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Coronary Risk Stratification of Chest Pain

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141. 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

142. Low Risk Chest Pain Under Age 40

of the provider EKG shows no ST elevations or depressions Vital signs are stable (no hypotension) No history of known heart disease Cardiac blood tests (troponin or CK-MB), if performed, are negative (normal) Source Document: Christenson et al. A clinical prediction rule for early discharge of patients with chest pain. Ann Emerg Med. 2006;47(1):1–10. Cullen et al. Comparison of Three Risk Stratification Rules for Predicting Patients With Acute Coronary Syndrome Presenting to an Australian Emergency Department (...) . Heart, Lung, and Circulation 2013;22:844-851. Greenslade et al. Validation of the Vancouver Chest Pain Rule using troponin as the only biomarker. Am J Emerg Med. 2013 Jul;31(7):1103-7. Halpern et al. Cardiac risk factors and risk scores vs cardiac computed tomography angiography: a prospective cohort study for triage of ED patients with acute chest American Journal of Emergency Medicine 31 (2013) 1479–1485. Hess et al. Development of a clinical prediction rulefor 30-day cardiac events in emergency

2010 theNNT

143. Low Risk Chest Pain Over Age 40

reviewed In Other Words: After Only An Initial Biomarker: 1 in 80 will have a heart attack After A 2nd Set of Biomarkers (at 6 hours): 1 in 250 will have a heart attack Risk Assessment Criteria Low risk chest pain according to the judgment of the provider EKG shows no ST elevations or depressions Vital signs are stable (no hypotension) Cardiac blood tests (troponin or CK-MB), if performed, are negative (normal) No history of known coronary artery disease Source Document: Christenson et al. A clinical (...) prediction rule for early discharge of patients with chest pain. Ann Emerg Med. 2006;47(1):1–10. Cullen et al. The new Vancouver Chest Pain Rule using troponin as the only biomarker: an external validation study. Amer J Emerg Med. 2014;32(129-134) Cullen et al. Comparison of Three Risk Stratification Rules for Predicting Patients With Acute Coronary Syndrome Presenting to an Australian Emergency Department. Heart, Lung, and Circulation 2013;22:844-851. Goldstein et al. The CT-STAT (Coronary Computed

2010 theNNT

144. EarlySense for heart and respiratory monitoring and predicting patient deterioration

of non-intensive care unit (ICU) hospital patients. Using the Vitals software module, it measures heart rate and respiratory rate and alerts healthcare professionals if these measurements change, helping early identification of patient deterioration. It would be used in non-critical care wards, in place of manual or separate measurements of heart rate and respiratory rate, where patients may be at risk of deterioration. This can include general (internal) medicine wards, surgical wards, acute medical (...) (HR) and respiratory rate (RR), may provide a mechanism to alert doctors or nurses of an imminent severe clinical event. The NICE guideline on acute illness in adults in hospital recommends that physiological parameters, including HR and RR, should be monitored at least every 12 hours. These physiological observations provide the basis for risk stratification of patients using systems such as the National Early Warning Score System (which uses respiratory rate, oxygen saturation, temperature

2016 National Institute for Health and Clinical Excellence - Advice

145. Moderate Risk Acute Coronary Syndrome Management

based) ( ) or NSTEMI ST Depression >1 mm Symmetrical T-wave inversion in precordial leads (>0.2 mV) Dynamic ST segment and changes with pain Less interpretable EKG findings increasing risk that has cardiac origin s Paced Rhythm VI. Imaging: Echocardiogram may assist in risk stratification of a patient with active Most helpful if completely normal Helpful also if significantly abnormal with wall motion abnormality (unless prior MI in the same region) VII. Labs: Serum Troponin Serum at presentation (...) Moderate Risk Acute Coronary Syndrome Management Moderate Risk Acute Coronary Syndrome Management 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

2018 FP Notebook

146. Low Risk Acute Coronary Syndrome Management

4 Low Risk Acute Coronary Syndrome Management Low Risk Acute Coronary Syndrome Management Aka: Low Risk Acute Coronary Syndrome Management , Non-diagnostic Electrocardiogram Protocol , Non-diagnostic EKG Protocol , Atypical Chest Pain , Low Risk Chest Pain From Related Chapters II. Indications: Electrocardiogram (EKG) suggestive of Low Risk Chest Pain Normal or unchanged ST Depression 0.5 to 1.0 mm inversion (<0.2 mV) or flattening Leads with dominant III. Contraindications: Moderate Risk (...) vigilence but may not absolutely contraindicate following the low risk protocol (especially if longstanding >10 years or uncontrolled) Typical (central, heavy, crushing, pressure or squeezing pain) Especially if associated with , diaphoresis, or Higher risk presentation than Atypical Chest Pain (sharp, localized or lateral ) IV. Labs: Cardiac Biomarkers (i.e. Troponin) Highly sensitive s sufficiently sensitive to replace all other biomarkers (e.g. , Myoglobin, CRP) Decision rules are used by accelerated

2018 FP Notebook

147. Modified TIMI risk score cannot be used to identify low-risk chest pain in the emergency department: a multicentre validation study. (Abstract)

Modified TIMI risk score cannot be used to identify low-risk chest pain in the emergency department: a multicentre validation study. The Thrombolysis in Myocardial Infarction (TIMI) risk score (range 0-7), used for emergency department (ED) risk stratification of patients with suspected acute coronary syndrome (ACS), underestimates risk associated with ECG changes or cardiac troponin elevation. A modified TIMI score (mTIMI, range 0-10), which gives increased weighting to these variables, has (...) ) for standard TIMI, respectively.mTIMI score performs better than standard TIMI score for ED risk stratification of chest pain, but neither is sufficiently sensitive at scores >0 to allow safe and early discharge without further investigation or follow-up. Observed differences in performance may be due to incorporation bias.

2013 Emergency Medicine Journal

148. 2017 AHA/ACC Key Data Elements and Definitions for Ambulatory Electronic Health Records in Pediatric and Congenital Cardiology: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards Full Text available with Trip Pro

is challenging; attaining evidence-based decision-making has been challenging, if not even more challenging, although groups such as the Pediatric Heart Network and the National Pediatric Cardiology Quality Improvement Collaborative have been breaking down this barrier. There are many obstacles within standardizing and sharing data in pediatric cardiac surgery—including variation in surgical techniques and skills, variations in perioperative care, variation in underlying anatomy, adequate risk stratification (...) Representative. Child Health Corporation of America Representative. Association of European Pediatric Cardiologists Representative. The Society of Thoracic Surgeons Representative. ACC/AHA Task Force on Clinical Data Standards Liaison to the Writing Committee. Congenital Heart Surgeons’ Society Representative. National Association of Children’s Hospitals and Related Institutions Representative. American Academy of Pediatrics Representative. Congenital Cardiac Anesthesia Society Representative. Task Force

2017 American Heart Association

149. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association Full Text available with Trip Pro

of heart failure (HF) and the risk of mortality. Patients with Killip class IV (CS) had a mortality of 81%. Subsequently, the Diamond and Forrester classification using right-sided heart catheterization described the role of cardiac hemodynamics in stratifying risk after acute MI in the prereperfusion era. Patients in Diamond and Forrester subgroup IV with a pulmonary capillary wedge pressure (PCWP) >18 mm Hg and a cardiac index (CI) <2.2 L·min −1 ·m −2 , indicative of CS, had a mortality of 51 (...) and clinical or laboratory signs of hypoperfusionClinical hypoperfusion: Cold extremities, oliguria, mental confusion, dizziness, narrow pulse pressureLaboratory hypoperfusion: Metabolic acidosis, elevated serum lactate, elevated serum creatinine CI indicates cardiac index; CS, cardiogenic shock; ESC, European Society of Cardiology; HF, heart failure; IABP-SHOCK II, Intraaortic Balloon Pump in Cardiogenic Shock II; LV, left ventricular; MI, myocardial infarction; PCWP, pulmonary capillary wedge pressure

2017 American Heart Association

150. 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non?ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures Full Text available with Trip Pro

With Acute Myocardial Infarction Registry Inpatient Facility Level Community, Population, and Public Health Quality Measures QM-1 Risk Stratification of NSTEMI Patients With a Risk Score Inpatient Facility or Provider Level Effective Clinical Care QM-2 Early Invasive Strategy (Within 24 Hours) in High-Risk NSTEMI Patients Inpatient Facility or Provider Level Effective Clinical Care QM-3 Therapeutic Hypothermia for Comatose STEMI Patients With Out-of-Hospital Cardiac Arrest Inpatient Facility or Provider (...) acknowledges that early invasive strategy (compared with a delayed invasive strategy) in high-risk NSTE-ACS patients predominantly reduces recurrent ischemia (rather than the hard outcomes of recurrent MI or death). Although this strategy additionally reduces length of stay and costs, it creates a logistical burden on cardiac catheterization labs, especially during weekends. Finally, objective risk stratification by risk scores is usually not available in current registries; thus, ascertaining which

2017 American Heart Association

151. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association Full Text available with Trip Pro

is discussed. Approximately 10% to 20% of patients do not respond to initial intravenous immune globulin, and recommendations for additional therapies are provided. Careful initial management of evolving coronary artery abnormalities is essential, necessitating an increased frequency of assessments and escalation of thromboprophylaxis. Risk stratification for long-term management is based primarily on maximal coronary artery luminal dimensions, normalized as Z scores, and is calibrated to both past (...) after fever onset, thrombocytosis is common. Other clinical findings may include the following: Cardiovascular Myocarditis, pericarditis, valvular regurgitation, shock Coronary artery abnormalities Aneurysms of medium-sized noncoronary arteries Peripheral gangrene Aortic root enlargement Respiratory Peribronchial and interstitial infiltrates on CXR Pulmonary nodules Musculoskeletal Arthritis, arthralgia (pleocytosis of synovial fluid) Gastrointestinal Diarrhea, vomiting, abdominal pain Hepatitis

2017 American Heart Association

152. Management of Patients on Non?Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association Full Text available with Trip Pro

Heart Association Clinical Pharmacology Subcommittee of the Acute Cardiac Care and General Cardiology Committee of the Coun- cil on Clinical Cardiol- ogy; Council on Car- diovascular Disease in the Young; and Council on Quality of Care and Outcomes Research Management of Patients on Non–Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting A Scientific Statement From the American Heart Association © 2017 American Heart Association, Inc. Key Words: AHA Scientific (...) fibrillation, venous thromboembolism, bleeding, intracranial, cardioversion, catheterization, cardiac implantable devices, kidney injury, transition, switching, pharmacology, andexanet alfa, idarucizumab, ciraparantag, gastrointestinal, trauma, surgery, percu- taneous coronary intervention, neuraxial anesthesia, stroke, and overdose. Writing group members were instructed to write subtopic sections aligned with their experience. Members were instructed to cite contempo- rary guidelines and scientific

2017 American Heart Association

153. The Learning Healthcare System and Cardiovascular Care: A Scientific Statement From the American Heart Association

prospectively, following defined protocols that adhere to standardized definitions of clinical variables of interest. Aggregated data from the registries provide nearly real-time information that allows providers to compare their performance with national benchmark data, completing the cycle of improvement. In cardiac care, established clinical registry programs such as the American Heart Association’s Get With The Guidelines (GWTG) programs, the Society of Thoracic Surgeons database programs (...) source of patient information in ambulatory cardiovascular care is the aforementioned CardioMEMs HF system (St. Jude Medical, St. Paul, MN). The system consists of a pressure sensor that is permanently implanted via cardiac catheterization into the pulmonary artery. The device communicates with an external data collection and processing unit that transmits pulmonary artery pressure, pressure waveforms, and heart rate data to a cloud-based secure website, allowing early detection of worsening HF

2017 American Heart Association

154. The Expressed Genome in Cardiovascular Diseases and Stroke: Refinement, Diagnosis, and Prediction: A Scientific Statement From the American Heart Association

statistic of 1.0 means a perfect test, whereas a C statistic of 0.5 means a worthless test providing no information beyond randomness. For the prediction of coronary heart disease in a previously healthy population, a model including only age and sex typically yields a C statistic of 0.65 to 0.70, whereas the Framingham Risk Score reaches ≈0.75. Calibration reflects the agreement between predicted and observed risk across groups of individuals with different baseline risk. A commonly used metric (...) -effectiveness analysis. Some existing risk algorithms, for example, the prediction of coronary heart disease in healthy populations, are already quite accurate, and as a result, additional risk markers need to show very large effect sizes to show any improvement in C statistics. It has been argued that it is a waste of time and resources to perform additional studies trying to discover novel biomarkers for risk prediction and that it would be better to focus on applying preventive measures known

2017 American Heart Association

155. Screening for Atrial Fibrillation: 2017 European Heart Rhythm Association (EHRA) Consensus Document

to increase risk were gender, the presence of a significant heart mur- mur, obesity, high blood pressure, treatment for hypertension, and a long PR interval. A score derived from the Atherosclerosis Risk in Communities (ARIC) study, based in a younger and biracial cohort, also found race (higher risk in white than African American), smoking status, height, history of diabetes and coronary heart disease, and left ventricular hypertrophy and left atrial enlargement (using ECG crite- ria) to be predictive (...) pressure, current smoking, use of antihypertensive drugs, diabetes, and history of myocardial in- farction and heart failure was found to have reasonable discrimination (C statistic 0.77, 95% CI 0.75–0.78) in prediction of AF over 5 years. A further risk score, 103 validated using an administrative database, similarly found that a score based on seven risk factors for AF (age, coronary artery disease; diabetes; sex; heart failure; hypertension; valvular disease) showed reasonable prediction

2017 Heart Rhythm Society

156. AIM Clinical Appropriateness Guidelines for Genetic Testing for Hereditary Cardiac Disease

of symptoms. Dilated Cardiomyopathy Dilated cardiomyopathy (DCM) is characterized by enlargement of the left ventricle of the heart and systolic impairment, in the absence of abnormal loading conditions or coronary artery disease sufficient to cause global systolic dysfunction (Haas 2015). The symptoms of DCM are similar to heart failure including shortness of breath, chest pain/tightness, fainting episodes and cardiac arrhythmias. The most serious complication of DCM is sudden, irregular heart rhythms (...) include dizziness, chest pain, palpitations, shortness of breath, syncope and an increased risk of stroke and sudden death. Some individuals with atrial fibrillation do not experience any symptoms. While the majority of cases of AF are not hereditary, familial clustering does occur. Familial cases of AF are indistinguishable from acquired cases. Although a number of genes have been associated with an increased risk of AF, the role of these common genetic variants in risk stratification, assessment

2017 AIM Specialty Health

157. Prospective validation of Thrombolysis in Myocardial Infarction and front door Thrombolysis in Myocardial Infarction risk scores in Chinese patients presenting to the ED with chest pain. (Abstract)

for TIMI0 to 37.5% for patients with TIMI6/7. Increasing TIMI and FDTIMI scores were associated with a higher incidence of MACE.This validation suggests that the TIMI/FDTIMI scores can be employed in Hong Kong Chinese; they may be useful for risk stratification of Chinese ED patients with undifferentiated chest pain elsewhere.Copyright © 2014 Elsevier Inc. All rights reserved. (...) Prospective validation of Thrombolysis in Myocardial Infarction and front door Thrombolysis in Myocardial Infarction risk scores in Chinese patients presenting to the ED with chest pain. Chest pain is a common complaint among emergency department (ED) patients. The Thrombolysis in Myocardial Infarction (TIMI) and front door TIMI (FDTIMI) scores are used to risk stratify chest pain patients in many Western countries; they have not been validated in patients with undifferentiated chest pain

2014 American Journal of Emergency Medicine

158. Safe and rapid disposition of low-to-intermediate risk patients presenting to the emergency department with chest pain: a 1-year high-volume single-center experience. (Abstract)

Safe and rapid disposition of low-to-intermediate risk patients presenting to the emergency department with chest pain: a 1-year high-volume single-center experience. Coronary CT angiography (CTA) is a powerful tool for the evaluation of chest pain in the emergency department (ED). Some debate persists regarding its cost-effectiveness in a low-to-intermediate risk population.This study sought to evaluate the safety and cost-effectiveness of coronary CTA for low-to-intermediate risk patients (...) presenting to the ED with chest pain in a closed-loop referral system.Chest pain patients were evaluated in the ED via a local rapid coronary CTA protocol and tracked prospectively for ED throughput, disposition, chest pain recidivism, and cost utilization as compared with an age-matched cohort evaluated for chest pain treated with usual care.One hundred eighty-three patients underwent the rapid coronary CTA protocol compared with an age-matched cohort of 184 patients treated with usual care. The median

2014 Journal of cardiovascular computed tomography

159. Risk Estimation in Type 2 Myocardial Infarction and Myocardial Injury: The TARRACO Risk Score. Full Text available with Trip Pro

, hypertension, absence of chest pain, dyspnea, and anemia. The score exhibited good discriminative accuracy (area under the curve = 0.74; 95% CI, 0.70-0.79). Patients were classified into low-risk (score 0-6) and high-risk (score ≥7) categories. Major adverse cardiovascular events rates were 5 times more likely in high-risk patients compared with those at low risk (78.9 vs 15.4 events/100 patient-years, respectively; logrank P < .001). The external validation showed equivalent prognostic capacity (area (...) under the curve=0.71, 0.65-0.78).A novel risk score based on bedside clinical variables and cTn concentrations allows risk stratification for death and cardiac-related rehospitalizations in patients with type 2 myocardial infarctions and myocardial injury. This score identifies patients at the highest risk of adverse events, a subset of patients who may benefit from close observation, medical intensification, or both.Copyright © 2018. Published by Elsevier Inc.

2019 EvidenceUpdates

160. Are Serial Electrocardiograms Additive to SeriAl Second-generations Troponins in Predicting Acute CoronAry Syndromes in PatienTs With Undifferentiated cHest Pain

: February 2018 Keywords provided by Wake Forest University Health Sciences: Acute Coronary Syndrome Chest pain Electrocardiograms Risk Stratification Emergency Department Additional relevant MeSH terms: Layout table for MeSH terms Syndrome Acute Coronary Syndrome Chest Pain Disease Pathologic Processes Myocardial Ischemia Heart Diseases Cardiovascular Diseases Vascular Diseases Pain Neurologic Manifestations Signs and Symptoms (...) electrocardiogram (ECG) changes aids in reclassifying participants' risk for major adverse cardiac events (MACE) over and above serial blood testing. Condition or disease Intervention/treatment Acute Coronary Syndrome Chest Pain Device: Serial Electrocardiograms Detailed Description: Chest pain is one of the most common symptoms evaluated in the Emergency Department (ED). One of the primary diagnostic concerns during the evaluation of this presentation is whether there is evidence of acute coronary syndromes

2013 Clinical Trials

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