Effectiveness and Safety of the European Society of Cardiology 0-/1-h Troponin Rule-Out Protocol: The Design of the ESC-TROP Multicenter Implementation Study

Chest pain is one of the most common complaints at the emergency department (ED), and it is commonly the perceived likelihood of acute coronary syndrome (ACS) that drives management. Guidelines from the European Society of Cardiology (ESC) recommend the use of a 0-/1-h high-sensitivity cardiac troponin T (hs-cTnT) protocol to rule out or in ACS, but this is mostly based on observational studies. The aim of the ESC-TROP trial is to determine the safety and effectiveness of the ESC 0-/1-h hs-cTnT protocol when implemented in routine care. Adult chest pain patients at 5 EDs in the Sk åne Region, Sweden, are included in the trial. The 0-/1-h hs-cTnT ESC protocol supplemented with clinical assessment and electrocardiography (ECG) is implemented at 3 EDs, and the other 2 EDs act as concurrent controls. Outcomes will be evaluated during the 10 months after the implementation and th e corresponding 10 months of the previous year. The 2 co-primary outcomes are (a) acute myocardial infarction (AMI) and all-cause death within 30 days in patients discharged from the ED, and (b) ED length of stay of the same patients. Secondary outcomes include the proportion of chest pain patients discharged from the ED and the number of ruled-out patients undergoing objective testing within 30 days. The ESC-TROP trial will determine the performance and applicability of the 0-/1-h hs-cTnT ESC protocol supplemented with clinical assessment and ECG when implemented in routine ED care. It will p rovid...
Source: Cardiology - Category: Cardiology Source Type: research

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CONCLUSION to the Case: The interventionalist finally took the patient to the cath lab. There was 100% occlusion of the RCA, which was stented.================NOTE: My sincere THANKS to Emmanuel Reisman (New York) for sharing the tracings and this case with us!================SmithQuickComments:Ken,Great case and great discussion!The modified Sgarbossa criteria are only 84% sensitive (if you use 20%) in our studies (Meyers Validation study), and if used on a consecutive group of chest pain patients with LBBB, it would probably be lower.  So indeed we need to look beyond these criteria in order to NOT mi...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Discussion:The management in this case is unfortunately common practice at many places around the world where we receive cases. Why would an interventionalist violate multiple recommendations from their own guidelines and watch at 10am while an LAD occlusion plays out in front of them? What could explain why some providers do not seem interested in the fact that LAD occlusion can be identified by something other than STEMI criteria? Or why the wall motion abnormality matching the distribution of concern is ignored? The only plausible explanation is that they have been taught that this is standard practice. Under the STEMI ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
This 50-something male with previous history of MI presented for intermittent CP and SOB for 2 days. CP lasted for hours at a time, was described as pleuritic, without radiation, but relieved by nitro. He was given nitro and full dose aspirin by EMS.  Prehospital ECG was similar to first ED ECG.Here is the ED ECG for ED visit #1:It is very abnormal, with potentially ischemic downsloping ST depressionThere were 3 ECGs during an ED visit for chest pain one month earlier.  Let's call that ED visit zero.Here is the last EKG from ED visit zero:There is minimal ST depression without the downsloping.Here ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Can a bedside echocardiogram help rule out STEMI in patients with suspicious ECG?No, it can’t  (Though, it may be tempting to use a rapid echo to look for wall motion defect to rule out ACS ) If your answer was No, probably you don’t need to read any further in this post. Diagnosis of STEMI* is based onClinicalECGBio-Markers *Please note, two of the most popular investigations namely Echo and Coronary angiogram are missing in the list.Middle-aged man with  chest pain.  Can an echocardiogram help you confirm  STEMI here? Most likely not. It may still be a evolving STEMI. But, obser...
Source: Dr.S.Venkatesan MD - Category: Cardiology Authors: Tags: Uncategorized diagnostic criteria for stemi gls in stemi role of echocardiography in diagnosis of acs stemi nstemi wall motion defect in stemi by echo Source Type: blogs
Conclusion: I suspect one or more of the anterior leads was placed too high on the chest (especially given the deep negative P wave in lead V1) — butregardless, the poor R wave progression we see in ECG #1 is consistent with prior anterior infarction (and this patient ’s past medical history is remarkable for a prior “silent” heart attack).ReST-T Wave Changes — There are some nonspecific ST-T wave changes in some limb leads (ie,leads I, II, aVL) — but these do not look acute. Of much more concern (as per Drs. Oberst, Mogul and Meyers) — there is 0.5-1.0mm of J-point ST elevation in...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Authors: Arai R, Fukamachi D, Akutsu N, Tanaka M, Okumura Y Abstract A 76-year-old man suffering from chest pain was admitted to our hospital with a suspected acute myocardial infarction (AMI). Emergent coronary angiography revealed a totally occluded proximal left circumflex artery (LCX). During primary percutaneous coronary intervention, his blood pressure suddenly fell within seconds, and he developed pulseless electrical activity (PEA). Surprisingly, the 12-lead electrocardiogram (ECG) findings including the heart rate remained unchanged before and after the PEA, but a heart rate reduction and asystole occurred...
Source: International Heart Journal - Category: Cardiology Tags: Int Heart J Source Type: research
AbstractAcute coronary syndrome is a precipitant of acute heart failure in a substantial proportion of cases, and the presence of both conditions is associated with a higher risk of short ‐term mortality compared to acute coronary syndrome alone. The diagnosis of acute coronary syndrome in the setting of acute heart failure can be challenging. Patients may present with atypical or absent chest pain, electrocardiograms can be confounded by pre‐existing abnormalities, and cardiac biomarkers are frequently elevated in patients with chronic or acute heart failure, independently of acute coronary syndrome. It is important t...
Source: European Journal of Heart Failure - Category: Cardiology Authors: Tags: Position Paper Source Type: research
ConclusionsSTE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important.Previously, Knotts et al. had published different, but also convincing, data:Knotts et al. found that such ECG findings (STE in aVR) only represented left main ACS in 14% of such ECGs: Only 23% of patients with the aVR STE pattern had any LM disease (fewer if defined as  ≥ 50% stenosis). Onl...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
CONCLUSIONS: No-reflow in CTO recanalization is rare, but associated with a high risk of periprocedural myocardial infarction, with incomplete protection from ischemia offered by the pre-existing collateral network. PMID: 32005785 [PubMed - in process]
Source: The Journal of Invasive Cardiology - Category: Cardiology Tags: J Invasive Cardiol Source Type: research
Rationale: A spontaneous rupture of the bladder diverticulum in an adult patient is extremely rare. The recommended treatment is surgery. However, some cases can be successfully treated with urinary catheterization, antibiotics, and/or percutaneous peritoneal drainage. In this case report, a spontaneous rupture of the bladder diverticulum was successfully treated non-surgically because it was deemed too risky for surgical intervention, such as non-ST segment elevation myocardial infarction (NSTEMI). Patient concerns: A 76-year-old man presented with abdominal pain, distention, diarrhea, and oliguria for 3 days and hyp...
Source: Medicine - Category: Internal Medicine Tags: Research Article: Clinical Case Report Source Type: research
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