Development and evolution of early exercise testng

Incorporation of treadmill exercise testing into current ADPs is a recent development based on ample data that has overcome initial concern regarding the possible hazards of this technique in potentially unstable patients. This early, Admit to hospital Manage via acute ischemia pathway Fig. 1. Management of patients presenting with symptoms suggestive of an acute coronary syndrome (ACS). ACC, American College of Cardiology AHA, American Heart Association. (Adapted from Braunwald E, Antman E,...

Management of the Patient with Chest Pain and a Normal Coronary Angiogram

The Center of Coronary Physiology and Imaging, Division of Cardiovascular Diseases, Mayo College of Medicine, 200 First Street Southwest, Rochester, Minnesota 55905, USA Approximately 20 to 30 of patients undergoing coronary angiography for symptomatic chest pain are found to have normal epicardial coronary arteries 1,2 . When compared with patients who present with obstructive coronary artery disease, these patients are more likely to be women and tend to be younger 3,4 . Several conditions...

Valvular rupture or disease

Dysfunction defined as an EF < 40 . Systolic dysfunction is most commonly the result of ischemic heart disease, although many other causes exist. The pathologic feature of systolic dysfunction is a ventricle that has difficulty ejecting blood. Impaired contractility leads to increased intracar-diac volumes and pressure, and increasing after-load sensitivity. Consequently, these patients are sensitive to hypertension, and maintaining blood pressure (BP) to as low as is tolerated becomes an...

Clinical use of troponin and other biomarkers in specific patient subsets seen in the emergency department or chest

The use of biomarkers is predicated in large part on the underlying nature of the patients being evaluated. The following suggestions are developed predicated on risk stratification. Patients with ST elevation and myocardial infarction Patients who present with ST elevation myo-cardial infarction (STEMI) do not need biomarker measurements before the initiation of therapy. Therapy should be started before the return of biomarker data to ensure the most rapid initiation of therapy, which is...

Pointof Care Testing and Cardiac Biomarkers The Standard of Care and Vision for Chest Pain Centers

Kost, MD, PhD, MS, FACBa b *, Nam K. Tran, BSa aPoint-of-Care Testing Center for Teaching and Research, Department of Pathology and Laboratory Medicine, UCD Health System, School of Medicine, University of California, Davis, CA, USA bAffiliate Faculty, Chulalongkorn University, Bangkok, Thailand Point-of-care testing (POCT) is defined as testing at or near the site of patient care 1 . POCT decreases therapeutic turnaround time (TTAT), increases clinical efficiency, and improves...

References

1 Gibler WB, Cannon CP, Blomkains AL, et al. Practical implementation of the guidelines for unstable angina non-st-segment elevation myocardial infarction in the emergency department. Ann Emerg Med 2005 46 185-97. 2 Pozen MW, D'Agostino RB, Selker HP, et al. Predictive instrument to improve coronary-care-unit admission practices in acute ischemic heart disease a prospective multicenter clinical trial. N Engl J Med 1984 310 1273-8. 3 Karlson BW, Herlitz J, Wiklund O, et al. Early prediction of...

Thyroid disease

Severe hypertension and peripheral vasoconstriction may suggest acute HF, even with audible wheezing. Pneumonia or pulmonary embolus can mimic or exacerbate HF. Finally, edema is common in HF, but is nonspecific because it is found in many hypoprotei-nemic states, including hepatic or renal failure, and vascular diseases. Effective HF care must begin with accurate diagnosis and be followed by expeditious treatment. Failure with either aspect will have adverse effects on...

Biochemical markers

Creatine kinase, single and serial measurements There is a large amount of evidence on creatine kinase (CK) as a single test administered at presentation to patients in the ED (see Tables 1 and 2) 57 . The evidence suggests that the sensitivity of a single CK reading for AMI is low (36 ), and specificity is modest (88 ). Limited evidence suggests that the sensitivity of the test depends on the duration of the patient's symptoms sensitivity increases with longer symptom duration. Test...

Box 1 Unique factors in women affecting exercise test results

Decreased exercise capacity Baseline electrocardiographic artery disease High rate of single vessel disease physiologic issues, the chest pain unit provides an important option for the evaluation of women. Their exclusion would result in the costly use of traditional hospital beds to evaluate these patients with a low rate of CAD, especially those of pre-menopausal age, no diabetes, and absence of a smoking history. Nevertheless, understanding these limitations is important for the prudent...

Newer Imaging Methods for Triaging Patients Presenting to the Emergency Department with Chest Pain

Amsterdam, MDb aHenry Ford Health System, Heart & Vascular Institute, 2799 West Grand Boulevard, K-14, Detroit, MI 48202-2689, USA bDepartment of Internal Medicine, University of California School of Medicine (Davis) and Medical Center, 4860 Y Street, Suite 200, Sacramento, CA 95817, USA Electron beam computed tomography (EBCT), also known as ultrafast CT, is highly sensitive for detecting and quantifying coronary artery calcium. Coronary artery calcium is absent...

Computerbased decision aids

Acute cardiac ischemia time-insensitive predictive instrument The acute cardiac ischemia time-insensitive predictive instrument ACI-TIPI 26 computes a 0 to 100 probability that a given patient has ACS either acute MI or unstable angina pec-toris see Tables 1 and 2 . Applicable to any patient in the ED presenting with any symptom suggestive of ACS, it is based on a logistic regression equation that uses presenting symptoms and ECG variables. Originally in hand-held calculator form, it is now...