Accuracy of gestalt perception of acute chest pain in predicting coronary artery disease

AIM To test accuracy and reproducibility of gestalt to predict obstructive coronary artery disease(CAD)in patients with acute chest pain.METHODS We studied individuals who were consecutively admitted to our Chest Pain Unit.At admission,investigators performed a standardized interview and recorded14 chest pain features.Based on these features,a cardiologist who was blind to other clinical characteristics made unstructured judgment of CAD probability,both numerically and categorically.As the reference standard for testing the accuracy of gestalt,angiography was required to rule-in CAD,while either angiography or non-invasive test could be used to rule-out.In order to assess reproducibility,a second cardiologist did the same procedure.RESULTS In a sample of 330 patients,the prevalence of obstructive CAD was 48%.Gestalt’s numerical probability was associated with CAD,but the area under the curve of0.61(95%CI:0.55-0.67)indicated low level of accuracy.Accordingly,categorical definition of typical chest pain had a sensitivity of 48%(95%CI:40%-55%)and specificity of 66%(95%CI:59%-73%),yielding a negligible positive likelihood ratio of 1.4(95%CI:0.65-2.0)and negative likelihood ratio of 0.79(95%CI:0.62-1.02).Agreement between the two cardiologists was poor in the numerical classification(95%limits of agreement=-71%to 51%)and categorical definition of typical pain(Kappa=0.29;95%CI:0.21-0.37).CONCLUSION Clinical judgment based on a combination of chest pain features is neither accurate nor reproducible in predicting obstructive CAD in the acute setting.

The early risk stratification of the patients with acute chest pain

Objective： This investigation was designed to stratify patients with acute chest pain based on their symptoms, electrocardiogram （ECG）, cardiac injury markers and the number of accompanying traditional risk factors（smoking, obesity, hyperlipemia, hypertension, diabetes）, and to assess the effect of the above factors to obtain a risk stratification for patients with chest pain. Methods： We identified 139 patients with acute chest pain, including 45 myocardiac infarction patients, 65 unstable angina patients and 29 chest pain patients without identified acute coronary syndrome（ACS） admitted to our Coronary Heart Center during December 2004 to February 2005. All patients accepted coronary angiography. All data was collected using questionnaires. Based on reported symptom, electrocardiogram （ECG）, cardiac injury markers and the number of the accompanying traditional risk factors, we stratified all patients into four groups： Group 1, patients with acute chest pain, ECG changes and abnormal cardiac injury biomarkers. Group 2, patients with acute chest pain and ECG changes（without abnormal cardiac injury biomarkers）. Group 3, patients with acute chest pain, normal ECG, normal cardiac injury biomarkers and 〉2 traditional risk factors. Group 4, patients with acute chest pain, normal ECG and normal cardiac injury biomarkers, but only ≤ 2 traditional risk factors. From this data we examined the difference of ACS incidence in the four groups. Results：After stratification the ACS incidence of the grouped patients in turn was 100%, 84%, 69.6% and 53.3%. The combination of early phase ECG and cardiac injury markers identified 70.9% patients with ACS（the specificity being 90.7%）. The mortality of group 3 was higher compared with group 4（69.6% vs 53.3%）, however the P value was more than 0.05 and didn＇ t show significant statistical difference. The correlation analysis found the number of the traditional risk factors had a significant positive correlation （r= 0.202, P = 0.044） with the number of stenosis being more than 50% of the artery diameter. Multiple linear regression showed the hypertension had a significant correlation with the number of the diseased regions（P= 0.014）. Conclusions：The risk stratification based on the symptom, ECG, cardiac injury markers and accompanying traditional risk factors is both important and available in practice. It is unsuitable for patients with a normal ECG and cardiac injury markers to differentiate ACS from non-cardiac chest pain relying only on the number of the accompanying traditional risk factors. However we found the number of the risk factors can indicate the disease severity.

The Role of Bedside Troponin T Test for Identification of High Risk Patients With Acute Chest Pain

Objectives Evaluation of patients with acute chest pain when they admitted is time-consuming. We prospectively investigated the role of bedside troponin T test for predicting the risk of death and acute heart failure of patients with acute chest pain.Methods and Results 502 consecutive patients with chest pain for less than 24 hours were determined by troponin T test at bedside and quantitative troponin I test in lab. For bedside troponin T tests, there were 160 patients in positive and 323 in negative. During 30 days of followed-up. Myocardial infarction evolved in 139 patients among 160 patients in positive troponin T test, only 7 patients in negative one. Acute heart failure occurred in 51 patients among the positive group, but 37 occurred it at negative group. The odds ratio of acute heart failure of positive group vs. negative group was 3.6. Patients died 39 in positive group, 15 in negative group, the all-cause death odds ratio of positive group vs. negative group was 6.7; 31 patients died with cardiac event in positive group, 5 in negative group only. Conclusions Bedside Troponin T test is a powerful and independent predictor of death and acute heart failure for patients with acute chest pain.

SVEAT score outperforms HEART score in patients admitted to a chest pain observation unit

BACKGROUND Timely and accurate identification of subgroup at risk for major adverse cardiovascular events among patients presenting with acute chest pain remains a challenge.Currently available risk stratification scores are suboptimal.Recently,a new scoring system called the Symptoms,history of Vascular disease,Electrocardiography,Age,and Troponin(SVEAT)score has been shown to outperform the History,Electrocardiography,Age,Risk factors and Troponin(HEART)score,one of the most used risk scores in the United States.AIM To assess the potential usefulness of the SVEAT score as a risk stratification tool by comparing its performance to HEART score in chest pain patients with low suspicion for acute coronary syndrome and admitted for overnight observation.METHODS We retrospectively reviewed medical records of 330 consecutive patients admitted to our clinical decision unit for acute chest pain between January 1st to April 17th,2019.To avoid potential biases,investigators assigned to calculate the SVEAT,and HEART scores were blinded to the results of 30-d combined endpoint of death,acute myocardial infarction or confirmed coronary artery disease requiring revascularization or medical therapy[30-d major adverse cardiovascular event(MACE)].An area under receiving-operator characteristic curve(AUC)for each score was then calculated.C-statistic and logistic model were used to compare RESULTS A 30-d MACE was observed in 11 patients(3.33%of the subjects).The AUC of SVEAT score(0.8876,95%CI:0.82-0.96)was significantly higher than the AUC of HEART score(0.7962,95%CI:0.71-0.88),P=0.03.Using logistic model,SVEAT score with cut-off of 4 or less significantly predicts 30-d MACE(odd ratio 1.52,95%CI:1.19-1.95,P=0.001)but not the HEART score(odd ratio 1.29,95%CI:0.78-2.14,P=0.32).CONCLUSION The SVEAT score is superior to the HEART score as a risk stratification tool for acute chest pain in low to intermediate risk patients.

Usefulness of PQRST pain assessment method for non-traumatic chest pain

Background The symptom of chest pain is one of the most common presenting complaints seen in primary and secondary care and is the leading cause of emergency department visits. PQRST pain assessment method might be useful, but contemporary researches of its feasibility for chest pain patients are limited. Methods Between March 2017 and August 2017, 533 consecutive patients as control group and 657 cases as treatment group were retrospectively recruited in the Emergency Department of our center. We compared the time took for the first cardiogram, the time spent in the emergency department, triage accuracy and patient stratification rate between two groups. Results In treatment group, statistically less time was spent to take the first cardiogram（5.3±1.2 vs. 11.2±2.5, P 〈 0.001）. This group had higher triage accuracy（92.34% vs. 86.91%, P = 0.003）and patient stratification（95.51% vs. 91.48%, P = 0.006）. Conclusions PQRST pain assessment method is useful and feasible for increasing triage accuracy and patient stratification rate of non-Traumatic chest pain patients in emergency department.