BACKGROUND

Chest pain is a common reason for emergency room visits. The HEART score is used as a risk stratification tool to aid in clinical decision making. The HEART score is a useful tool due to its good sensitivity, however it has low specificity. The SVEAT score was developed as an improved risk stratification tool which outperformed the HEART score in previous studies. Both the performance of HEART and SVEAT scores lack data in our locality.

To compare the performance of Symptoms, Vascular disease, Electrocardiography, Age, Troponin-I (SVEAT) score and History, Electrocardiography, Age, Risk factors, Troponin-I (HEART) score as predictors of in-hospital Major Adverse Cardiovascular Events (MACE) among adult patients admitted in Chong Hua Hospital Cebu for chest pain.

This single-center, retrospective, observational analytic study included adult patients, ages 18 years old and above, who were admitted for chest pain from January 1, 2022 to December 31, 2022. All patients who passed the inclusion and exclusion criteria were included in the data analysis. Both SVEAT and HEART scores were calculated for each of the included subjects. The performance of both scoring criteria was compared using logistic regression and area under the receiving-operator characteristic curve.

A total of 113 cases were analyzed after exclusion criteria were applied. A total of 50 (44.2%) individuals suffered MACE. The difference in AUC of both SVEAT (0.946, 95%CI) and HEART (0.936, 95%CI) was not statistically significant (95% CI – 0.013 – 0.033, p = 0.400). With a cut-off ofCONCLUSION

SVEAT and HEART scores had similar performance in predicting in hospital MACE. Using a cut-off value of
Human ; Chest Pain ; Heart ; Myocardial Infarction ; Acute Coronary Syndrome

OBJECTIVE: We aimed to assess the feasibility and superiority of machine learning (ML) methods to predict the risk of Major Adverse Cardiovascular Events (MACEs) in chest pain patients with NSTE-ACS. METHODS: Enrolled chest pain patients were from two centers, Beijing Anzhen Emergency Chest Pain Center Beijing Bo'ai Hospital, China Rehabilitation Research Center. Five classifiers were used to develop ML models. Accuracy, Precision, Recall, F-Measure and AUC were used to assess the model performance and prediction effect compared with HEART risk scoring system. Ultimately, ML model constructed by Naïve Bayes was employed to predict the occurrence of MACEs. RESULTS: According to learning metrics, ML models constructed by different classifiers were superior over HEART (History, ECG, Age, Risk factors, & Troponin) scoring system when predicting acute myocardial infarction (AMI) and all-cause death. However, according to ROC curves and AUC, ML model constructed by different classifiers performed better than HEART scoring system only in prediction for AMI. Among the five ML algorithms, Linear support vector machine (SVC), Naïve Bayes and Logistic regression classifiers stood out with all Accuracy, Precision, Recall and F-Measure from 0.8 to 1.0 for predicting any event, AMI, revascularization and all-cause death ( vs. HEART ≤ 0.78), with AUC from 0.88 to 0.98 for predicting any event, AMI and revascularization ( vs. HEART ≤ 0.85). ML model developed by Naïve Bayes predicted that suspected acute coronary syndrome (ACS), abnormal electrocardiogram (ECG), elevated hs-cTn I, sex and smoking were risk factors of MACEs. CONCLUSION Compared with HEART risk scoring system, the superiority of ML method was demonstrated when employing Linear SVC classifier, Naïve Bayes and Logistic. ML method could be a promising method to predict MACEs in chest pain patients with NSTE-ACS.
Humans ; Acute Coronary Syndrome/epidemiology* ; Bayes Theorem ; Feasibility Studies ; Risk Assessment/methods* ; Chest Pain/etiology* ; Myocardial Infarction/diagnosis*

Kounis syndrome is defined as the occurrence of acute coronary syndrome associated with vasoactive mediators, such as histamines in the setting of hypersensitivity and allergic reactions or anaphylactic insults. The condition can be caused by various drugs, foods, or environmental factors that cause allergic reactions. A 35-year-old male visited the emergency room with anaphylaxis accompanied by chest pain approximately 20 minutes after taking zaltoprofen, a nonsteroidal anti-inflammatory drug. After acute treatment for the anaphylaxis, the patient was stabilized and all symptoms disappeared, but the ischemic changes in the electrocardiogram and elevation of the cardiac enzymes were observed. The emergency cardiac angiography and echocardiography were all normal. The allergic reaction of this patient to zaltoprofen was believed to cause a temporary coronary arterial vasospasm, inducing Type 1 Kounis syndrome. Thus far, there have been case reports of Kounis syndrome caused by a range of nonsteroidal anti-inflammatory drugs, but there are no reports of the condition being caused by zaltoprofen. According to the pathophysiology, both cardiac and allergic symptoms must be solved simultaneously, so rapid treatment and diagnosis are needed. Doctors treating acute allergic reactions and anaphylaxis patients must check the cardiovascular symptoms thoroughly and consider the possibility of Kounis syndrome.
Acute Coronary Syndrome ; Adult ; Anaphylaxis ; Angiography ; Chest Pain ; Diagnosis ; Echocardiography ; Electrocardiography ; Emergencies ; Emergency Service, Hospital ; Humans ; Hypersensitivity ; Male

OBJECTIVE: To rapidly and safely identify the risk of developing acute coronary syndrome in patients with chest pain who present to the emergency department, the clinical use of the History, Electrocardiogram, Age, Risk Factors, and Troponin (HEART) scoring has recently been proposed. This study aimed to assess the inter-rater reliability of the HEART score calculated by a large number of Italian emergency physicians.METHODS: The study was conducted in three academic emergency departments using clinical scenarios obtained from medical records of patients with chest pain. Twenty physicians, who took the HEART score course, independently assigned a score to different clinical scenarios, which were randomly administered to the participants, and data were collected and recorded in a spreadsheet by an independent investigator who was blinded to the study’s aim.RESULTS: After applying the exclusion criteria, 53 scenarios were finally included in the analysis. The general inter-rater reliability was good (kappa statistics [κ], 0.63; 95% confidence interval, 0.57 to 0.70), and a good inter-rater agreement for the high- and low-risk classes (HEART score, 7 to 10 and 0 to 3, respectively; κ, 0.60 to 0.73) was observed, whereas a moderate agreement was found for the intermediate-risk class (HEART score, 4 to 6; κ, 0.51). Among the different items of the HEART score, history and electrocardiogram had the worse agreement (κ, 0.37 and 0.42, respectively).CONCLUSION: The HEART score had good inter-rater reliability, particularly among the high- and low-risk classes. The modest agreement for history suggests that major improvements are needed for objectively assessing this component.
Acute Coronary Syndrome ; Chest Pain ; Electrocardiography ; Emergencies ; Emergency Service, Hospital ; Heart ; Humans ; Medical Records ; Observational Study ; Research Personnel ; Risk Factors ; Troponin

OBJECTIVE: Bedside consultation by cardiologists may facilitate safe discharge of selected patients from the emergency department (ED) even when admission is recommended by the History, Electrocardiogram, Age, Risk factors, Troponin (HEART) pathway. If bedside evaluation is unavailable, phone consultation between emergency physicians and cardiologists would be most impactful if the resultant disposition is discordant with the HEART pathway. We therefore evaluate discordance between actual disposition and that suggested by the HEART pathway in patients presenting to the ED with chest pain for whom cardiology consultation occurred exclusively by phone and to assess the impact of phone-consultation on disposition.METHODS: We performed a single-center, retrospective study of adults presenting to the ED with chest pain whose emergency physician had a phone consultation with a cardiologist. Actual disposition was abstracted from the medical record. HEART pathway category (low-risk, discharge; high-risk, admit) was derived from ED documentation. For discharged patients, major adverse cardiac events were assessed at 30 days by chart review and phone follow-up.RESULTS: For the 170 patients that had cardiologist phone consultation, discordance between actual disposition and the HEART pathway was 17%. The HEART pathway recommended admission for nearly 80% of discharged patients. Following cardiologist phone-consultation, 10% of high-risk patients were discharged, with the majority having undergone a functional study recommended by the cardiologist. At 30 days, discharged patients had experienced no episodes of major adverse cardiac events or rehospitalization for cardiac reasons.CONCLUSION: For patients presenting to the ED with chest pain, cardiology phone-consultation has the potential to safely impact disposition, primarily by facilitating functional testing in high-risk individuals.
Acute Coronary Syndrome ; Adult ; Cardiology ; Chest Pain ; Electrocardiography ; Emergencies ; Emergency Service, Hospital ; Follow-Up Studies ; Heart ; Humans ; Medical Records ; Retrospective Studies ; Risk Factors ; Troponin

Takotsubo syndrome, also known as stress-induced cardiomyopathy, is a transient cardiac syndrome that mimics acute coronary syndrome. This condition should be suspected if the patient presents with chest pain after intense emotional stress, accompanied by an abnormal electrocardiogram, elevated levels of myocardial enzymes, and left ventricular apical akinesia on echocardiography. Coronary angiography should be performed for prompt differentiation from ischemic heart disease. A 77-year-old female presented with traumatic multiple fractures of the left sixth and seventh ribs resulting from a violent strike. Clinical findings of physical examination, laboratory tests, electrocardiogram, and coronary angiography provided the diagnosis of Takotsubo syndrome. We performed conservative management including pain control, and the patient was uneventfully discharged seven days after admission.
Acute Coronary Syndrome ; Aged ; Cardiomyopathies ; Chest Pain ; Coronary Angiography ; Diagnosis ; Echocardiography ; Electrocardiography ; Female ; Fractures, Multiple ; Humans ; Myocardial Ischemia ; Physical Examination ; Rib Fractures* ; Ribs* ; Stress, Psychological ; Strikes, Employee ; Takotsubo Cardiomyopathy*

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

BACKGROUND: High-sensitivity cardiac troponin I (hs-cTnI) and the soluble isoform of suppression of tumorigenicity 2 (sST2) are useful prognostic biomarkers in acute coronary syndrome (ACS). The aim of this study was to test the short term prognostic value of sST2 compared with hs-cTnI in patients with chest pain. METHODS: Assays for hs-cTnI and sST2 were performed in 157 patients admitted to the Emergency Department (ED) for chest pain at arrival. In-hospital and 30-day follow-up mortalities were assessed. RESULTS: The incidence of ACS was 37%; 33 patients were diagnosed with ST elevation myocardial infarction (STEMI), and 25 were diagnosed with non-ST elevation myocardial infarction (NSTEMI). Compared with the no acute coronary syndrome (NO ACS) group, the median level of hs-cTnI was higher in ACS patients: 7.22 (5.24-14) pg/mL vs 68 (15.33-163.50) pg/mL (P<0.0001). In all patients, the sST2 level at arrival showed higher independent predictive power than hs-cTnI (odds ratio [OR] 20.13, P<0.0001 and OR 2.61, P<0.0008, respectively). sST2 at ED arrival showed a greater prognostic value for cardiovascular events in STEMI (area under the curve [AUC] 0.80, P<0.001) than NSTEMI patients (AUC 0.72, P<0.05). Overall, 51% of the STEMI patients with an sST2 value>35 ng/mL at ED arrival died during the 30-day follow-up. CONCLUSIONS: sST2 has a greater prognostic value for 30-day cardiac mortality after discharge in patients presenting to the ED for chest pain compared with hs-cTnI. In STEMI patients, an sST2 value >35 ng/mL at ED arrival showed the highest predictive power for short-term mortality.
Acute Coronary Syndrome/diagnosis/*mortality ; Aged ; Area Under Curve ; Biomarkers/analysis ; Chest Pain ; Emergency Service, Hospital ; Female ; Follow-Up Studies ; Humans ; Interleukin-1 Receptor-Like 1 Protein/*analysis ; Male ; Middle Aged ; Odds Ratio ; Prognosis ; ROC Curve ; Troponin I/*analysis

Intramural hematoma of the esophagus is a rare condition that can be spontaneous or secondary to trauma, toxic ingestion, or intervention. If it is the spontaneous type, it usually presents initially with epigastric pain, hematemesis or dysphagia. We present a case of intramural hematoma of the esophagus mimicking acute coronary syndrome. A 63-year-old man presented with severe acute chest pain. He has four coronary stents that were inserted five years ago, from a different hospital, and is on dual antiplatelet agents. Coronary angiography was performed immediately under the suspicion of acute coronary syndrome, and we found that there was no obvious clogging of the coronary arteries. Next, chest computed tomography was performed due to suspected aortic dissection, and the result was also negative. Four days later, endoscopy was performed and intramural hematoma covered with large ulcers was diagnosed.
Acute Coronary Syndrome* ; Chest Pain ; Coronary Angiography ; Coronary Vessels ; Deglutition Disorders ; Eating ; Endoscopy ; Esophagus* ; Hematemesis ; Hematoma* ; Humans ; Middle Aged ; Platelet Aggregation Inhibitors ; Stents ; Thorax ; Ulcer

OBJECTIVE: Chest pain is one of the most common complaints in the emergency department (ED). Cardiac computed tomography angiography (CCTA) is a frequently used tool for the early triage of patients with low- to intermediate-risk acute chest pain. We present a study protocol for a multicenter prospective randomized controlled clinical trial testing the hypothesis that a low-dose CCTA protocol using prospective electrocardiogram (ECG)-triggering and limited-scan range can provide sufficient diagnostic safety for early triage of patients with acute chest pain. METHODS: The trial will include 681 younger adult (aged 20 to 55) patients visiting EDs of three academic hospitals for acute chest pain or equivalent symptoms who require further evaluation to rule out acute coronary syndrome. Participants will be randomly allocated to either low-dose or conventional CCTA protocol at a 2:1 ratio. The low-dose group will undergo CCTA with prospective ECG-triggering and restricted scan range from sub-carina to heart base. The conventional protocol group will undergo CCTA with retrospective ECG-gating covering the entire chest. Patient disposition is determined based on computed tomography findings and clinical progression and all patients are followed for a month. The primary objective is to prove that the chance of experiencing any hard event within 30 days after a negative low-dose CCTA is less than 1%. The secondary objectives are comparisons of the amount of radiation exposure, ED length of stay and overall cost. RESULTS AND CONCLUSION: Our low-dose protocol is readily applicable to current multi-detector computed tomography devices. If this study proves its safety and efficacy, dose-reduction without purchasing of expensive newer devices would be possible.
Acute Coronary Syndrome ; Adult ; Angiography* ; Chest Pain ; Coronary Angiography ; Electrocardiography ; Emergencies* ; Emergency Service, Hospital ; Heart ; Humans ; Length of Stay ; Prospective Studies ; Radiation Exposure ; Retrospective Studies ; Thorax ; Triage