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Coronary Risk Stratification of Chest Pain

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141. Chest Pain

, Precordial Pain From Related Chapters II. Risk Factors See s See III. Epidemiology Acute and Chest Pain are the two most commonly litigated ED claims IV. Precautions No single finding is absolutely pathognomonic nor completely reassuring in Chest Pain presentation Risk stratification, evaluation and management is based on an overall analysis of all clinical data Approach should be based on combination of factors Exam, ekg and s Consider atypical presentations of coronary syndromes in atypical patients (...) Chest Pain Chest Pain Toggle navigation Brain Head & Neck Chest Endocrine Abdomen Musculoskeletal Skin Infectious Disease Hematology & Oncology Cohorts Diagnostics Emergency Findings Procedures Prevention & Management Pharmacy Resuscitation Trauma Emergency Procedures Ultrasound Cardiovascular Emergencies Lung Emergencies Infectious Disease Pediatrics Neurologic Emergencies Skin Exposure Miscellaneous Abuse Cancer Administration 4 Chest Pain Chest Pain Aka: Chest Pain , Chest Pain Causes

2015 FP Notebook

142. Design of the Rule Out Myocardial Ischemia/Infarction Using Computer Assisted Tomography: a multicenter randomized comparative effectiveness trial of cardiac computed tomography versus alternative triage strategies in patients with acute chest pain in the (PubMed)

was a randomized comparative effectiveness trial enrolling patients 40 to 74 years old without known coronary artery disease who presented to the ED with chest pain but without ischemic electrocardiographic (ECG) changes or elevated initial troponin and who required further risk stratification. Overall, 1000 patients at 9 sites within the United States were randomized to either CCTA as the first diagnostic test following serial biomarkers or to standard of care, which included no testing or functional testing (...) . Tertiary end points were institutional, physician, and patient characteristics associated with primary and secondary outcomes. Rate of missed acute coronary syndrome within 28 days was the safety end point. The ROMICAT II will provide rigorous data on whether CCTA is more efficient than standard of care in the management of patients with acute chest pain at intermediate risk for acute coronary syndrome.Copyright © 2012 Mosby, Inc. All rights reserved.

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2012 American heart journal Controlled trial quality: uncertain

143. Cardiac Imaging in Low-Risk and Asymptomatic Patients

. The health technology assessment by the Agency for Healthcare Research and Quality (AHRQ) 1 examined the gold standard tests for the diagnosis of coronary artery disease (CAD) and/or acute coronary syndrome (ACS) (with or without chest pain) in patients at low to intermediate risk. AHRQ reported that among low-risk patients who are not referred for coronary angiography but who undergo clinical observation and non-invasive testing, several noninvasive tests have served as acceptable reference standards (...) review of guidelines on imaging of asymptomatic CAD 3 reported that the guidelines contained conflicting recommendations. Cardiac Imaging in Low Risk Patients 3 The identified non-randomized study 4 on cardiovascular risk stratification in asymptomatic diabetic patients without overt CAD evaluated coronary flow reserve (CFR) assessed by noninvasive transthoracic Doppler echocardiography as a predictor of prognosis. The authors reported that the CFR obtained with this test provided independent

2015 Canadian Agency for Drugs and Technologies in Health - Rapid Review

144. Diagnostic Accuracy of a New High-Sensitivity Troponin I Assay and Five Accelerated Diagnostic Pathways for Ruling Out Acute Myocardial Infarction and Acute Coronary Syndrome. (PubMed)

and acute coronary syndrome, using the Beckman's Access high-sensitivity troponin I assay with the new Vancouver Chest Pain Rule or No Objective Testing Rule enabled approximately one third of patients to be safely discharged after 2-hour risk stratification with no further testing. The EDACS, m-ADAPT, or HEART pathway enabled half of ED patients to be rapidly referred for objective testing.Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved. (...) ) in Australia. Patients were classified as being at low risk according to 5 rules: modified accelerated diagnostic protocol to assess patients with chest pain symptoms using troponin as the only biomarker (m-ADAPT), the Emergency Department Assessment of Chest Pain Score (EDACS) pathway, the History, ECG, Age, Risk Factors, and Troponin (HEART) pathway, the No Objective Testing Rule, and the new Vancouver Chest Pain Rule. Endpoints were 30-day acute myocardial infarction and acute coronary syndrome

2017 Annals of Emergency Medicine

145. Acute Coronary Syndrome Screening and Diagnostic Practice Variation. (PubMed)

) variation in the use of noninvasive testing (NIVT) to identify obstructive coronary artery disease or detect inducible ischemia.We found that 85% of EDs utilize a formal triage protocol to screen patients for an early ECG to diagnose STEMI. Of these, 17% use chest pain as the sole criteria. For the diagnosis of NSTEMI, 58% use intervals ≥4 hours for a second troponin and 34% routinely risk stratify before troponin testing. For the diagnosis of noninfarction ischemia, the median percentage of patients (...) epidemiology study with the ED as the unit of analysis characterizing variability in the ACS evaluation across 62 diverse EDs. We explored three domains of screening and diagnostic practice: 1) variability in criteria used by EDs to identify patients for an early electrocardiogram (ECG) to diagnose ST-elevation myocardial infarction (STEMI), 2) nonuniform troponin biomarker and formalized pre-troponin risk stratification use for the diagnosis of non-ST-elevation myocardial infarction (NSTEMI), and 3

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2017 Academic Emergency Medicine

146. A2 AR as a Novel Biomarkers for Physician Decision-making Improvement Evaluation's Patients With Suspected Acute Coronary Syndrome But Negative Troponin.

. It would be a powerful tool for risk stratification of patients presenting with chest pain but unremarkable ECG and blood tests. the investigateors therefore designed a blind multicentrique prospective study to evaluate expression and functionnaly activity of A2AR in the management of undifferentiated chest pain The objective of the study was to evaluate diagnostic accuracy between this novel biomarkers A2AR and invasive and non -invasive evaluation of patients with suspected coronary artery disease (...) patients with biomarker testing at presentation to facilitate the clinically-appropriate rapid discharge from the emergency department of patients who present with low-intermediate risk chest pain, and conversely to triage appropriate Non sustained ST elevation acute coronary syndrome (NSTE-ACS) patients to Cardiology beds, stress and non-invasive imaging modalities. Biomarkers such as high-sensitivity troponin (hs-cTn), heart-type fatty acid-binding protein (H-FABP), CRP, brain natriuretic peptide

2017 Clinical Trials

147. CORonary MICrovascular Angina (CorMicA)

. FDA-regulated Drug Product: No Studies a U.S. FDA-regulated Device Product: No Additional relevant MeSH terms: Layout table for MeSH terms Angina Pectoris Coronary Disease Coronary Artery Disease Angina, Stable Coronary Vasospasm Myocardial Ischemia Heart Diseases Cardiovascular Diseases Vascular Diseases Chest Pain Pain Neurologic Manifestations Signs and Symptoms Arteriosclerosis Arterial Occlusive Diseases (...) Waiting Times Centre Board Study Details Study Description Go to Brief Summary: Angina is form of chest pain that is due to a lack of blood to the heart muscle. Angina is commonly triggered by stress and exertion, and is a common health problem worldwide. The diagnosis and treatment of angina is usually focused on detection of blockages in heart arteries, and relief of this problem with drugs, stents or bypass surgery. However, about one third of all invasive angiograms that are performed in patients

2017 Clinical Trials

148. Cardiac magnetic resonance assessment of diastolic dysfunction in acute coronary syndrome (PubMed)

studies have investigated more sensitive and specific imaging modalities that can be used. Diastolic dysfunction occurs early following coronary artery occlusion and its detection is useful in confirming the diagnosis, risk stratification, and prognosis post-ACS. Cardiac magnetic resonance provides a single imaging modality for comprehensive evaluation of chest pain in the acute setting. In particular, cardiac magnetic resonance has many imaging techniques that assess diastolic dysfunction post (...) Cardiac magnetic resonance assessment of diastolic dysfunction in acute coronary syndrome Chest pain is an important presenting symptom. However, few cases of chest pain are diagnosed as acute coronary syndrome (ACS) in the acute setting. This results in frequent inappropriate discharge and major delay in treatment for patients with underlying ACS. The conventional methods of assessing ACS, which include electrocardiography and serological markers of infarct, can take time to manifest. Recent

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2017 The Journal of international medical research

149. The Updated NICE Guidelines: Cardiac CT as the First-Line Test for Coronary Artery Disease (PubMed)

The Updated NICE Guidelines: Cardiac CT as the First-Line Test for Coronary Artery Disease Cost-effective care pathways are integral to delivering sustainable healthcare programmes. Due to the overestimation of coronary artery disease using traditional risk tables, non-invasive testing has been utilised to improve risk stratification and initiate appropriate management to reduce the dependence on invasive investigations. In line with recent technological improvements, cardiac CT is a modality (...) that offers a detailed anatomical assessment of coronary artery disease comparable to invasive coronary angiography.The recent publication of the National Institute for Health and Care Excellences (NICE) Clinical Guideline 95 update assesses the performance and cost utility of different non-invasive imaging strategies in patients presenting with suspected anginal chest pain. The low cost and high sensitivity of cardiac CT makes it the non-invasive test of choice in the evaluation of stable angina

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2017 Current cardiovascular imaging reports

150. B-type natriuretic peptide and high sensitive C-reactive protein predict 2-year all cause mortality in chest pain patients: a prospective observational study from Salta, Argentina. (PubMed)

B-type natriuretic peptide and high sensitive C-reactive protein predict 2-year all cause mortality in chest pain patients: a prospective observational study from Salta, Argentina. Several mechanisms are involved in the pathophysiology of the Acute Coronary Syndrome (ACS). We have addressed whether B-type natriuretic peptide (BNP) and high-sensitive C-reactive protein (hsCRP) in admission samples may improve risk stratification in chest pain patients with suspected ACS.We included 982 patients (...) consecutively admitted with chest pain and suspected ACS at nine hospitals in Salta, Northern Argentina. Total and cardiac mortality were recorded during a 2-year follow up period. Patients were divided into quartiles according to BNP and hsCRP levels, respectively, and inter quartile differences in mortality were statistically evaluated applying univariate and multivariate analyses.119 patients died, and the BNP and hsCRP levels were significantly higher among these patients than in survivors

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2011 BMC Cardiovascular Disorders

151. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update

and logistic EuroSCORE are the most commonly used. Although both are accurate in low-risk patients, accuracy is less in higher-risk subsets. These 2 scores include different covariates. The logistic EuroSCORE is based on 12 covariates derived from 14,799 patients undergoing all types of cardiac operations (mostly coronary bypass) in 8 European countries in 1995. On the other hand, the STS risk predictor is based on 24 covariates derived from 67,292 patients undergoing isolated AVR only in the United States (...) . Alternatives to AVR 3.2.1. Medical Therapy There are no proven medical treatments to prevent or delay the disease process in the aortic valve leaflets. However, evaluation and modification of cardiac risk factors is important in patients with aortic valve disease to prevent concurrent coronary artery disease (CAD). The association of AS with risk factors similar to those associated with atherosclerosis (5,6) had suggested that intervention may be possible to slow or prevent disease progression in the valve

2012 Society for Cardiovascular Angiography and Interventions

152. The PressureWire fractional flow reserve measurement system for coronary artery disease

that are visible on angiogram. Stable angina occurs when the blood flow to the heart is restricted by a narrowing of the coronary arteries. It causes chest pain after physical exercise or stress. There is a risk that it may lead to acute coronary syndrome, including unstable angina and myocardial infarction. In myocardial The PressureWire fractional flow reserve measurement system for coronary artery disease (MIB2) © NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms (...) -and- conditions#notice-of-rights). Page 21 of 51Inclusion/ exclusion criteria Inclusion criteria: Stable angina, or atypical / no chest pain but documented ischaemia on non- invasive testing At least one stenosis =50% in native coronary artery with diameter =2.5mm, supplying viable myocardium Eligible for PCI Exclusion criteria: Preferred treatment is CABG Left main coronary artery disease needing revascularisation Patients with a recent STEMI or non-STEMI ( 80 years, chronic occlusion of one of the non

2014 National Institute for Health and Clinical Excellence - Advice

153. Social Determinants of Risk and Outcomes for Cardiovascular Disease

early-life SEP to CVD. The Mechanisms Mediating the Relationship Between Societal Conditions and CVD section provides a detailed discussion. SEP and CVD Risk Prediction Given the substantial evidence linking SEP and CVD and findings that suggest that the Framingham risk score overestimates the risk of coronary heart disease in high-SEP individuals and underestimates the risk in low–socioeconomic status individuals, recent studies have begun to evaluate the potential benefit of including SEP in risk (...) clinicians’ decisions about their patients’ medical treatment, with incorrect, often stereotypical assumptions leading to lower-quality care for minority than for white patients. A study by Schulman and colleagues used scripted videotaped interviews of actors portraying patients with chest pain, finding that physicians were less likely to recommend catheterization for black women than for white men reporting the same symptoms. The authors found no difference in the rate of physician-recommended

2015 American Heart Association

154. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery

The safety of nonsteroidal anti-inflammatory agents for analgesia is controversial, with greater evidence for adverse cardiovascular events with the selective cyclooxygenase-2 inhibitors than the nonselective agents. A 2007 AHA Scien- tific statement presented a stepped-care approach to the management of musculoskeletal pain in patients with or at risk for coronary artery disease (CAD), with the goal of limiting the use of these agents to patients in whom safer therapies fail. 47 In patients hospitalized (...) 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery ACCF/AHA Practice Guideline 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons WRITING COMMITTEE MEMBERS* L. David Hillis, MD, FACC, Chair

2011 American Heart Association

155. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention

(≥50% diameter stenosis) left main coronary artery stenosis. (Level of Evidence: B) Class IIa PCI to improve survival is reasonable as an alternative to CABG in selected stable patients with significant (≥50% diameter stenosis) unprotected left main CAD with: 1) anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (eg, a low SYNTAX score [≤22], ostial or trunk left main CAD); and 2) clinical characteristics that predict (...) a significantly increased risk of adverse surgical outcomes (eg, STS-predicted risk of operative mortality ≥5%). , , , , (Level of Evidence: B) PCI to improve survival is reasonable in patients with UA/NSTEMI when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG. , , , , (Level of Evidence: B) PCI to improve survival is reasonable in patients with acute STEMI when an unprotected left main coronary artery is the culprit lesion, distal coronary flow

2011 American Heart Association

156. Diagnostic value of coronary artery calcium scoring in low-intermediate risk patients evaluated in the emergency department for acute coronary syndrome. (PubMed)

Diagnostic value of coronary artery calcium scoring in low-intermediate risk patients evaluated in the emergency department for acute coronary syndrome. Early and accurate triage of patients with possible ischemic chest pain remains challenging in the emergency department because current risk stratification techniques have significant cost and limited availability. The aim of this study was to determine the diagnostic value of the coronary artery calcium score (CACS) for the detection (...) of obstructive coronary artery disease (CAD) in low- to intermediate-risk patients evaluated in the emergency department for suspected acute coronary syndromes. A total of 225 patients presenting to the emergency department with acute chest pain and Thrombolysis In Myocardial Infarction (TIMI) scores <4 who underwent non-contrast- and contrast-enhanced coronary computed tomographic angiography were included. CACS was calculated from the noncontrast scan using the Agatston method. The prevalence

2011 American Journal of Cardiology

157. The clinics of acute coronary syndrome (PubMed)

The clinics of acute coronary syndrome Risk stratification and management of patients with chest pain continues to be challenging despite considerable efforts made in the last decades by many clinicians and researchers. The throutful evaluation necessitates that the physicians have a high index of suspicion for acute coronary syndrome (ACS) and always keep in mind the myriad of often subtle and atypical presentations of ischemic heart disease, especially in certain patient populations (...) such as the elderly ones. In this article we aim to review and discuss the available evidence on the value of clinical presentation in patients with a suspected ACS, with special emphasis on history, characteristics of chest pain, associated symptoms, atypical presentations, precipitating and relieving factors, drugs, clinical rules and significance of clinical Gestalt.

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2016 Annals of Translational Medicine

158. The Accuracy of the Mini RELF Device for the Diagnosis of an Acute Coronary Artery Occlusion.

on an individual basis an elevation of the ST segment that is indicative for an acute coronary occlusion. The investigators aim to evaluate the accuracy of Mini RELF device when it is self-applied on a daily basis by patients with coronary artery disease. Condition or disease Intervention/treatment Phase Chest Pain ST Elevation Myocardial Infarction Device: Diagnostic accuracy of Mini Relf Device Not Applicable Detailed Description: The increasing availability of small hand held medical devices is a novel (...) by University Ghent: RELF method Medical device Admission delay Additional relevant MeSH terms: Layout table for MeSH terms Infarction Myocardial Infarction Chest Pain ST Elevation Myocardial Infarction Coronary Occlusion Ischemia Pathologic Processes Necrosis Myocardial Ischemia Heart Diseases Cardiovascular Diseases Vascular Diseases Pain Neurologic Manifestations Signs and Symptoms Coronary Disease

2016 Clinical Trials

159. Do gender and race make a difference in acute coronary syndrome pretest probabilities in the emergency department? (PubMed)

Do gender and race make a difference in acute coronary syndrome pretest probabilities in the emergency department? The objective was to test for significant differences in subjective and objective pretest probabilities for acute coronary syndrome (ACS) in a large cohort of chest pain patients stratified by race or gender. Secondarily we wanted to test for any differences in rates of ACS, rates of 90-day returns, cost, and chest radiation exposure after these stratifications.This is a secondary (...) analysis of a prospective outcomes study of ED patients with chest pain and shortness of breath. We performed two separate analyses. The data set was divided by gender for analysis 1 while the analysis 2 stratification was made by race (nonwhite vs. white). For each analysis, groups were compared on several variables: provider visual analog scales (VAS) for likelihood of ACS, PREtest Consult ACS probabilities, rates of ACS, total radiation exposure to the chest, total costs at 30 days, and 90-day

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2016 Academic Emergency Medicine

160. Factors Influencing Time-dependent Quality Indicators for Suspected Acute Coronary Syndrome Patients (PubMed)

Factors Influencing Time-dependent Quality Indicators for Suspected Acute Coronary Syndrome Patients Rapid risk stratification and timely treatment are critical to favorable outcomes for patients with acute coronary syndrome (ACS). Our objective was to identify patient and system factors that influence time-dependent quality indicators (QIs) for patients with unstable angina/non-ST elevation myocardial infarction (NSTEMI) in the emergency department (ED).A retrospective, cohort study (...) %, respectively. Cox regression models revealed that chief complaints without chest pain and the timing of stress testing and medication administration were associated with the most significant delays.Patient and system factors both significantly influenced QI times in this cohort with unstable angina/NSTEMI. These results illustrate both the complexity of diagnosing patients with NSTEMI and the competing effects of clinical and system factors on patient flow through the ED.

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2016 Journal of patient safety

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