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Coronary Risk Stratification of Chest Pain

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141. Primary Care Corner with Geoffrey Modest MD: Chest pain prediction tool

Primary Care Corner with Geoffrey Modest MD: Chest pain prediction tool Primary Care Corner with Geoffrey Modest MD: Chest pain prediction tool | BMJ EBM Spotlight by by Dr Geoffrey Modest The second article on the ED evaluation of chest pain involved an instrument to predict/stratify cardiac risk, finding it to be quick, reliable and efficient (see doi:10.7326/M16-1600). Details: –Nine Dutch hospitals assessed the HEART instrument prospectively to evaluate unselected patients presenting to EDs (...) with chest pain, in a sequence where every 6 weeks, 1 hospital was randomly switched to using the instrument. Publicly-funded study. –3648 patients (1827 receiving usual care, 1821 HEART care) –Exclusion criteria included evident ST-segment elevation MI. –The HEART score is based on History, Electrocardiogram, Age, Risk Factors, and Troponin levels , with each having a score range of 0-2 (go to for HEART score calculator): –score of 0-3 is low-risk, and the patient was to be discharged with reassurance

2017 Evidence-Based Medicine blog

142. EANM guideline for ventilation/perfusion single-photon emission computed tomography (SPECT) for diagnosis of pulmonary embolism and beyond Full Text available with Trip Pro

high early mortality [ ]. In the case of central PE, chest pain may have the characteristics of angina, probably because of right ventricular ischemia, and poses the problem of differentiating PE from acute coronary syndrome and aortic dissection [ ]. The clinical features of PE are also common in patients without PE [ , ], and the prevalence of PE in patients with clinically suspected VTE is only about 20% [ , ]. Therefore, there is a risk that an undue number of patients might receive (...) from asymptomatic to sudden death [ , ]. Most patients with PE have symptoms including dyspnoea, tachypnoea, chest pain (pleuritic or retrosternal), cough, fever, haemoptysis, syncope, unilateral leg pain or swelling, palpitations, tachycardia or dizziness due to hypotension [ , ]. Arterial hypotension and shock are rare signs indicating central massive PE and/or a severely reduced haemodynamic reserve, and these clinical signs and symptoms indicate high-risk PE. It is associated with particularly

2019 European Association of Nuclear Medicine

143. Gut microbiota-dependent trimethylamine N-oxide in acute coronary syndromes: a prognostic marker for incident cardiovascular events beyond traditional risk factors. Full Text available with Trip Pro

, the prognostic value of TMAO in the setting of acute coronary syndromes (ACS) remains unknown.We investigated the relationship of TMAO levels with incident cardiovascular risks among sequential patients presenting with ACS in two independent cohorts. In the Cleveland Cohort, comprised of sequential subjects (n = 530) presenting to the Emergency Department (ED) with chest pain of suspected cardiac origin, an elevated plasma TMAO level at presentation was independently associated with risk of major adverse (...) patients presenting with chest pain predict both near- and long-term risks of incident cardiovascular events, and may thus provide clinical utility in risk stratification among subjects presenting with suspected ACS.Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.

2017 European Heart Journal

144. Chronic Heart Failure in Congenital Heart Disease Full Text available with Trip Pro

cardiac complications, including heart failure (HF). HF management in the setting of CHD is challenged by the wide range of ages at which HF occurs, the heterogeneity of the underlying anatomy and surgical repairs, the wide spectrum of HF causes, the lack of validated biomarkers for disease progression, the lack of reliable risk predictors or surrogate end points, and the paucity of evidence demonstrating treatment efficacy. The purposes of this statement are to review the literature pertaining (...) . Although nuances and specific details may be controversial, the broad definition from the Heart Failure Society of America guidelines states the following: “In physiologic terms, HF is a syndrome characterized by either or both pulmonary and systemic venous congestion and/or inadequate peripheral oxygen delivery, at rest or during stress, caused by cardiac dysfunction.” The definition of chronic HF in this document concurs with that of the European Society of Cardiology guidelines, which emphasize

2016 American Heart Association

145. Heart Failure Full Text available with Trip Pro

in patients with either a suspected diagnosis or new diagnosis of heart failure, to assess cardiac rhythm, QRS duration, and the presence of underlying conditions such as myocardial ischaemia or LV hypertrophy. Strong FOR Low A chest X-ray is recommended in patients with either a suspected diagnosis or new diagnosis of heart failure, to detect signs of pulmonary congestion and to identify alternative cardiac or non-cardiac causes for the patient’s symptoms. Strong FOR Very low Plasma B-type natriuretic (...) . Strong FOR Low Invasive coronary angiography should be considered in patients with heart failure associated with refractory angina, resuscitated cardiac arrest, sustained ventricular arrhythmias, or with evidence of ischaemic heart disease on other investigations, or an intermediate-to-high pretest probability for coronary artery disease, to determine the need for coronary revascularisation. Strong FOR Low Either computed tomography (CT) coronary angiography or cardiac magnetic resonance imaging (CMR

2018 Cardiac Society of Australia and New Zealand

146. Adults With Congenital Heart Disease

innominate vein, and right upper pulmonary vein(s) connecting high on the superior vena cava. Long-term sequelae of anomalous pulmonary venous connections reflect the impact of right heart volume overload and are similar to the sequelae of ASDs. Surgical repair can be challenging as low-velocity venous flow imparts risk of thrombosis of the surgically operated vein. See Section 3.3 for recommendations on who should perform surgeries, cardiac catheterization, and other procedures in these patients (...) , the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline, was conducted from April 2014 to November 2014. Key search words included but were not limited to the following: adult congenital heart disease, anesthesia, aortic aneurysm, aortic stenosis, atrial septal defect, arterial switch operation, bradycardia, bicuspid aortic valve, cardiac catheterization, cardiac imaging, cardiovascular magnetic resonance, cardiac reoperation, cardiovascular surgery, chest

2018 American College of Cardiology

147. Management of Valvular Heart Disease Full Text available with Trip Pro

; MSCT = multislice computed tomography; PCI = percutaneous coronary intervention; TAVI = transcatheter aortic valve implantation; VHD = valvular heart disease. a Class of recommendation. b Level of evidence. c MSCT may be used to exclude CAD in patients who are at low risk of atherosclerosis. d Chest pain, abnormal non-invasive testing. e ≥50% can be considered for left main stenosis. 3.1.3.2 Cardiac catheterization The measurement of pressures and cardiac output or the assessment of ventricular (...) 3.1.2.1 Stress testing 2744 3.1.2.2 Cardiac magnetic resonance 2745 3.1.2.3 Computed tomography 2745 3.1.2.4 Cinefluoroscopy 2745 3.1.2.5 Biomarkers 2745 3.1.3 Invasive investigations 2745 3.1.3.1 Coronary angiography 2745 3.1.3.2 Cardiac catheterization 2746 3.1.4 Assessment of comorbidity 2746 3.2 Risk stratification 2746 3.3 Special considerations in elderly patients 2746 3.4 Endocarditis prophylaxis 2746 3.5 Prophylaxis for rheumatic fever 2746 3.6 Concept of the Heart Team and heart valve centres

2017 European Society of Cardiology

148. AIM Clinical Appropriateness Guidelines for Advanced Imaging of the Heart

? Patients awaiting solid organ transplantation who have not undergone evaluation for coronary artery disease within the preceding one (1) year Suspected coronary artery disease in symptomatic patients who have not had evaluation of coronary artery disease (MPI, stress echo, cardiac PET, coronary CTA or cardiac catheterization) within the preceding sixty (60) days ? Chest pain ? With intermediate or high pretest probability of CAD (Table 1); OR ? With low or very low pretest probability of CAD (Table 1 (...) ) and high risk of CAD (SCORE) ? Atypical symptoms: syncope, shortness of breath (dyspnea), neck, jaw, arm, epigastric or back pain, or sweating (diaphoresis) ? With moderate or high risk of CAD (SCORE) ? Other symptoms; palpitation, dizziness, lightheadedness, near syncope, nausea, vomiting, anxiety, weakness, fatigue, etc. ? With high risk of CAD (SCORE) ? Patients with any cardiac symptom who have diseases/conditions with which coronary artery disease commonly coexists such as: ? Diabetes mellitus

2018 AIM Specialty Health

149. Length of stay following percutaneous coronary intervention: An expert consensus document update from the society for cardiovascular angiography and interventions

imbalance, or ongoing pain, bleeding, ischemia, or dysrhythmia after the procedure. In addition, some patients may be considered higher risk for complications based on coronary anatomy, left ventricular dysfunction, procedural complexity, and comorbidities. Finally, there may be appropriate logistical reasons that require a patient to remain in the hospital overnight, such as procedures that end too late in the day for a safe discharge the same day, lack of transportation, or inadequate social support (...) shock/salvage 54 43 37 22 11 0 NYHA class within 2 weeks NYHA class IV NYHA class Cardiac arrest within 24 hr No Yes 0 13 BMI, body mass index; CVD, cerebrovascular disease; EF, ejection fraction; GFR, glomerular filtration rate; PAD, peripheral artery disease; NYHA, New York Heart Association. The very low rates of in‐hospital mortality and complications after elective PCI are reassuring for the development of SDD policies. The main challenge with risk scores is deciding how

2018 Society for Cardiovascular Angiography and Interventions

150. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease Full Text available with Trip Pro

or de- velop new problems over time, with an increased risk of cardiac arrest. This population commonly develops myocardial dysfunction, arrhythmia, and unbalanced pulmonary and systemic circulation. Specific drugs and the indications for administration and dosing can differ for infants and children with heart disease. In addition, there are many variations of CHD, and the underlying physiological substrates can have a significant impact on systemic perfusion and pulmonary blood flow (PBF (...) Management Risk Factors for Cardiac Arrest and Death The following factors have been identified as contributing to early death in the neonate or infant with single ven- tricle: (1) anatomic diagnosis of HLHS, total anomalous pulmonary venous connection (TAPVC), and pulmonary atresia with intact ventricular septum with RV-dependent coronary circulation; (2) decreased ventricular function; (3) hemodynamically significant semilunar or atrio- ventricular valve insufficiency; and (4) comorbidities including

2018 American Heart Association

151. Suspected New-Onset and Nonacute Heart Failure

changes in static images (ie, CTA; or, without the use ACR Appropriateness Criteria ® 6 Suspected New-Onset and Known Nonacute Heart Failure of intravenous contrast for coronary calcification, calcium scoring for risk stratification). Delayed imaging helps further the detection of fibrous or fatty tissue replacement in cardiac structures (eg, LV wall) [26,29,30]. Despite marked improvements, prevailing concerns about potential complications are still limitations to the use of this modality (...) ???? Tc-99m SPECT/CT MPI rest and stress Usually Not Appropriate ???? US echocardiography transthoracic stress Usually Not Appropriate O Radiography chest Usually Not Appropriate ?ACR Appropriateness Criteria ® 3 Suspected New-Onset and Known Nonacute Heart Failure Variant 3: Confirmed new-onset heart failure with reduced ejection fraction of uncertain etiology: ischemic versus nonischemic. Procedure Appropriateness Category Relative Radiation Level CTA coronary arteries with IV contrast Usually

2018 American College of Radiology

152. Sirens to Scrubs: Acute Coronary Syndrome – Beyond Door-to-Balloon

, depending on where you read this from) is not a diagnostic tool so do not use it as such. Pain caused by ACS may be refractory to nitroglycerin therapy, whilst the pain caused by oesophageal spasm (for example), can be relieved with nitrates. 12 13 For a good review of the positive and negative predictive values of clinical exam findings for myocardial infarction, see the JAMA Rational Clinical Examination series, What if the ECG is Normal!? Time for risk stratification! Scores such as the HEART Score (...) Sirens to Scrubs: Acute Coronary Syndrome – Beyond Door-to-Balloon Sirens to Scrubs: Acute Coronary Syndromes, Part One - Beyond Door-to-Balloon - CanadiEM Sirens to Scrubs: Acute Coronary Syndromes, Part One – Beyond Door-to-Balloon In , by Richard Armour September 27, 2018 Emergency Medical Services receives a 9-1-1 call for a 52-year-old female suffering with chest pain. As Paramedics rush to the scene, they discuss the physiology of Acute Coronary Syndromes… About Sirens to Scrubs Sirens

2018 CandiEM

153. Stable Coronary Artery Disease (2nd Edition)

testing 56 7.5.1 Coronary Calcium (CAC) Score 56 7.5.2 Computed Tomography Angiography (CTA) 57 7.5.3 Risk Stratification by Invasive Coronary Angiography (ICA) 58 7.5.4 Risk assessment by Physiological Assessment of the functional severity of coronary lesions 58 7.6 Guidelines for referral to a tertiary cardiac center 60 8. MANAGEMENT (Fig 2, pg 25) 62 8.1 Behavioural modification therapy (BMT) 63 8.1.1 Patient education 63 8.1.2 Diet 63 8.1.3 Physical activity 63 8.1.4 Smoking Cessation 67 8.1.5 (...) of Stable CAD by Anatomic testing 56 7.5.1 Coronary Calcium (CAC) Score 56 7.5.2 Computed Tomography Angiography (CTA) 57 7.5.3 Risk Stratification by Invasive Coronary Angiography (ICA) 58 7.5.4 Risk assessment by Physiological Assessment of the functional severity of coronary lesions 58 7.6 Guidelines for referral to a tertiary cardiac center 60 8. MANAGEMENT (Fig 2, pg 25) 62 8.1 Behavioural modification therapy (BMT) 63 8.1.1 Patient education 63 8.1.2 Diet 63 8.1.3 Physical activity 63 8.1.4

2018 Ministry of Health, Malaysia

154. Transcatheter Aortic Valve Implantation in Patients With Severe, Symptomatic Aortic Valve Stenosis at Intermediate Surgical Risk

is an open-heart surgery that requires cardiopulmonary bypass (using a heart– lung machine) and is performed under general anesthesia. 2 Patients undergoing SAVR who require revascularization may be considered for SAVR combined with a coronary artery bypass graft (CABG). March 2020 Ontario Health Technology Assessment Series; Vol. 20: No. 2, pp. 1–121, March 2020 11 In North America, a patient’s surgical risk is assessed by a multidisciplinary heart team informed by the Society of Thoracic Surgeons (STS (...) (the heart’s lower left chamber) and the aorta (the main artery that distributes blood from the heart to the body). Aortic valve stenosis is a narrowing of the aortic valve, which prevents it from opening completely and reduces blood flow from the heart. This causes the heart to work harder to pump blood to the body and may lead to symptoms such as chest pain, shortness of breath, and fatigue. Surgical aortic valve replacement (SAVR) is the usual treatment for people who have severe, symptomatic aortic

2020 Health Quality Ontario

155. Admission glycaemia and its association with acute coronary syndrome in Emergency Department patients with chest pain. (Abstract)

Admission glycaemia and its association with acute coronary syndrome in Emergency Department patients with chest pain. This study aims to evaluate admission blood glucose level (BGL) in patients presenting to the emergency department (ED) as a risk factor for a major adverse cardiac event (MACE) on presentation and up to 30 days post discharge. Admission BGL is a prognostic indicator in patients with confirmed acute coronary syndrome (ACS). It is unclear if admission BGL improves the diagnosis (...) and stratification of patients presenting to the ED with suspected ACS.This study is an analysis of data collected from a prospective observational study. The study population consisted of ED patients from Brisbane, Australia and Christchurch, New Zealand. Patients were enrolled between November 2007 and February 2011. Admission BGL was taken as part of routine admission blood with fasting status unknown. The primary end point for this study was a MACE at presentation and up to 30 days post discharge. Logistic

2014 Emergency Medicine Journal

156. Chest pain: if it hurts a lot, is heart attack more likely? (Abstract)

Chest pain: if it hurts a lot, is heart attack more likely? In previous studies including patients with suspected cardiac chest pain, those who had acute myocardial infarction (AMI) reported more severe chest pain than those without AMI. However, many patients with AMI present with very mild pain or discomfort. We aimed to investigate whether peak pain severity, as reported by patients in the Emergency Department, has any potential role in the risk stratification of patients with suspected (...) cardiac chest pain.In this secondary analysis from a prospective diagnostic cohort study, we included patients presenting to the Emergency Department with suspected cardiac chest pain. Patients were asked to report their maximum pain severity using a 11-point numeric rating scale at the time of initial presentation. The primary outcome was a diagnosis of AMI, adjudicated by two independent investigators on the basis of reference standard (12 h) troponin testing.Of the 455 patients included

2014 European Journal of Emergency Medicine

157. Diagnostic importance of admission platelet volume indices in patients with acute chest pain suggesting acute coronary syndrome Full Text available with Trip Pro

be of benefit to detect chest pain resulting in MI from that of non-cardiac one, and also for risk stratification of patients who suffered from an acute chest discomfort.Copyright © 2014 Cardiological Society of India. Published by Elsevier B.V. All rights reserved. (...) Diagnostic importance of admission platelet volume indices in patients with acute chest pain suggesting acute coronary syndrome Acute coronary syndrome (ACS) is a challenging issue in cardiovascular medicine. Given platelet role in atherothrombosis, we sought to determine whether platelet indices can be used as diagnostic tests for patients who suffered from an acute chest discomfort.We prospectively enrolled 862 patients with an acute chest pain and 184 healthy matched controls. They were

2014 Indian heart journal

158. Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications

intracellular prostacyclin synthesis, which eventually impairs the release of tissue-type plasminogen activator. As chronic pain frequently coexists with mental stress, characterized by a hypercoagulable state, patients with chronic pain may be placed at an increased risk for coronary or cerebrovascular events after discontinuation of protective antiplatelet and anticoagulant medications. This underscores the importance of coordinating the perioperative handling of these medications with the prescribing (...) trial. | Summary recommendation for non–aspirin NSAIDs Non–aspirin NSAIDs are used for pain control and, unlike aspirin, are not required for cardiac and cerebral protection. Therefore, these drugs may be discontinued without negatively affecting cardiac and cerebral function. For interventional pain procedures where the bleeding risks and consequences of hematoma development may be higher (eg, high-risk procedures; ), consideration should be given to discontinue these medications. Besides ibuprofen

2018 American Society of Regional Anesthesia and Pain Medicine

159. Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications

frequently coexists with mental stress, characterized by a hypercoagulable state, chronic pain patients may be at an increased risk of coronary or cerebrovascular events after discontinuation of protective antiplatelet and anticoagulant medications. This underscores the importance of coordinating the perioperative handling of these medications with the prescribing cardiologist or neurologist. | Nonsteroidal Anti-inflammatory Drugs Nonsteroidal anti-inflammatory drugs inhibit prostaglandin production (...) NSAIDs. | Summary Recommendations for Non-ASA NSAIDs Non-ASA NSAIDs are used for pain control and, unlike ASA, are not required for cardiac and cerebral protection. Therefore, these drugs may be discontinued without negatively affecting cardiac and cerebral function. For interventional pain procedures where the bleeding risks and the consequences of hematoma development may be higher (eg, high-risk procedures; ) consideration should be given to discontinue these medications. Besides ibuprofen

2018 American Society of Regional Anesthesia and Pain Medicine

160. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain Full Text available with Trip Pro

, and other mechanisms. Parameters such as heart rate, blood pressure, cardiac output, and myocardial oxygen consumption increase even with subanesthetic doses. In the pulmonary system, ketamine causes bronchodilation that appears to be due to circulating catecholamines. Pharyngeal and laryngeal reflexes are mostly preserved, as is respiratory function, and there are increased secretions. The speed of injection may play a role in maintenance of respiratory function, implying that subanesthetic infusions (...) in the setting of hypovolemia, septic shock, or pulmonary disease and have led some experts to recommend and utilize ketamine as a potential first-line treatment for battlefield injuries. The direct, dose-dependent negative inotropic effects on cardiac muscle are typically realized only in catecholamine depleted individuals (eg, long-term trauma or intensive care patients). The dissociative properties associated with ketamine are thought to result from the combination of reduced activation

2018 American Society of Regional Anesthesia and Pain Medicine

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