in the early phase of ACS and, in contrast to BNP, is not affected by the amount of myocardial cell necrosis.
Acute Coronary Syndrome/*diagnosis/diagnostic imaging ; Aged ; Antigens, CD146/blood ; Biomarkers/blood ; Chest Pain/diagnostic imaging/*pathology ; Electrocardiography ; Enzyme-Linked Immunosorbent Assay ; Female ; Humans ; Male ; Middle Aged ; Myocardial Infarction/diagnosis ; Natriuretic Peptide, Brain/*blood ; Severity of Illness Index ; Troponin T/blood

Myocardial bridging (MB) occurs when the myocardium covers a segment of a major epicardial coronary artery, resulting in a tunneled arterial segment. Although MB is generally considered benign, it has been associated with myocardial ischemia. A 70-year-old man with MB (50% luminal narrowing during systole) at the mid-left anterior descending artery (LAD) on previous coronary angiography (CAG) visited our hospital with worsening chest pain. His blood pressure (BP) was not well controlled because of poor compliance. Follow-up CAG showed that MB at the mid-LAD progressed to severe stenosis (>90% luminal narrowing during systole) and the total length of tunneled artery extended from 22.5 to 23.9 mm. His chest pain was relieved by BP control. This is the first report of myocardial ischemia secondary to progression of MB demonstrated by CAG in Korea.
Aged ; Arteries ; Blood Pressure ; Chest Pain ; Compliance ; Constriction, Pathologic ; Coronary Angiography ; Coronary Vessels ; Follow-Up Studies ; Humans ; Hypertension ; Ischemia ; Korea ; Myocardial Bridging* ; Myocardial Ischemia* ; Myocardium ; Phenobarbital

Pulmonary embolism (PE) is generally thought to occur between days 5 to 7 after acute injury. However, PE can occur early after injury and the features of early PE after injury have not been well studied. We report on two cases of acute PE within two days after thoracic and lower extremity injury. First, a 39-year-old female presented to the emergency department complaining of chest pain and dyspnea. Fifteen hours earlier, she had fallen from a 1 m height drawer at home. She had a history of idiopathic pulmonary arterial hypertension. Initial blood pressure was normal; however, oxygen saturation was 83% on room air. Chest computerized tomography (CT) showed a low density filling defect in the left main pulmonary artery. However, no deep vein thrombus was observed on low extremity CT angiogram. Second, a 21-year-old male was transferred from a local clinic to the emergency department. He had pelvic ramus, right femur shaft and ankle fracture from a motorcycle accident, which had occurred 36 hours ago. Initial vital signs were stable and he had no symptoms related to PE, except leg pain. We performed CT scan in order to rule out injury associated with pelvic bone fracture. CT scan showed filling defects in the segmental pulmonary artery of the left lower lobe. We did not find deep vein thrombus on low extremity CT angiogram. PE related to trauma can occur in early days after injury and is not commonly associated with deep vein thrombus. Emergency physicians should consider PE in the differential for patients with unexplained dyspnea, even early after injury.
Adult ; Ankle Fractures ; Blood Pressure ; Chest Pain ; Dyspnea ; Emergencies ; Emergency Service, Hospital ; Extremities ; Female ; Femur ; Humans ; Hypertension ; Leg ; Lower Extremity ; Male ; Motorcycles ; Oxygen ; Pelvic Bones ; Pulmonary Artery ; Pulmonary Embolism* ; Thorax ; Thrombosis ; Tomography, X-Ray Computed ; Veins ; Venous Thromboembolism ; Vital Signs ; Young Adult

Reninoma is a tumor of the renal juxtaglomerular cell apparatus that causes hypertension and hypokalemia because of hypersecretion of renin. We present a case of a 29-year-old female patient with reninoma and concomitant variant angina. The patient had uncontrolled hypertension and elevated plasma renin activity and aldosterone levels. Imaging studies revealed a mass in the left kidney, which was further confirmed as a renin-producing lesion via selective venous catheterization. During the evaluation, the patient had acute-onset chest pain that was diagnosed as variant angina after a provocation test. After partial nephrectomy, the plasma renin activity and plasma aldosterone levels decreased and blood pressure normalized. We report a case of reninoma with variant angina.
Adult ; Aldosterone ; Angina, Unstable ; Blood Pressure ; Catheterization ; Catheters ; Chest Pain ; Female ; Humans ; Hypertension ; Hypokalemia ; Kidney ; Kidney Neoplasms ; Nephrectomy ; Plasma ; Renin