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Chest pain, a frequent reason for medical consultation, can have benign causes or be a sign of serious conditions requiring thorough assessment. Identifying "red flags" (hypotension, tachycardia) and conducting a comprehensive evaluation, including medical history, vital signs, electrocardiogram (ECG), biomarkers, and imaging, is essential to distinguish between benign and critical causes. Acute coronary syndromes, such as ST-elevation/non-ST-elevation myocardial infarction, are guided by European recommendations based on troponins and 24-hour ECG monitoring. Chronic coronary syndromes require early screening for risk factors, lifestyle optimisation, and personalised treatment, improving diagnosis, management, and outcomes., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Takotsubo syndrome is an acquired pathological condition that occurs mainly in postmenopausal women in response to stressful events of a variety of psychophysical nature and, especially in the acute phase, may be indistinguishable from acute coronary syndrome. The clinical presentation of Takotsubo syndrome is characterized by chest pain, an increase in biomarkers of myocardial necrosis, wall motion abnormalities and ECG changes that may completely overlap with cardiac ischemia. It is therefore of paramount importance to make a correct differential diagnosis between these two conditions, which have different therapeutic and prognostic implications. As evidence of this, we report the case of a Takotsubo syndrome with an atypical ECG presentation, known as the de Winter pattern, suggestive of acute coronary syndrome. This case report further highlights the need for urgent coronary angiography combined with ventriculography to allow for a proper differential diagnosis.

Background: Acute coronary syndrome (ACS) and acute myocardial infarction (AMI) account for a large portion of cardiovascular deaths. Signs and symptoms for these syndromes, such as chest pain, are non-specific and can be caused by a variety of non-cardiac conditions, especially in low-prevalence settings such as general practice. The diagnostic value of these signs and symptoms can be assessed using diagnostic meta-analyses, but the last one dates from 2012., Methods: We performed a diagnostic meta-analysis in accordance with PRISMA guidelines. We searched PubMed, Embase and CENTRAL from 2006 to 2024. We included studies that assessed the diagnostic accuracy of thirteen different signs and symptoms. We divided patients into two subgroups (AMI and ACS) on which analysis was performed independently., Results: We selected 24 articles for inclusion. Our analysis indicates that signs and symptoms have a limited role in the diagnosis of AMI or ACS. The most useful (highest diagnostic odds ratios, DOR) in the diagnosis of AMI were pain radiating to both arms (DOR 2.95 (95%CI 1.57-5.06)), absence of chest wall tenderness (DOR 3.51 (95%CI 1.64-6.61)), pain radiating to the right arm (DOR 5.17 (95%CI 1.77-11.9)) and sweating (DOR 5.75 (95%CI 2.51-11.4)). For ACS these were pain radiating to the right arm (DOR 3.9 (95%CI 0.7-12.6)) and absence of chest wall tenderness (DOR 7.73 (95%CI 2.19-19.8))., Conclusion: We report the accuracy of thirteen signs and symptoms in the diagnosis of AMI and ACS. These can be useful to calibrate general practitioners' diagnostic assessment of chest pain in primary care settings.

Background: Social media is a common source of health-related information. However, more clarity regarding ACS symptom information posted on social media is needed., Objectives: The objective was to describe ACS symptom information on social media platforms, including Twitter (now named X), Instagram, and TikTok., Methods: A cross-sectional, qualitative descriptive design was used. The three social media platforms were searched in 2022 for posts containing ACS symptom information. A random sample of posts meeting inclusion was drawn. Posts were analyzed using a qualitative coding process, and network analysis was used to triangulate data., Results: Posts (N = 342) included in the final analysis were most often published by healthcare organizations (46.2 %), lay persons (20.8 %), or healthcare professionals (13.7 %). Five key themes were identified: 1) a focus on gendered symptom experiences, 2) diverse types of symptom messages (educational, emphasis on getting help, personal testimony, advertising, diagnostic help, research findings), 3) variety of specific symptoms mentioned, 4) different dimensions of symptoms included, and 5) varying levels of information quality and accuracy. Chest pain was the most common ACS symptom highlighted in posts, and symptom differences between men and women were often emphasized., Conclusions: Of particular concern was incorrect or misleading ACS symptom information on social media that could create misconceptions and contribute to delays in seeking care for ACS. The findings from this study provide more insight into the ACS symptom information shared on social media platforms and provide preliminary information that can influence practice and future research., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) has a significant impact on cardiovascular mortality in elderly patients. Identification of high-risk patients is essential to optimize clinical management. This study investigates the relationship between the TyG index and CAD complexity, as measured by the SYNTAX score, in elderly patients with NSTE-ACS., Methods: We performed a retrospective analysis of 216 patients aged >65 years undergoing coronary angiography stratified according to tertiles of the TyG index and the SYNTAX score (SYNTAX score ≤ 22 versus SYNTAX score > 22)., Results: After adjustment for confounders, the TyG index was identified as an independent predictor of moderate/high scores (SYNTAX score > 22). As a continuous variable, it was significantly associated with moderate/high SYNTAX scores in both diabetic ( P  = 0.003) and nondiabetic groups ( P  = 0.004). When presented as a categorical variable, the TyG index remained a significant predictor after adjustment for sex, hypertension, BMI, and glomerular filtration rate. Compared with the T1 group, the risk of a moderate/high SYNTAX score was 5.410-fold (95% CI: 1.034-28.315; P  = 0.046) and 7.774-fold (95% CI: 1.836-32.916; P  = 0.005) higher in the T2 and T3 groups, respectively. The TyG index showed superior predictive ability for CAD complexity with an AUC of 0.747 compared with the AUC of 0.624 for HbA1c ( P  = 0.005)., Conclusion: This study showed that the TyG index is an independent predictor of moderate/high SYNTAX scores in elderly patients with NSTE-ACS, demonstrating superior predictive performance compared to HgA1c and highlighting its potential as a valuable tool for assessing CAD severity in this population., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Dual Antiplatelet Therapy (DAPT) plays an important role in the secondary prevention of ischemic events after treatment for acute coronary syndrome (ACS). The long-term use of DAPT is associated with an increased risk of bleeding, which affects morbidity and mortality. Risk stratification scores have been developed to predict this risk and provide a balance against the risk of ischemic events. The aim of this study was to determine the incidence of bleeding in a cohort of patients in Kenya on DAPT and assess the performance of the PRECISE-DAPT Score in predicting the risk of bleeding., Methods: This was a retrospective study conducted in three hospitals in Kenya among patients on DAPT after ACS between January 2019 and April 2022. We reviewed medical records for demographic and clinical characteristics and conducted telephone interviews to assess bleeding for patients on DAPT for a minimum period of one year. Bleeding events were categorized according to the TIMI criteria for bleeding, and the PRECISE-DAPT Score was calculated using an online calculator. The cumulative one-year incidence of bleeding was calculated and presented as frequencies and percentages. Receiver operating characteristic (ROC) analysis and C-statistics were used to quantify the ability of the PRECISE-DAPT Score to predict bleeding events, whereas calibration was estimated using the Hosmer‒Lemeshow goodness-of-fit test., Results: A total of 202 patients were enrolled in the study. The study population was predominantly male (n = 156, 77.2%) and African (n = 141, 69.8%), with a median age of 61 years (IQR 52-72). Majority were admitted with ST-Elevation Myocardial infarction (STEMI) (n = 126, 62.4%) and had a mildly reduced left ventricle ejection fraction (n = 124, 61.4%). Fourteen patients (6.9%) met the TIMI criteria for bleeding, of whom 11 (5.4%) had minimal bleeding and 3 (1.5%) had minor bleeding. There was no incidence of major bleeding. The discrimination and calibration of the PRECISE-DAPT Score was good {ROC curve 0.699 (95% CI: 0.564-0.835)} and the Hosmer-Lemeshow goodness-of-fit test (Chi-square, 6.53; p = 0.588), respectively., Conclusion: The incidence of bleeding was low, with the majority of patients having minimal bleeding that did not require medical intervention. The PRECISE-DAPT Score performed well in predicting bleeding in patients on DAPT., Competing Interests: Declarations. Ethics approval and consent to participate: The study protocol was presented and approved by the Departmental Research Review Committee (DRRC), Department of Internal Medicine, Aga Khan University, Nairobi. It was approved by Aga Khan University, Nairobi Institutional Scientific and Ethics Review Committee (ISERC) Reference Number (2022/ISERC-47, v2). It was also approved by the National Commission for Science, Technology and Innovation (NACOSTI), Licence Number: NACOSTI/P/24/32538. Informed consent was obtained from all the patients via a consent form approved by ISERC. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Contrast-induced nephropathy (CIN) is a significant complication in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). The role of the stress hyperglycemia ratio (SHR) as a predictor of CIN and mortality in these patients remains unclear and warrants investigation., Objective: To assess the relationship between SHR and CIN, as well as its impact on short-term mortality in ACS patients undergoing PCI., Methods: We conducted a retrospective cohort study using the MIMIC-IV database, including 552 ACS patients. SHR was calculated as the ratio of admission glucose to estimated average glucose from hemoglobin A1c. CIN was defined as a ≥ 0.5 mg/dL or ≥ 25% increase in serum creatinine within 48 h of PCI. Logistic regression and spline models were used to analyze the association between SHR and CIN, while Kaplan-Meier curves assessed 30-day mortality., Results: Higher SHR levels were independently associated with increased CIN risk (OR 2.36, 95% CI: 1.56-3.57, P < 0.0001). A J-shaped relationship was observed, with CIN risk rising sharply when SHR exceeded 1.06. SHR was also a predictor of higher 30-day mortality (P < 0.0001). Subgroup analysis revealed a stronger SHR-CIN association in non-diabetic patients., Conclusion: SHR is an independent predictor of CIN and short-term mortality in ACS patients undergoing PCI. It offers potential for risk stratification and clinical decision-making, especially in non-diabetic patients., Competing Interests: Declarations. Ethics approval and consent to participate: This study was conducted using the publicly available, de-identified Medical Information Mart for Intensive Care IV (MIMIC-IV) database, which does not require individual patient consent. Ethical approval for the use of the MIMIC-IV database was obtained by completing the Collaborative Institutional Training Initiative (CITI) Program's “Data or Specimens Only Research” course (Certification No. 63998837). Consent for publication: This study does not include any data from individual persons. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Emergency department (ED) routine data offer a unique opportunity for syndromic surveillance of communicable and noncommunicable diseases (NCDs). In 2020, the Robert Koch Institute established a syndromic surveillance system using ED data from the AKTIN registry. The system provides daily insights into ED utilization for infectious diseases. Adding NCD indicators to the surveillance is of great public health importance, especially during acute events, where timely monitoring enables targeted public health responses and communication., Objective: This study aimed to develop and validate syndrome definitions for the NCD indicators of acute coronary syndrome (ACS), myocardial infarction (MI), and stroke (STR)., Methods: First, syndrome definitions were developed with clinical experts combining ED diagnosis, chief complaints, diagnostic certainty, and discharge information. Then, using the multicenter retrospective routine ED data provided by the AKTIN registry, we conducted internal validation by linking ED cases fulfilling the syndrome definition with the hospital discharge diagnoses and calculating sensitivity, specificity, and accuracy. Lastly, external validation comprised the comparison of the ED cases fulfilling the syndrome definition with the federal German hospital diagnosis statistic. Ratios comparing the relative number of cases for all syndrome definitions were calculated and stratified by age and sex., Results: We analyzed data from 9 EDs, totaling 704,797 attendances from January 1, 2019, to March 5, 2021. Syndrome definitions were based on ICD-10 (International Statistical Classification of Diseases and Related Health Problems 10th Revision-German Modification) diagnoses, chief complaints, and discharge information. We identified 4.3% of all cases as ACS, 0.6% as MI, and 3.2% as STR. Patients with ACS and MI were more likely to be male (58.3% and 64.7%), compared to the overall attendances (52.7%). For all syndrome definitions, the prevalence was higher in the older age groups (60-79 years and >80 years), and the highest proportions of cases were assigned an urgency level (3=urgent or 2=very urgent). The internal validation showed accuracy and specificity levels above 96% for all syndrome definitions. The sensitivity was 85.3% for ACS, 56.6% for MI, and 80.5% for STR. The external validation showed high levels of correspondence between the ED data and the German hospital statistics, with most ratios ranging around 1, indicating congruence, particularly in older age groups. The highest differences were noted in younger age groups, with the highest ratios in women aged between 20 and 39 years (4.57 for MI and 4.17 for ACS)., Conclusions: We developed NCD indicators for ACS, MI, and STR that showed high levels of internal and external validity. The integration of these indicators into the syndromic surveillance system for EDs could enable daily monitoring of NCD patterns and trends to enhance timely public health surveillance in Germany., (© Madlen Schranz, Mirjam Rupprecht, Annette Aigner, Leo Benning, Carmen Schlump, Nesrine Charfeddine, Michaela Diercke, Linus Grabenhenrich, Alexander Ullrich, Hannelore Neuhauser, Birga Maier, AKTIN Research Group, Felix Patricius Hans, Sabine Blaschke. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org).)

Background: We aimed to compare the agreement between two common frailty assessment tools, Clinical Frailty Scale (CFS) and Hospital Frailty Risk Score (HFRS), and their ability to predict mid-term adverse outcomes in older patients admitted with acute coronary syndrome (ACS)., Methods: We conducted a prospective analysis of patients aged ≥ 60 admitted with ACS at multiple centers in Vietnam between July 2022 and June 2023. A cross-tabulation method was used to describe the correlation between CFS and HFRS. To test the predictive accuracy of HFRS for identifying patients with frailty according to CFS, we evaluated the area under the curves of receiver operating characteristic (ROC) analysis. Youden J index was used to identify a new optimal probability threshold for HFRS. We employed Cox regression models to investigate the association between frailty assessed by CFS, HFRS (using both old and new cut-offs), and 9-month mortality., Results: We included 504 older patients admitted with ACS (median age 72.7 years; male: 59.9%). The correlation between CFS and HFRS was fair (AUC = 0.787, p < 0.010). HFRS had a sensitivity of 39.7% and a specificity of 79.2% to detect frailty based on CFS classification. The new optimal probability threshold of HFRS (≥ 1.15 points) improved the instrument's performance with a significantly higher sensitivity of 90.2%. While frailty categorized by HFRS with the original cut-off did not impact mid-term all-cause and cardiovascular mortality, frailty according to CFS and HFRS with the new threshold was shown to be a predictor of mid-term all-cause and cardiovascular mortality (HR = 4.48, p < 0.001 vs. HR = 2.29, p = 0.001; HR = 5.19, p < 0.001 vs. HR = 1.99, p = 0.020)., Conclusions: Although a fair correlation existed between the CFS and the HFRS in older patients with ACS, HFRS demonstrated limited predictive validity for mid-term mortality. We advocate for a revised cutoff (HFRS ≥ 1.15 points) to enhance its sensitivity and predictive accuracy. Future research should prioritize the integration of additional clinical biomarkers and conducting longitudinal studies to assess the efficacy of targeted interventions informed by frailty scores, ultimately striving to improve outcomes in this vulnerable population., Competing Interests: Declarations. Ethics approval and consent to participate: This study was approved by the Ethics Committee of the University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam (reference number: 672/HĐĐĐ-ĐHYD August 2022). Participants were informed of the study and provided written consent. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests. Clinical trial number: Not applicable., (© 2025. The Author(s).)

Background: The neutrophil-to-high-density lipoprotein cholesterol ratio (NHR) is closely related to the occurrence and severeness of coronary stenosis in subjects with acute coronary syndrome (ACS). Men have higher NHR levels than women. The study was designed to examine the usefulness of NHR for predicting severe coronary stenosis in male and female ACS subjects., Methods: We enrolled 165 ACS patients (105 males and 60 females) who underwent coronary angiography. Clinical parameters; fasting glucose, creatinine, and uric acid levels; lipid profiles; and routine blood indices were measured. The NHR was computed by dividing the neutrophil numbers by the concentration of high-density lipoprotein cholesterol. Coronary stenosis severity was assessed using the Gensini score (GS). A GS˃41 points was regarded as a high GS., Results: The NHR was clearly greater in male ACS individuals than in their female counterparts (P = 0.001). The NHR was positively linked to the GS (r = 0.330, P = 0.001) in men, whereas there was no association between NHR and the GS in women (r=-0.0.032, P = 0.805). Univariate logistic regression analyses indicated that the NHR predicted a high GS in male ACS patients but not in their female counterparts. Multivariate logistic regression analyses indicated that a high NHR was an independent marker of severe coronary lesions in men (P = 0.001) but not in women (P = 0.274). The areas under the receiver operating characteristic curve of the NHR for the prediction of severe atherosclerosis were 0.681 (P = 0.001) and 0.560 (P = 0.431) in male and female subjects, respectively. An NHR value > 3.99 had a specificity and a sensitivity of 68% and 64%, respectively, for forecasting severe atherosclerosis in male subjects., Conclusions: The NHR could be utilised to independently predict the severeness of coronary lesions in male ACS subjects but not in their female counterparts. Therefore, the NHR should be used with caution when screening female ACS patients for severe coronary restrictions., Competing Interests: Declarations. Ethics approval and consent to participate: All participants provided written informed consent, and the research proposal was approved by the institutional ethics committee. The study followed the principles of the Declaration of Helsinki. Consent for publication: All authors read and approved the final manuscript. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Advances in managing non-ST-elevation acute coronary syndrome (NSTE-ACS) have yet to clarify the optimal treatment for elderly patients, whose complex health profiles and underrepresentation in trials add challenges to decision-making., Methods: We systematically searched PubMed, Embase, Web of Science, and Scopus for randomized controlled trials comparing invasive versus conservative strategies in elderly patients (≥ 70 years) with NSTE-ACS through October 2024. Co-primary outcomes were all-cause and cardiovascular mortalities, with secondary outcomes including myocardial infarction (MI), revascularization, stroke, decompensated heart failure, and bleeding events. Outcomes were analyzed using both risk ratios (RR) and hazard ratios (HR)., Results: Analysis of 11 trials (4,114 patients) showed no significant differences in all-cause mortality (RR: 1.04, 95% CI: 0.98-1.11; HR: 1.10, 95% CI: 0.94-1.29) or cardiovascular mortality (RR: 0.98, 95% CI: 0.85-1.12; HR: 0.94, 95% CI: 0.73-1.20) between strategies. The invasive approach significantly reduced subsequent revascularization (RR: 0.41, 95% CI: 0.27-0.62; HR: 0.30, 95% CI: 0.19- 0.47; p < 0.01 in both analyses) and MI risk (RR: 0.75, 95% CI: 0.57-0.99, p = 0.04; HR: 0.64, 95% CI: 0.49-0.83, p < 0.01), though with some levels of heterogeneity in sensitivity analyses for MI. Stroke and heart failure outcomes were comparable between strategies. However, it significantly increased the risk of both composite major and minor bleeding risk (RR: 1.50, 95% CI: 1.02-2.20, p = 0.04) and major bleeding alone (RR: 1.92, 95% CI: 1.04-3.56, p = 0.04)., Conclusion: In elderly patients with NSTE-ACS, an invasive strategy reduces revascularization needs and, potentially, MI risk without impacting survival, but at the cost of increased bleeding risk. This supports individualized treatment decisions based on patient-specific characteristics, particularly bleeding risk and geriatric factors., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Aims: Safety of aspirin-free strategy immediately after percutaneous coronary intervention (PCI) for cardiovascular events in patients with diabetes was unknown., Methods and Results: We conducted the prespecified subgroup analysis on diabetes in the STOPDAPT-3 trial, which randomly compared prasugrel (3.75 mg/day) monotherapy (2984 patients) to dual antiplatelet therapy (DAPT) with prasugrel and aspirin (2982 patients) in patients with acute coronary syndrome or high bleeding risk. The co-primary endpoints were major bleeding events (Bleeding Academic Research Consortium 3 or 5) and cardiovascular events (a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or stroke) at 1 month. Of 5966 study patients, there were 2715 patients (45.5%) with diabetes. Patients with diabetes more often had chronic coronary syndrome, heart failure or cardiogenic shock, and comorbidities than those without. Patients with diabetes compared to those without had higher incidences of major bleeding and cardiovascular events. Regardless of diabetes, the effect of no-aspirin relative to DAPT was not different for the co-primary bleeding (diabetes: 5.05% vs. 5.47%; HR, 0.92; 95%CI, 0.66-1.28 and non-diabetes: 3.99% vs. 4.07%; HR, 0.98; 95%CI, 0.69-1.38; P for interaction = 0.81) and cardiovascular (diabetes: 5.54% vs. 5.15%; HR, 1.08; 95%CI, 0.78-1.49 and non-diabetes: 2.95% vs. 2.47%; HR, 1.20; 95%CI, 0.79-1.82; P for interaction = 0.70) endpoints. The incidences of subacute definite or probable stent thrombosis and any coronary revascularization were higher in the no-aspirin group than in the DAPT group regardless of diabetes., Conclusions: The effects of an aspirin-free prasugrel monotherapy (3.75 mg/day) relative to DAPT for major bleeding and cardiovascular events were not different regardless of diabetes., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

This study evaluated the effectiveness of history, electrocardiogram, age, risk factors, and troponin (HEART), troponin-only Manchester acute coronary syndromes (T-MACS), and history and electrocardiogram-only Manchester acute coronary syndromes (HE-MACS) in diagnosing and managing acute coronary syndrome in patients presenting with chest pain in the emergency department. These scoring systems are crucial for risk stratification and the prediction of major adverse cardiac events (MACEs) and mortality within 30 days. A single-center prospective analytical study was conducted following the STROBE guidelines, with 560 patients presenting with chest pain or ischemic equivalent symptoms at the Ege University Faculty of Medicine Hospital from August 2020 to March 2021. The HEART, T-MACS, and HE-MACS scores were calculated for each patient, and their predictive values for MACE and mortality were analyzed using receiver operating characteristic analysis. The HEART score demonstrated an area under the curve (AUC) of 0.929 for predicting mortality, with 100% sensitivity and 81% specificity. It has been identified as the most reliable predictor of mortality. The T-MACS score showed an AUC of 0.875 for mortality prediction with 85.7% sensitivity and 83.9% specificity. It is particularly effective for high-risk patients, predicting 30-day MACE development rates, which is consistent with the literature. The HE-MACS score yielded an AUC of 0.729 for mortality prediction, with 71.4% sensitivity and 80.7% specificity. Although it effectively excludes MACE in very-low-risk patients, it is limited by its application to a highly isolated group. The discussion interprets the results and compares them with existing literature. The study confirms the high effectiveness of the HEART score in mortality risk assessment, the specificity of the T-MACS score for high-risk patients, and the utility of the HE-MACS score for excluding very-low-risk cases. The limitations of each scoring system are discussed and recommendations for their application in clinical practice are provided. The study concluded that selecting the most appropriate scoring system based on individual patient characteristics is essential for optimal patient management in the emergency department. For optimal patient management, it is essential to select the most appropriate scoring system based on the individual patient characteristics., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2025 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: Symptoms of dizziness/lightheadedness are more often reported by females than males with an acute coronary syndrome (ACS). Therefore, we investigated if these symptoms are helpful for triage and diagnosis of ACS in females and males with acute chest discomfort., Design: Cross-sectional study., Setting: Nine out-of-hours service in primary care (OHS-PC) in the Netherlands participated, covering both rural and urban areas, serving a total population of 1.5 million people., Participants: 2195 patients were selected calling the OHS-PC with acute chest discomfort, 55.4% were females. Calls were selected based on International Classification of Primary Care codes and keywords, that is, chest pain, heart complaints, heart, myocardial infarction, heart attack, heart infarction or common abbreviations of these keywords. Recordings were excluded if (1) they were of poor quality, (2) the conversation was not a triage conversation, (3) patients were <18 years, (4) patients did not live in the vicinity of the OHS-PC, and (4) general practitioners did not want to provide follow-up information including the final diagnosis., Primary and Secondary Outcome Measures: The prevalence of dizziness/lightheadedness among patients calling the OHS-PC with acute chest discomfort and the relation between dizziness/lightheadedness and (1) urgency allocation and (2) a final diagnosis of ACS., Results: Among 2195 patients who called the OHS-PC with acute chest discomfort, 251 (11.4%) had an ACS (8.3% females, 15.3% males). Females more often reported concurrent dizziness/lightheadedness than males (14.7% vs 10.9%, p=0.008). However, this was not observed in those with confirmed ACS (9.9% of the females vs 9.3% of the males, p=0.881). Reporting of dizziness/lightheadedness was not positively related to an ACS diagnosis in females (OR 0.61 (95% CI 0.31 to 1.21)) or in males (OR 0.82 (95% CI 0.45 to 1.47)). In contrast, both females and males with concurrent dizziness/lightheadedness more often received a high urgency allocation than those without these symptoms., Conclusions: Dizziness/lightheadedness are common symptoms but are not positively related to an ACS diagnosis in both females and males with acute chest discomfort. It seems not worthwhile to give females and males with acute chest discomfort and concurrent dizziness/lightheadedness a higher urgency allocation than those without these symptoms., Trial Registration Number: NTR7331., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Background: The early assessment of heart failure (HF) risk in patients with acute coronary syndrome (ACS) can help reduce mortality. S100A8/A9 is not only rapidly released after myocardial ischemia, but is also involved in reperfusion injury, which is an important predictor of HF after ACS. We attempted to construct a reliable HF risk stratification tool for evaluating patients with ACS after reperfusion therapy based on S100A8/A9 dynamic changes., Methods and Results: This prospective study included 3 independent cohorts of patients with ACS who received reperfusion therapy. The discovery cohort was divided into 2 subgroups: the longitudinal subgroup (n=264) with serum S100A8/A9 levels measured at admission and on days 1, 2, 3, and 4 postadmission, respectively, and the 2-point subgroup (n=798) with S100A8/A9 levels measured at admission and on day 1 postadmission, respectively. Validation cohorts 1 (n=1399) and 2 (n=1183) both had S100A8/A9 levels measured on day 1 postadmission. HF events included in-hospital HF events after the initial presentation and long-term HF events after discharge. The median follow-up for the discovery cohort, validation cohort 1, and validation cohort 2 was 4.2, 2.6, and 1.8 years, respectively. In the discovery cohort, S100A8/A9's predictive ability at day 1 surpassed other time points. Through the S100A8/A9-guided risk stratification, patients deemed high risk (>7900 ng/mL) exhibited a higher 1-year HF event rate (46% versus 2%, 38% versus 5%) than patients at low risk (<2100 ng/mL) in both validation cohorts. Among patients without left ventricular dysfunction after ACS, β-blocker therapy correlated with reduced 1-year HF events in intermediate-to- high-risk patients but not in low-risk patients., Conclusions: S100A8/A9 levels on day 1 accurately classified patients at varying risks of HF, serving as a robust tool for HF risk prediction and treatment guidance., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03752515.

Background: The High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome) pathway risk stratifies emergency department patients with possible acute coronary syndrome. This study aims to determine if the High-STEACS hs-cTnT (high-sensitivity cardiac troponin T) pathway can achieve the ≥99% negative predictive value (NPV) safety threshold for 30-day cardiac death or myocardial infarction (CDMI) in a multisite US cohort of patients with and without known coronary artery disease (CAD)., Methods: A secondary analysis of the STOP-CP (High-Sensitivity Cardiac Troponin T [Gen 5 STAT Assay] to Optimize Chest Pain Risk Stratification) cohort, which enrolled adult emergency department patients with possible acute coronary syndrome at 8 US sites (January 25, 2017-September 6, 2018). Participants were classified into outpatient and admission dispositions using the High-STEACS hs-cTnT pathway. Known CAD was defined as prior MI, coronary revascularization, or ≥70% coronary stenosis. Outcomes included 30-day CDMI and efficacy, defined as the proportion identified for outpatient disposition. NPVs and negative likelihood ratios for 30-day CDMI were calculated. NPVs were compared between CAD subgroups using a Fisher exact test., Results: Among 1351 patients, 53.2% (719/1351) were male, 31.4% (424/1351) had known CAD, and the mean age was 57.4±12.8 years. At 30 days, CDMI occurred in 13.8% (187/1351). High-STEACS classified 63.4% (857/1351) to outpatient disposition, of which 2.0% (17/857) had 30-day CDMI, corresponding to an NPV of 98.0% (95% CI, 96.8-98.8) and negative likelihood ratio of 0.13 (95% CI, 0.08-0.20). In patients with CAD, 46.9% (199/424) were classified to outpatient disposition, of which 4.0% (8/199) had 30-day CDMI. Among patients without CAD, 71.0% (658/927) were classified to outpatient disposition with 1.4% (9/658) having 30-day CDMI. The NPV for 30-day CDMI was 96.0% (95% CI, 92.2-98.2) in patients with CAD versus 98.6% (95% CI, 97.4-99.4) among patients without CAD ( P =0.04). The negative likelihood ratio for 30-day CDMI among patients with CAD was 0.16 (95% CI, 0.08-0.31) and 0.12 (95% CI, 0.06-0.22) among patients without CAD., Conclusions: The High-STEACS hs-cTnT pathway had high efficacy but was unable to achieve the ≥99% NPV safety threshold for 30-day CDMI., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02984436., Competing Interests: Dr Ashburn receives funding from the National Heart, Lung, and Blood Institute (NHLBI; K23HL169929), Agency for Healthcare Quality and Research, Health Resources and Services Administration (R01HS029017), and the Emergency Medicine Foundation. Dr Snavely receives funding from NHLBI (K23HL169929), Abbott, HRSA (1H2ARH399760100), AHRQ (R01HS029017 and R21HS029234), and the Emergency Medicine Foundation. Dr Supples receives funding from the National Institutes of Health (NIH; UL1TR001420), AHRQ (R01HS029017), and the National Foundation of Emergency Medicine. Dr Mahler receives funding/support from Roche Diagnostics, Abbott Laboratories, QuidelOrtho, Siemens, Grifols, Pathfast, Beckman Coulter, Genetesis, Cytovale, National Foundation of Emergency Medicine, BlueJay Diagnostics, Duke Endowment, the Emergency Medicine Foundation, Brainbox, HRSA (1H2ARH399760100), and AHRQ (R01HS029017 and R21HS029234). He is a consultant for Roche, QuidelOrtho, Abbott, Siemens, Inflammatix, and Radiometer and is the Chief Medical Officer for Impathiq, Inc. Dr Allen receives research funding/support from Roche Diagnostics, Siemens, and Beckman Coulter. He is a consultant for Roche Diagnostics, Beckman Coulter, and Abbott. Dr Mumma has research support from the NIH (5K08HL130546) and Roche Diagnostics. Dr Wilkerson received research funding from Regeneron Pharmaceuticals, Inc, Lilly USA, LLC, BioAge Labs, Inc, Roche Diagnostics, Global Blood Therapeutics, Inc, Novartis Pharmaceuticals, Egetis Therapeutics AB, Endpoint Health, Inc, Blade Therapeutics, Janssen R&D LLC, ProvePharma, the National Foundation of Emergency Medicine, and Pfizer, Inc. He has received research funding from CoapTech, LLC through an NIH/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) grant (R44DK115325). He has received research support in the form of equipment and supplies from Cepheid and Eldon Biologicals A/s. He is an uncompensated advisor to CSL Behring. Dr Christenson is a consultant for and receives funding/support from Roche Diagnostics, Siemens Healthineers, Beckman Coulter Diagnostics, Becton Dickinson and Co, Quidel Corp, and Sphingotec GMBH. The other authors report no conflicts.

Coronary artery disease (CAD) is the leading cause of death worldwide. Acute coronary syndrome (ACS) encompasses a spectrum of diagnoses ranging from unstable angina pectoris to myocardial infarction with and without ST-segment elevation and frequently presents as the first clinical manifestation. It is crucial in this scenario to perform a timely and comprehensive assessment of patients by evaluating the clinical presentation, electrocardiogram and laboratory diagnostics using highly sensitivity cardiac troponin in order to initiate a timely and risk-adapted continuing treatment with immediate or early invasive coronary angiography. In addition to revascularization, the subsequent antithrombotic and lipid-lowering treatment plays a major role in the further secondary prevention of CAD. The choice and duration of medication over time should be tailored to the individual risk profile of the patient. Furthermore, appropriate patient education regarding risk factor management is of paramount importance., Competing Interests: Einhaltung ethischer Richtlinien. Interessenkonflikt: Gemäß den Richtlinien des Springer Medizin Verlags werden Autoren und Wissenschaftliche Leitung im Rahmen der Manuskripterstellung und Manuskriptfreigabe aufgefordert, eine vollständige Erklärung zu ihren finanziellen und nichtfinanziellen Interessen abzugeben. Autoren: M. Buske, H.-J. Feistritzer, A. Jobs und H. Thiele geben an, dass kein Interessenkonflikt besteht. Wissenschaftliche Leitung: Die vollständige Erklärung zum Interessenkonflikt der Wissenschaftlichen Leitung finden Sie am Kurs der zertifizierten Fortbildung auf www.springermedizin.de/cme . Der Verlag: erklärt, dass für die Publikation dieser CME-Fortbildung keine Sponsorengelder an den Verlag fließen. Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background and Importance: The diagnostic accuracy of focused cardiac ultrasound (FoCUS) performed in patients presenting to the emergency department (ED) with chest pain is currently unknown., Objective: The objective of this study was to assess the diagnostic accuracy of regional wall motion abnormalities detected with FoCUS for non-ST-elevation acute coronary syndrome (NSTE-ACS) diagnosis., Design: A Single-center prospective observational study conducted in 2022 in the ED of the University Hospital Careggi, Italy., Setting and Participants: Adult patients presenting to the ED with acute nontraumatic chest pain were enrolled, irrespective of the presence of previous regional wall motion abnormalities. Patients with ST-segment elevation myocardial infarctions and patients with hemodynamic instability were excluded. FoCUS was performed at presentation by a trained ED physician., Outcome Measures and Analysis: The final diagnosis of NSTE-ACS vs. alternative diagnosis was adjudicated by an ED physician blinded to FoCUS results after a 30-day follow-up. To assess if regional wall motion abnormalities were an independent predictor of NSTE-ACS, a multivariable logistic regression model was built. Diagnostic performance measures were calculated. A sensitivity analysis considering only type-1 NSTEMIs (i.e. plaque rupture/thrombosis) was conducted., Main Results: Among 686 patients, NSTE-ACS was adjudicated in 106 (15.5%) patients, 67 of which were NSTEMIs. A total of 87 (12.7%) patients had regional wall motion abnormalities detected by FoCUS, which were an independent predictor of NSTE-ACS in the multivariable logistic regression analysis. Regional wall motion abnormalities had a sensitivity of 42.5% (33.0-51.9), a specificity of 92.8% (90.6-94.9), a negative predictive value of 89.8% (87.4-92.2), and a positive predictive value of 51.7% (41.2-62.2), for NSTE-ACS. Results were consistent in the sensitivity analysis., Conclusions: In ED patients with chest pain and no ST elevation, the detection of regional wall motion abnormalities was a predictor of NSTE-ACS. Despite a high specificity, which indicated a possible role of FoCUS in the rule-in of NSTE-ACS, sensitivity was too low to allow a safe rule-out using FoCUS results alone., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Aims: Patients with recent Acute Coronary Syndrome (ACS) or Chronic Coronary Syndrome (CCS) are all at very high CardioVascular (CV) risk. However, some of them are more likely to experience recurrent cardiovascular events (i.e extreme CV risk). A definition of which patients should be included in this category has been recently proposed by the European Society of Cardiology but data on its prevalence are still lacking, especially in the context of Cardiac Rehabilitation (CR). Furthermore, if this condition had an impact on the CR related functional improvement is not known. Our study has been designed to answer to both these questions., Methods and Results: The study included 938 ACS/CCS patients who attended the CR program at the Niguarda Hospital (Milan). Extreme CV patients were defined as the presence of a previous CV events within 2 years or the presence of peripheral arteriopathy or the presence of a multivessel coronary involvement. Functional improvement was evaluated through 6-Minute Walking Test (6-MWT). As many as 26.9% of the patients had an extreme CV risk. They were older (67.8 ± 10.4 vs 64.1 ± 11.1 years; p ≤ 0.001), had a higher prevalence of CV risk factors and comorbidities and had a lower functional improvement during CR (102.9 ± 68.6 vs 138.1 ± 86.5 m; p ≤ 0.001). Extreme CV risk present a significant association with the 6-MWT results at multivariate analysis., Conclusion: Extreme CV risk is a very frequent condition among patients with ACS/CCS reaching the prevalence of 26.9%. Furthermore, being at extreme CV risk adversely affects the patient's functional improvement obtained during CR., (Copyright © 2025 The Authors. Published by Elsevier B.V. All rights reserved.)

T helper (Th) and regulatory T (Treg) cells regulate atherosclerosis, plaque, inflammation to involve in acute coronary syndrome (ACS). The current study aimed to investigate the clinical implications of Th and Treg cells in ACS patients receiving percutaneous coronary intervention (PCI). Blood Th1, Th2, Th17 and Treg cells were detected in 160 ACS patients before PCI, after PCI, at 1 month (M). Short physical performance battery (SPPB) at M1/M3 and major adverse cardiac event (MACE) during follow-ups were evaluated. Th1 and Th17 both showed upward trends during PCI, then greatly declined at M1 (P < 0.001). Th2 exhibited an upward trend during PCI but decreased slightly at M1 (P < 0.001). Treg remained stable during PCI but elevated at M1 (P < 0.001). Moreover, a positive correlation between Th1 and Th17, a negative correlation between Th17 and Treg, were discovered at several timepoints (most P < 0.050). Interestingly, the receiver operating curve (ROC) analyses revealed that Th1 [area under curve (AUC) between 0.633-0.645] and Th17 (AUC between 0.626-0.699) exhibited values estimating SPPB score <= 6 points at M1 or M3 to some extent. Importantly, Th1 (AUC between 0.708-0.710), Th17 (AUC between 0.694-0.783), and Treg (AUC between 0.706-0.729) predicted MACE risk. Multivariate models involving Th and Treg cells along with other characteristics revealed acceptable values estimating SPPB score <= 6 points at M1 or M3 (AUC between 0.690-0.813), and good values predicting MACE risk (AUC between 0.830-0.971). Dynamic variations in Th and Treg cells can predict the prognosis of ACS patients receiving PCI., Competing Interests: Declarations. Competing Interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Chest pain is a common chief complaint in the emergency department. When looking at patients with chest pain cases of acute coronary syndrome, pulmonary embolism and aortic dissection account for the majority of cases that involve an allegation of malpractice. While it is likely impossible to catch all these cases having a structured approach to these patients may improve outcomes for both patients and clinicians., Competing Interests: Disclosure The authors have no financial disclosures or conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Ventricular premature depolarizations (VPDs) in the setting of acute coronary syndrome (ACS) were associated with increased hospital mortality in the early revascularization era., Objective: Examine the predictive value of VPDs and their morphology for hospital and post-discharge mortality in patients admitted for ACS., Methods: We identified patients admitted with ACS across 13 Northwell Health Hospitals from 2015 to 2021 and had VPDs captured on a 12-lead ECG or full disclose telemetry. We characterized and reported descriptively the VPDs based on bundle branch block pattern (right or RBBB vs. left or LBBB), frontal (inferior vs. superior) and horizontal (leftward vs. rightward) axis, QRS width, and coupling interval (CI). Hierarchical generalized linear mixed modeling was used to assess the association between VPDs and hospital mortality, while Cox regression was used for post-discharge mortality., Results: Of 18 009 patients admitted for ACS, we identified 627 patients with VPDs with complete data (65.7% RBB, 49.9% superior, and 63.4% leftward axis). Mean VPD QRS width and CI were 175 ± 30 and 523 ± 157 ms, respectively. Hospital mortality was higher in the VPD group (7.8% vs. 4.9%, p < 0.001) with most common mode of death being arrhythmic (28.1% vs. 14.5%). After adjusting for clinical covariates, only VPDs with RBBB patterns were associated with hospital mortality (OR 2.26, 95% CI 1.06-4.82). Conversely, age-adjusted post-discharge mortality was higher only for patients with superior axis VPDs (HR 1.59, 95% CI 1.13-2.24)., Conclusion: Among patients with VPDs during an ACS admission, presence of RBBB pattern predicts hospital mortality, whereas superior axis is associated with post-discharge mortality., (© 2024 Wiley Periodicals LLC.)

Acute coronary syndrome (ACS) is a leading cause of death worldwide. Prompt and accurate diagnosis of acute myocardial infarction (AMI) or ACS is crucial for improved management and prognosis of patients. The rapid growth of machine learning (ML) research has significantly enhanced our understanding of ACS. Most studies have focused on applying ML to detect ACS, predict prognosis, manage treatment, identify risk factors, and discover potential biomarkers, particularly using data from electrocardiograms (ECGs), electronic medical records (EMRs), imaging, and omics as the main data modality. Additionally, integrating ML with smart devices such as wearables, smartphones, and sensor technology enables real-time dynamic assessments, enhancing clinical care for patients with ACS. This review provided an overview of the workflow and key concepts of ML as they relate to ACS. It then provides an overview of current ML algorithms used for ACS diagnosis, prognosis, identification of potential risk biomarkers, and management. Furthermore, we discuss the current challenges faced by ML algorithms in this field and how they might be addressed in the future, especially in the context of medicine., Competing Interests: Declarations. Conflict of Interest: Shanshan Nie, Shan Zhang, Yuhang Zhao, Xun Li, Huaming Xu, Yongxia Wang, Xinlu Wang, and Mingjun Zhu have nothing to disclose. Ethical Approval: This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors., (© 2024. The Author(s), under exclusive licence to Springer Healthcare Ltd., part of Springer Nature.)

Background: The present study aimed to investigate whether newly defined serum uric acid (SUA) to serum creatinine ratio (SUA/SCr) predicts no-reflow phenomenon (NRP) development in patients with non-ST-elevated acute coronary syndrome (NSTE-ACS)., Methods: The study group was divided into two groups: those who developed NRP and those who did not. Complete blood counts, SUA, serum creatinine, C-reactive protein (CRP) and albumin were obtained at admission. The SUA/SCr, SUA to albumin ratio (UAR), C-reactive protein to albumin ratio (CAR) and systemic immune inflammation (SII) index values of all patients were calculated and their relationships with NRP were evaluated., Results: Patients with NRP had higher mean SUA/SCr ratio (7.19 ± 2.14 vs 5.30 ± 1.70, p  < 0.001), mean UAR (1.73 ± 0.69 vs 1.38 ± 0.47, p  < 0.001), median CAR (1.73 vs 1.54, p  = 0.002), and median SII index (861.9 vs 730.9, p  = 0.015) levels than in those who did not develop NRP. According to multivariant analysis models, SUA/SCr ratio, UAR, CAR and SII index were found to be independent predictors of NRP development ( p  < 0.05 for all) but only the area under the curve (AUC) for SUA/SCr ratio (AUC = 0.73, p  < 0.001) was above the 0.70 proficiency level, performing markedly better than the other evaluated parameters. A SUA/SCr ratio ≥5.34 predicted the NRP with 75% sensitivity and 55% specificity., Conclusion: SUA/SCr ratio can be used as a reliable marker in prediction the development of NRP in NSTE-ACS patients.

Aim: To determine the characteristics of atherosclerotic plaques (ASP) remaining after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS), that are significantly associated with cardiovascular events (CVE), according to computed tomography angiography (CTA) data., Material and Methods: CTA was performed in 249 ACS patients on days 3-7 of the disease (in 41 patients, on a 64-slice CT scanner, and in the rest, on a 320-slice CT scanner). CTA data of all patients were analyzed on a Vitrea workstation. Patients with at least one noncalcified atherosclerotic plaque were included., Results: During 39.1 [18.0; 57.4] months of follow-up (from 7 days to 128 months), 71 of 249 (28.5%) ACS patients had the primary endpoint (PEP), which included non-fatal myocardial infarction, unstable angina, cardiac death, PCI, and ischemic stroke. According to the univariate Cox analysis, 14 of 30 CTA characteristics of ASP turned out to be significant predictors of achieving the PEP: the number of involved arteries (HR=1.314, CI: 1.06-1.628, p=0.013, C=0.59); the total length of ASPs (HR=1.013, CI: 1.005-1.022, p=0.002, C=0.62); the number of ASPs with obstructive stenosis (HR=1.286, CI: 1.095-1.509, p=0.002, C=0.61); the minimum density (HR=0.968, CI: 0.949-0.987, p=0.001, C=0.64); a minimum density &lt;30 HU (HR=2.695, CI: 1.495-4.869, p=0.0009, C=0.62); the number of ASPs with a minimum density &lt;30 HU (HR=1.391, CI: 1.186-1.633, p=0.00005, C=0.64); the number of ASPs with a minimum density ≤46 HU (HR=1.211, CI: 1.043-1.407, p=0.012, C=0.58); the presence of a low-density area &lt;30 HU (HR=2.387, CI: 1.389-4.101, p=0.001, C=0.57); the number of atherosclerotic plaques with a low-density area &lt;30 HU (OR=1.912, CI: 1.317-2.775, p=0.001, C=0.57); the number of atherosclerotic plaques with spotty calcifications (HR=1.384, CI: 1.134-1.688, p=0.001, C=0.59); the maximum length (HR=1.014, CI: 1.001-1.028, p=0.041, C=0.61); the maximum stenosis (HR=1.018, CI: 1.002-1.033, p=0.025, C=0.61); the presence of a low-density area ≤46 HU (HR=2.049, CI: 1.24-3.386, p=0.005, C=0.57); the number of ASPs with a low-density area ≤46 HU (HR=1.643, CI: 1.191-2.265, p=0.002, C=0.58). [HR, hazard ratio; CI, 95% confidence interval; C, Harrell's C statistics]. According to the multivariate analysis, the first 10 of the listed CTA characteristics retained their prognostic significance, while the predictive significance was found for the "total plaque burden", a conditional characteristic we first proposed, which is the sum of the areas (burden) of all plaques identified by CTA in the patient., Conclusion: 14 CTA characteristics of ASPs in patients with ACS are significant predictors of future CVE, and 11 of them are independent of known risk factors.

Background: Medical regulation of chest pain is challenging due to the multitude of potential diagnoses. The key challenge is to avoid misdiagnosing acute coronary syndrome while preventing over-triage. The SCARE score (based on age, sex, smoking, typical coronary pain, inaugural pain, sweats, and dispatcher's conviction) classifies patients as low, intermediate, or high risk of acute coronary syndrome. This study aimed to determine the diagnostic performance of the SCARE score among patients calling with chest pain., Methods: This single-center prospective study was conducted at the Charleville-Mézières Emergency Medical Communication Centre. Data collection included standardized questionnaires and call tape reviews. The SCARE score was compared with final diagnoses from medical records., Results: From October 2 to November 16, 2023, 194 patients were included, with 32 (16%) diagnosed with acute coronary syndrome. Of these, 24 patients (75%) were managed by a prehospital medical team. The AUROC for the SCARE score was 0.80 [95% CI 0.73-0.87]. At a low-risk threshold (26), sensitivity was 100% [95% CI 89-100] and specificity was 45% [95% CI 37-53]. At a high-risk threshold (36), sensitivity was 72% [95% CI 53-86] and specificity was 70% [95% CI 63-77]., Conclusion: The SCARE score exhibited excellent sensitivity and overall acceptable performance in predicting acute coronary syndrome in patients calling with non-traumatic chest pain., Trial Registration: ID-RCB 2023-A01672-43., Competing Interests: Declarations. Ethics approval and consent to participate: An information letter was sent to each patient included in the study. Patients had the opportunity to fill out an opposition form, resulting in exclusion from the study. EMCC dispatchers received a letter informing them of the study and its objectives and signed individual, free, and informed consent forms to listen to their dispatch tapes. This study was approved by the Comité de Protection des Personnes Est III on September 22, 2023. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Purpose of Review: What is the pathophysiology and clinical findings as well as management of patients presenting with INOCA/MINOCA (Ischemia/Myocardial Infarction with Non-Obstructive Coronary Arteries)., Recent Findings: INOCA/MINOCA has a complex pathophysiology. In this review article, we aim to summarize the complex pathophysiology and clinical diagnosis, and review the current management options., Competing Interests: Declarations. Competing Interests: The authors declare no competing interests. Human and Animal Rights and Informed Consent: This article does not contain any studies with human or animal subjects performed by any of the authors., (© 2025. The Author(s).)

Type 2 diabetes mellitus (T2DM) represents a major healthcare condition of the 21st century. It is characterised by persistently elevated blood glucose occurring as a result of peripheral insulin resistance and reduced insulin production which may lead to multiple long-term health conditions such as retinopathy, neuropathy, and nephropathy. The estimated number of individuals suffering from diabetes mellitus (DM) is expected to rise to 591 million by the year 2035 with 4.4 million in the United Kingdom (UK) alone, 90% of which is attributed to T2DM. Moreover, a significant proportion of individuals may have undetected diabetes mellitus, especially among those presenting with symptoms of ischaemic heart disease (IHD). This is particularly important in those individuals presenting with acute coronary syndromes (ACS) who are at the highest risk of complications and sudden cardiac death. Identifying abnormal levels of common biochemical markers of diabetes, such as capillary blood glucose or glycated haemoglobin (HbA1c) in these patients is important for early diagnosis, which will then allow for timely intervention to improve outcomes. However, a significant proportion of individuals who meet the criteria for the diagnosis of diabetes remain undiagnosed, representing missed opportunities for early intervention. This may result in a prolonged period of untreated hyperglycaemia, which can result resulting in significant further microvascular and macrovascular complications. There is an increased risk of IHD, heart failure, cerebrovascular accidents (CVA), and peripheral artery disease (PVD). These account accounting for 50% of deaths in patients with T2DM. Cardiovascular diseases in the context of diabetes particular represent a significant cause of morbidity and mortality with a two to three times higher risk of cardiovascular disease in individuals with T2DM than in those without the condition normo-glycaemia. In the United Kingdom UK alone, around 120 amputations, 770 CVA, 590 heart attacks, and more than 2300 presentations with heart failure per week are attributed to diabetes DM. with One 1 in six 6 hospital beds and around 10% of the healthcare budget may be being spent on managing diabetes DM or its complications. Therefore, it represents a significant burden on our healthcare system., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2025 Shah, Roebuck, Srinivasan, Ward, Squires, Hills and Lee.)

The PCL-5 is a psychometrically sound measure of Post-Traumatic Stress Disorder (PTSD) symptoms. Although the scale is commonly applied to past external traumas (e.g., combat, assault), PTSD symptoms have also been assessed about potentially life-threatening cardiovascular events that represent ongoing internal threats. To date, there is a paucity of studies that have examined the updated scale factor structure for PTSD in patients with suspected acute coronary syndromes (ACS)., Methods: Exploratory and confirmatory factor analyses (EFA, CFA) were conducted using PCL-5 data completed by 830 patients enrolled in the REactions to Acute Care and Hospitalization (REACH) study, an observational cohort study of patients recruited from the emergency department during evaluation for ACS. Follow-up measurement invariance tests were conducted on pre-selected models and on the best-fitting model identified by EFA to evaluate invariance across diagnosis (confirmed v. rule-out ACS), sex, and language., Results: The EFA identified a two-factor model with "Memories of Trauma" (MT) and "Cognitive Behavioral Symptoms" (CBS) factors offering a balanced fit and interpretability. In CFAs, the Anhedonia CFA model performed the best overall. Measurement invariance tests supported strong invariance across confirmed and ruled-out ACS, male and female sex, and English and Spanish language for all models., Limitations: Only 34 % of the sample was diagnosed with ACS at discharge, which limits generalizability., Conclusion: Our study contributes to the understanding of PTSD in the context of internal traumatic reminders and may guide future research and clinical practice by informing intervention targets to improve health and well-being after suspected ACS., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier B.V.)

Background: The overall risk of long-term adverse events of a transient episode of new-onset atrial fibrillation (AF) in patients with acute coronary syndrome (ACS) remains uncertain. This meta-analysis aimed to assess the prognostic impact of transient new-onset AF complicating ACS., Methods and Results: Cohort studies examining the risk of adverse events in patients with transient new-onset AF compared to those in sinus rhythm after ACS were identified through a comprehensive search of MEDLINE, Scopus, Cochrane, and Google Scholar Library. Studies reporting the incidence of ischaemic stroke events, recurrent AF, or all-cause mortality at the longest follow-up were included. Adjusted hazard ratios (aHRs) with 95% confidence intervals (CI) were synthesized using inverse variance-weighted random-effects meta-analysis. In the seven observational studies included, comprising 151 735 patients, 6 597 (4.3%) experienced transient new-onset AF, which was associated with an increased risk of ischaemic stroke, recurrent AF, or all-cause mortality (HR: 2.24, 95% CI: 1.75-2.85; P < 0.0001; I2 = 30.76%; seven studies). The results remained consistent across each individual endpoint, including ischaemic stroke (HR 2.38, 95% CI: 1.64-3.44; P < 0.01; I2 = 50.2%; five studies), recurrent AF (HR 4.68, 95% CI: 2.07-10.59; P = 0.0002; I2 = 50.2%; four studies), and all-cause mortality (HR 1.36, 95% CI: 1.08-1.71; P = 0.0089; I2 = 53.25%; four studies). Meta-regression analyses revealed a significant increase in these adverse events associated with ST-elevation myocardial infarction (P = 0.001), while there was a tendency for their decrease associated with oral anticoagulant prescription at discharge (P = 0.07)., Conclusions: The occurrence of transient new-onset AF is associated with an elevated long-term risk of stroke, recurrent AF, and all-cause mortality in patients with ACS. Consequently, these data urge randomized clinical trials to assess the best antithrombotic regimen while potentially helping the current treatment decision-making process for these patients., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Coronary computed tomography angiography (CCTA) and fractional flow reserve (FFR) derived from CCTA (FFR-CT) may provide a means of reducing unnecessary invasive coronary angiography (ICA) in patients with suspected non-ST-elevation acute coronary syndromes (NSTE-ACS)., Aims: The aim of this study was to evaluate the capacity of FFR-CT and CCTA to rule out significant lesions in high-risk NSTE-ACS patients, using ICA with invasive FFR as the gold standard., Methods: High-risk NSTE-ACS patients admitted to 4 European centres were enrolled in this single-arm, prospective core lab-adjudicated study. Patients underwent CCTA with FFR-CT analysis, followed by ICA with invasive FFR., Results: Out of the 250 initially planned NSTE-ACS patients, 168 were included, of whom 151 (92%) had sufficient CCTA image quality to undergo CCTA and FFR-CT analysis. The median high-sensitivity troponin T level at 1 hour post-hospitalisation was 5.3 (interquartile range: 1.8-18.6) times the upper reference limit. At the patient level, the diagnostic performance of FFR-CT was numerically higher as compared to CCTA though not statistically significant (sensitivity: 94% vs 93%, specificity: 63% vs 54%, positive predictive value: 83% vs 79%, negative predictive value: 85% vs 80% and accuracy: 83% vs 79%; p=0.58), suggesting an enhanced capability to avoid unnecessary ICA. At the lesion level, the ability of FFR-CT to detect significant lesions was significantly better than that of CCTA (receiver operating characteristic curves: 0.84 vs 0.65 respectively; p<0.01)., Conclusions: In patients with high-risk NSTE-ACS, FFR-CT offers better diagnostic accuracy - though not statistically significant - and a higher ability to rule out haemodynamically significant stenoses as compared to CCTA. This indicates that FFR-CT can reduce unnecessary invasive procedures by more accurately identifying patients requiring further intervention.

Background & Objective: Timely intervention for Acute coronary syndrome (ACS) could effectively reduce the mortality rate of ACS patients. This study aimed to investigate the clinical significance of miR-30c-5p for ACS and to provide a convenient biomarker for diagnosing of ACS., Methods: Baseline information was collected from a total of 173 subjects (98 ACS subjects and 65 healthy subjects). The miR-30c-5p expression was evaluated by the Polymerase chain reaction (PCR). The predictive value of miR-30c-5p for ACS was assessed by Receiver Operating Characteristic (ROC) curve and multivariate logistic regression analysis. The relationship between miR-30c-5p expression and ACS severity was assessed by correlation analysis. Furthermore, the prognostic value of miR-30c-5p on Major Adverse Cardiovascular Events (MACE) occurrence was assessed by the Kaplan-Meier (K-M) curve to evaluate its prognostic significance., Results: Downregulation of miR-30c-5p was observed in ACS subjects and its diagnostic value on ACS was confirmed by the ROC curve. MiR-30c-5p could also discriminate acute myocardial infarction (AMI) from unstable angina pectoris (UAP) subjects in ACS. The expression of miR-30c-5p was negatively correlated with the cardiac troponin I (cTnI) levels and the Gensini score. A lower miR-30c-5p expression was observed in ACS subjects who developed MACE (P = 0.020), and the K-M curve further confirmed the close correlation between miR-30c-5p expression and MACE occurrence in ACS. MiR-30c-5p was also identified as an independent prognostic factor for MACE in ACS., Conclusions: Serum miR-30c-5p expression was correlated with the severity of ACS, and downregulated miR-30c-5p expression showed a diagnostic and prognostic value in ACS., Competing Interests: Declarations. Ethics approval and consent to participate: The study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of The First People’s Hospital of Xiaoshan District before the study began. The informed consent has been obtained from the participants involved. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

According to the ESC guidelines, cangrelor may be considered in P2Y12-inhibitor-naïve acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). The aim of this review is to summarize available evidence on the optimal maintenance therapy with P2Y12 receptor inhibitor after cangrelor. Transitioning from cangrelor to a thienopyridine, but not ticagrelor, can be associated with a drug-drug interaction (DDI); therefore, a ticagrelor loading dose (LD) can be given any time before, during, or at the end of a cangrelor infusion, while a LD of clopidogrel or prasugrel should be administered at the time the infusion of cangrelor ends or within 30 minutes before the end of infusion in the case of a LD of prasugrel. Administration of any oral antiplatelet agent at the end of a cangrelor infusion will also result in a transient period of increased platelet reactivity. The inter-individual variability of this period is difficult to predict because it depends on many factors related to the patient and the treatment. In addition, experimental studies indicate that cangrelor may exert a cardioprotective effect beyond the blockade of platelet aggregation. Considering the available data, the potential use of cangrelor in ACS patients goes well beyond the current indications. Furthermore, we believe that it might be prudent to avoid use of thienopyridines during and soon after a cangrelor infusion until conclusive data on the effect of the DDI on the clinical outcome are available. On the other hand, ticagrelor seems to be an optimal oral agent for continuation of P2Y12 inhibition in patients receiving cangrelor infusion.

Objectives: To study the clinical and demographic characteristics of the patients with symptomatic acute coronary syndrome (ACS). To determine the outcomes in terms of single-vessel disease (SVD), double-vessel disease (DVD), and triple-vessel disease (TVD) among the patients. To determine the risk factors of TVD., Methods: A prospective observational study was conducted on 111 patients with ACS. Demographic and clinical profiles of the patients were noted. Patients with unstable angina (UA) and asymptomatic patients were excluded from the study. Outcomes were noted in terms of the involvement of the number of coronary vessels and the risk factors of TVD., Results: The mean age of the patients was 55.7 ± 13.7 years, with 75.68% males and 24.32% females. Chest pain was the most common symptom in 69 (62.16%) cases. SVD, DVD, and TVD were seen in 64 (42.30%), 17 (23.40%), and 30 (34.20%) patients, with the most common vessel involved being the left anterior descending (LAD) artery. Fatigue was predominantly found in SVD, chest pain was predominantly found in DVD, and shortness of breath was the most common symptom in TVD, with a p -value of 0.049. Univariate logistic regression showed that none of the factors among age, gender, comorbidities, and family history were significant independent risk factors for TVD., Conclusion: It can be concluded that ACS patients are predominantly elderly males with comorbidities like diabetes, hypertension, a family history of heart disease, and dyslipidemia. The LAD was the most commonly involved coronary artery in ACS. The occurrence of SVD surpassed DVD and TVD among ACS patients. None of the risk factors was significantly associated with TVD independently., (© Journal of The Association of Physicians of India 2025.)

Cardiovascular disease (CVD) is one of the leading causes of death in men and women throughout the world even after achieving advancement in the treatment and diagnosis. If considering patients in their old age, women tend to develop CVD later in life as compared to men as they are more likely to develop obesity and also diabetes. Recognizing the differences of sex in terms of acute coronary syndrome (ACS) and its management is very important for improving outcomes in women who present with ACS. This article reviews our current understanding of risk factors related to ACS and also its pathophysiology, management, and its outcomes in women., Competing Interests: Disclosure None to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Data comparing the performance of sex-specific to overall (non-sex-specific) high-sensitivity cardiac troponin (hs-cTn) cut-points for diagnosing acute coronary syndrome (ACS) are limited. This study aims to compare the safety and efficacy of sex-specific versus overall 99th percentile high-sensitivity cardiac troponin T (hs-cTnT) cut-points., Methods: We conducted a secondary analysis of the STOP-CP cohort, which prospectively enrolled emergency department patients ≥ 21 years old with symptoms suggestive of ACS without ST-elevation on initial electrocardiogram across eight U.S. sites (January 25, 2017-September 6, 2018). Participants with both 0- and 1-h hs-cTnT measures less than or equal to the 99th percentile (sex-specific 22 ng/L for males, 14 ng/L for females; overall 19 ng/L) were classified into the rule-out group. The safety outcome was adjudicated cardiac death or myocardial infarction (MI) at 30 days. Efficacy was defined as the proportion classified to the rule-out group. McNemar's test and a generalized score statistic were used to compare rule-out and 30-day cardiac death or MI rates between strategies. Net reclassification improvement (NRI) index was used to further compare performance., Results: This analysis included 1430 patients, of whom 45.8% (655/1430) were female; the mean ± SD age was 57.6 ± 12.8 years. At 30 days, cardiac death or MI occurred in 12.8% (183/1430). The rule-out rate was lower using sex-specific versus overall cut-points (70.6% [1010/1430] vs. 72.5% [1037/1430]; p = 0.003). Among rule-out patients, the 30-day cardiac death or MI rates were similar for sex-specific (2.4% [24/1010]) vs. overall (2.3% [24/1037]) strategies (p = 0.79). Among patients with cardiac death or MI, sex-specific versus overall cut-points correctly reclassified three females and incorrectly reclassified three males. The sex-specific strategy resulted in a net of 27 patients being incorrectly reclassified into the rule-in group. This led to an NRI of -2.2% (95% CI -5.1% to 0.8%)., Conclusions: Sex-specific hs-cTnT cut-points resulted in fewer patients being ruled out without an improvement in safety compared to the overall cut-point strategy., (© 2024 The Author(s). Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Background: The effects of thyroid hormone on patients hospitalized in coronary intensive care units are still controversial., Objective: We retrospectively examined thyroid hormone levels and their impact on cardiovascular morbidity in patients admitted to coronary intensive care units., Methods: A total of 208 (Female/Male; 46.6%/53.4%) patients without any history of thyroid disease were enrolled and screened. Patients with specific heart disease and existing thyroid hormone parameters were included in the study. Low triiodothyronine syndrome is characterized by reduced serum total or free T3 (fT3) concentrations in normal free T4 (fT4) and TSH levels., Results: The common diagnosis of the patients in the coronary care unit is acute coronary syndrome (n = 59, 28.2 %) and heart failure (n = 46, 23.3%). Patients were divided into two groups according to left ventricular ejection fraction percentages (LVEF ≤39% vs LVEF ≥40%). Plasma fT3 levels were significantly correlated with low LVEF (≤39%) (p =0.002). fT3 (r = -0.183, p =0.013) and hospitalization etiology (r = -0.161, p =0.023) were also the most critical parameters affecting the length of hospitalization., Conclusion: Low fT3 was associated with reduced ejection fraction and prolonged hospitalization, which may lead to potential morbidities in HF patients and may be useful in risk stratification and treatment strategies., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

The absolute value of small dense low-density lipoprotein (sd-LDL) including small LDL (s-LDL) and very small LDL (vs-LDL) has been shown to be associated with increased incidence of atherosclerosis. However, the impact of short-timeframe increases in sd-LDL on arteriosclerosis has not yet been elucidated. Therefore, we investigated the clinical roles of ex-vivo induced sd-LDL in acute coronary syndrome (ACS) using a novel method. This is a prospective, single-blind, and observational study that screened patients who underwent coronary angiography (CAG) for the treatment of ACS or investigation of heart-failure etiology between June 2020 and April 2022 (n = 247). After excluding patients with known diabetes mellitus and advanced renal disease, the patients were further divided into the ACS (n = 34) and control (non-obstructive coronary artery, n = 34) groups. The proportion of sd-LDL (s-LDL + vs-LDL) in total lipoproteins was observed before and after 2-h incubation at 37 ℃ (to approximate physiologic conditions) using 3% polyacrylamide gel electrophoresis. The coronary plaque burden was quantified upon CAG in the ACS group. There were no significant differences between the ACS and control groups in terms of clinical coronary risk factors. The baseline of large, medium, small, and very small LDL were comparable between the two groups. Following a 2-h incubation period, significant increases were observed in the ratios of s-LDL and vs-LDL in both the ACS and control groups (ACS, p = 0.01*; control, p = 0.01*). Notably, the magnitude of increase in sd-LDL was more pronounced in the ACS group compared to the control group, with s-LDL showing a significant difference (p = 0.03*) and vs-LDL showing a tread toward significance (p = 0.08). In addition, in both groups, there was a decrease in IDL and L-LDL, while M-LDL remained unchanged. The plaque burden index and rate of short-timeframe changes in both s-LDL (p = 0.01*) and vs-LDL (p = 0.04*) before and after incubation were significantly correlated in the ACS group. The enhanced production rate of sd-LDL induced under short-term physiologic culture in an ex-vivo model was greater in patients with ACS than in the control group. The increase in sd-LDL is positively correlated with coronary plaque burden. Short-timeframe changes in sd-LDL may serve as markers for the severity of coronary artery disease., Competing Interests: Declarations. Conflict of interest: The authors declare that they do not have any conflict of interest. Ethical approval: This study was approved by the Clinical Research Appropriate Promotion Center at Saitama Medical University International Medical Center (No. 19-307), and written informed consent was obtained from all participants., (© 2024. Springer Nature Japan KK, part of Springer Nature.)

Aims: Little data exists for evaluating the prevalence and patient characteristics of familial hypercholesterolemia (FH) according to the latest 2022 guidelines for FH published by the Japan Atherosclerosis Society (JAS), which revised the Achilles tendon thickness (ATT) threshold from 9.0 mm in both sexes to 8.0 mm in men and 7.5 mm in women. This study used a nationwide registry of patients with acute coronary syndrome (ACS) to evaluate the prevalence of FH according to the latest diagnostic criteria for FH and to investigate the application of Achilles tendon imaging in the diagnosis of FH.A previous prospective observational study at 59 Japanese centers involving consecutive patients with ACS who were managed between April 2015 and August 8, 2016 was conducted to explore lipid management and persistent risk in patients hospitalized for ACS (EXPLORE-J). The study population consisted of 1,944 EXPLORE-J enrollees., Results: According to the diagnostic criteria for FH in the 2022 JAS guidelines, the prevalence of probable or definite was among patients with ACS was 6.6% (127/1944). Among patients with premature ACS (male, age ＜55 years; female, age ＜65 years), the prevalence of FH was 10.1% (43/427). The mean ages were of the probable FH and definite FH groups were 59.9 and 61.0 years, respectively, while the mean age of the possible-or-unlikely FH group was 66.4 years (significantly older). Relative to the possible-or-unlikely FH group, the low-density lipoprotein cholesterol (LDL-C) levels were similar in the probable FH group and and significantly higher in the definite FH group., Conclusions: The prevalence of FH was considerably higher than previously reported, especially for patients with premature ACS. The age and LDL-C levels of the patients in the probable FH and definite FH groups were similar.

Background: Patients post-coronary artery bypass graft (CABG) can re-present with acute coronary syndrome (ACS); however, culprit lesion identification, as well as revascularization, is often challenging. Furthermore, the impact of revascularization in this patient group is relatively unknown., Objectives: The purpose of our study was to evaluate the efficacy of percutaneous coronary intervention (PCI) in patients with previous CABG surgery presenting with ACS., Methods: Using data from the Manitoba Center for Health Policy, we identified patients treated with CABG between April 1979 and March 2018, who subsequently presented with the primary diagnosis of ACS. Patients were divided into four groups: (1) managed medically and not investigated by cardiac catheterization and (2) investigated by cardiac catheterization and treated (2a) medically, (2b) with PCI, and (2c) with redo-CABG. Inverse probability treatment-weighted survival analyses were performed. Ethical approval was obtained from the local research board., Results: Nearly 20% of patients treated with CABG presented with ACS at a median of 7.2 years (age at the time of CABG: 66 years (interquartile range: 58-73 years); 75.6% male). Patients treated with PCI ( N  = 929) demonstrated improved survival compared to the patients investigated by catheterization but treated medically ( N  = 952; hazard ratio 0.87, 95% confidence interval 0.77-0.97, p  = 0.02). Patients who underwent redo CABG ( N  = 171) experienced 13% mortality within the first year, but subsequently, demonstrated a trend toward improved survival., Conclusion: ACS is not uncommon following CABG. Revascularization is associated with prognostic improvement; however, such could be accounted for by inherent group differences, including comorbidities and coronary anatomy These findings should be validated in a prospective randomized study.

Background: Kounis syndrome (KS) is defined by the association of acute coronary syndrome secondary to an anaphylactic reaction. KS is often underdiagnosed, and new etiologies have been proposed., Aims: To synthesize the available evidence on clinical profile, management, diagnosis, and etiologies in patients with KS., Methods: A search was conducted in the following databases: PubMed, Scopus, EMBASE and Web of Science from inception to March 19th, 2024. Case reports, case series, and observational studies were included. Letters to the editor, editorials, comments, notes, narrative reviews, and systematic reviews were excluded., Results: A total of 190 studies were included (174 case reports, 13 case series, and 3 observational studies, 214 patients). A predominance of male gender was observed (69.63 %). Mean age was 54.4 ± 16.5 years. The most common comorbidities were hypertension (33.64 %), diabetes (16.82 %), and dyslipidemia (16.35 %). The most frequent clinical manifestations were chest pain (66.35 %) and difficulty breathing (34.11 %). Three variants of KS were identified: type I or allergic coronary vasospasm was the most frequent (43.46 %), and type III, the least common (8.88 %). The most frequent etiology was drug use (38.32 %), primarily antibiotics (42.68 %), followed by animal stings or bites (26.17 %). The calculated KS rate was 11.12 per 1000 people. The mortality rate was 7.47 %, and the majority had a favorable outcome (86.92 %) after management., Conclusions: KS is a complex and underdiagnosed disease that should be considered as a differential diagnosis in acute coronary syndrome associated with an allergic reaction., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interests., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: The present study aimed to explore the relationship between neutrophil count on admission and major adverse cardiovascular and cerebrovascular events (MACCE) and left ventricular ejection fraction (LVEF) during hospitalization in young ACS patients, which have rarely been investigated in previous studies., Methods: This study included 400 young ACS patients (<45 years old) who underwent coronary angiography. According to the median neutrophil count at admission, the patients were divided into two groups. The relationship between neutrophil count and MACCE and LVEF during hospitalization was analyzed by regression analysis. The receiver operating characteristic (ROC) curve and the Youden index was used to determine the optimal cut-off value of neutrophil count., Results: Neutrophil count at admission was an independent risk factor of in-hospital MACCE (OR: 1.33, 95% CI: 1.13-1.56, P<0.001) and LVEF <50% (OR: 1.28, 95% CI: 1.12-1.47, P<0.001) in young ACS patients.The cutoff value of neutrophil count for predicting the occurrence of in-hospital MACCE was 6.935 × 10^ 9 /L with a sensitivity of 92.1%, specificity of 59.4%, and AUC is 0.820 (95% CI: 0.7587-0.8804, P<0.001), and for identifying the LVEF <50% was 8.660 × 10^ 9 /L with a sensitivity of 69.8%, specificity of 76.8%, and AUC is 0.775 (95% CI: 0.6997-0.8505, P<0.001)., Conclusion: The neutrophil count upon admission is an independent predictor of in-hospital MACCE and LVEF in young ACS patients, giving important information for predicting the poor prognosis of young ACS patients., Competing Interests: Declaration of competing interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

A 58-year-old hypertensive man was admitted with severe central chest pain and palpitation. His electrocardiogram (ECG) showed fast atrial fibrillation with features suggestive of left main coronary artery occlusion. He was taken to the Cath-lab but surprisingly, coronary angiogram (CAG) showed no stenosis. Meanwhile, other labs showed high D-dimer and lactate. Hence, bedside Transthoracic echocardiography (TTE) was carried out and showed dissecting flap in the ascending aorta. Immediately, a CT (Computed Tomography) was arranged and it revealed Stanford Type-A Aortic Dissection (AD). Then urgently, he was taken for surgery but unfortunately, he died after long surgical procedure. Here, the misleading factors were that his presentation and ECG changes were so typical of acute coronary syndrome (ACS) that heading us to think about coronary artery disease (CAD). Therefore, the intriguing question: is a bedside echocardiography before shifting to Cath-lab could have given the clue for early detection of AD.

Objective: Changing cardiac troponin (cTn) assays may affect a hospital's admission and myocardial infarction rates. The effect of changing from a contemporary to high-sensitivity (hs) cTnI assay has been well described, but the real-life impact on disposition and diagnosis of changing from one hs-cTnI assay to another has not., Methods: All patients who received a troponin measurement in the ED during 16 weeks were adjudicated to identify those the attending physician investigated for possible acute coronary syndrome (ACS) and for clinical outcomes. The Abbott ARCHITECT hs-cTnI assay was in use for the first 8 weeks, followed by the Beckman Coulter hs-cTnI assay for the second 8 weeks., Results: Fewer patients were investigated with the Abbott assay (2213), than the Beckman assay (2683). A larger proportion were investigated for ACS in the Abbott (64.8%) than the Beckman (60.3%) arm. Among those investigated for ACS the rate of myocardial infarction decreased on changing from Abbott (12.8%) to Beckman (8.8%). Adjusted odds of a myocardial infarction were lower for the Beckman arm, Odds Ratio 0.69 (95% CI 0.55 to 0.88). A lower proportion of Abbott than Beckman had myocardial injury (at least one ED cTnI ≥ upper reference limit) 26.4% compared with 29.8%. The proportion admitted to hospital decreased from the Abbott arm (42.5%) to the Beckman arm (36.8%)., Conclusions: A change in cTnI assay resulted in a decreased rate of myocardial infarction and admission despite an increase in rate of myocardial injury among patients investigated for ACS., (© 2025 The Author(s). Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for Emergency Medicine.)

Background: Computerized clinical decision support systems (CDSS) are increasingly being used in clinical practice to improve health care delivery. Mobile apps are a type of CDSS that are currently being increasingly used, particularly in lifestyle interventions and disease prevention. However, the use of such apps in acute patient care, diagnosis, and management has not been studied to a great extent. The Pathway for Acute Coronary Syndrome Assessment (PACSA) is a set of guidelines developed to standardize the management of suspected acute coronary syndrome across emergency departments in New South Wales, Australia. These guidelines, which risk stratify patients and provide an appropriate management plan, are currently available as PDF documents or physical paper-based PACSA documents. The routine use of these documents and their acceptability among clinicians is uncertain. Presenting the PACSA guidelines on a mobile app in a sequential format may be a more acceptable alternative to the current paper-based PACSA documents., Objective: This study aimed to assess the utility and acceptability of a clinician-developed app modeling the PACSA guidelines as an alternative to the existing paper-based PACSA documents in assessing chest pain presentations to the emergency department., Methods: An app modeling the PACSA guidelines was created using the Research Electronic Data Capture (REDCap) platform by a cardiologist, with a total development time of <3 hours. The app utilizes a sequential design, requiring participants to input patient data in a step-wise fashion to reach the final patient risk stratification. Emergency department doctors were asked to use the app and apply it to two hypothetical patient scenarios. Participants then completed a survey to assess if the PACSA app offered any advantages over the current paper-based PACSA documents., Results: Participants (n=31) ranged from junior doctors to senior physicians. Current clinician adherence to the paper-based PACSA documents was low with 55% (N=17) never using it in their daily practice. Totally, 42% of participants found the PACSA app easier to use compared to the paper-based PACSA documents and 58% reported that the PACSA app was also faster to use. The perceived usefulness of the PACSA app was similar to the perceived usefulness of the paper-based PACSA documents., Conclusions: The PACSA app offers a more efficient and user-friendly alternative to the current paper-based PACSA documents and may promote clinician adherence to evidence-based guidelines. Additional studies with a larger number of participants are required to assess the transferability of the PACSA app to everyday practice. Furthermore, apps are relatively easy to develop using existing online platforms, with the scope for clinicians to develop such apps for other evidence-based guidelines and across different specialties., (© Madhu Prita Prakash, Aravinda Thiagalingam. Originally published in JMIR Cardio (https://cardio.jmir.org).)

Background: The COVID-19 lockdown had profound effects on society and healthcare. Cardiology departments reported declines in chest pain evaluations and acute coronary syndrome (ACS) diagnoses. However, the pattern of chest pain in primary care is not clear yet. This study aims to assess the impact of the COVID-19 lockdown on the number of patients presenting with chest pain in primary care., Methods: Routine primary care data from the Extramural LUMC (Leiden University Medical Center) Academic Network (ELAN) in the Netherlands were used. Chest pain consultations from January 2017 to December 2020 were included. An interrupted time series analysis was performed to compare the incidence rate (IR) of chest pain consultations during the COVID-19 lockdown to the expected IR. Secondary outcomes were the type of consultations, referral proportions, and the IR of registered ACS diagnoses., Results: In total 9,908 chest pain consultations were included. During the COVID-19 lockdown the IR was 6.16 per 1000 person-years while the expected IR was 7.55 (95% CI 7.03-8.12). The immediate effect of the lockdown yielded an incidence rate ratio (IRR) of 0.62 (95% CI 0.50-0.77). A similar decrease was seen for ACS diagnoses (IRR 0.62, 95% CI 0.48-0.79), with no compensatory increase after the lockdown (IRR 1.04, 95% CI 0.89-1.21). Face-to-face consultations shifted to telephone consultations (p < 0.001) and hospital referrals decreased (9.9% vs. 19.0% (p < 0.001))., Conclusions: During the COVID-19 lockdown the number of chest pain consultations and registered ACS diagnoses in primary care decreased significantly. In addition, fewer patients were assessed face-to-face and fewer patients were referred to the hospital., Competing Interests: Declarations. Ethics approval and consent to participate: This study was assessed by the Medical Ethical Committee of Leiden, Den Haag and Delft (METC-LDD). In accordance with institutional guidelines and the nature of the study, which involved the analysis of pseudonymized routinely collected health data, the need for ethics approval was waived. Informed consent was also waived by this committee. Reference number: G20.170. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: Ischaemic heart disease is the single most common cause of death worldwide. Traditionally, distinguishing patients with cardiac ischaemia from patients with less alarming disease, in prehospital triage of chest pain, is challenging for both general practitioners and ambulance paramedics. Less than 20% of patients with chest pain, transferred to the emergency department (ED), have an acute coronary syndrome (ACS) and the transportation and analysis at the ED of non-ACS patients result in substantial healthcare costs and a great patient burden. Advanced risk stratification, with the help of cardiac troponin measurements, seems crucial to improve prehospital diagnostic accuracy., Methods and Analysis: The URGENT 2.0 trial is a randomised controlled trial in which the primary objective is to reduce the referral of non-cardiac chest pain (NCCP) patients, using a modified HEART score including a high-sensitivity capillary point-of-care high-sensitivity cardiac troponin I measurement. Patients are included by ambulance paramedics and 1:1 randomised for (1) regular care (control group) or (2) modified HEART score analysis (intervention group) and non-referral in case of a low modified HEART score (0-3). In total, 852 patients will be included. Follow-up will be performed at 30 days, 6 months and 12 months. Both referral rates of NCCP patients and the occurrence of major adverse cardiac events are defined as primary outcome measures., Ethics and Dissemination: The medical ethics committee Zuyderland-Zuyd Hogeschool (Netherlands) has approved this trial (reference numbers NL71820.096.19 and METCZ20190139). Written informed consent will be obtained from all participating patients. The results of this trial will be disseminated in one main paper and in additional papers with subgroup analyses., Trial Registration: ClinicalTrials.gov, NCT04904107., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: This study aimed to investigate the value of the inflammatory prognostic score (IPS) system for predicting the risk of all-cause major adverse cardiovascular events (MACEs) and cardiac-related MACEs in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI)., Methods: Overall, 1384 patients with ACS who underwent PCI between January 2016 and December 2018 were consecutively enrolled. Demographic characteristics and related laboratory results for 11 inflammatory markers were collected. Least absolute shrinkage and selection operator (LASSO)-COX regression, Kaplan- Meier, restricted cubic spline (RCS), receiver operator characteristic curve (ROC), time-dependent ROC, and Cox hazard proportional regression were applied to explore the values of individual and IPS parameters., Results: Based on the LASSO analysis, albumin (ALB) and monocyte-to-lymphocyte ratio (MLR) were included in the construction of the IPS system. A higher IPS was associated with a significantly worse long-term prognosis in the Kaplan-Meier analysis (log-rank p < 0.001). The Cox proportional hazards model demonstrated that the IPS was an independent risk factor for patients with ACS undergoing PCI. In addition, the IPS remained an independent prognosticator compared to the lowest tertiles. The time-dependent ROC showed satisfactory values for the long-term prognosis of different MACEs. Additionally, RCS showed a linear association with IPS, all-cause MACEs, and cardiac-related MACEs., Conclusions: A higher IPS level was associated with an increased risk in patients with ACS undergoing PCI, suggesting that the IPS may be a useful method for risk stratification in the assessment of the long-term prognosis of ACS., Competing Interests: Declarations. Ethical approval: This report of this case was obtained from the Institutional Review Board of The Affiliated Hospital of Chengde Medical University (Approval number: CYFYLL2015006). Written informed consent was obtained from the patients. Consent for publication: Not Applicable. Competing interests: The authors declare no competing interests. Clinical trial number: Not applicable., (© 2024. The Author(s).)

Background: The optimal timing of complete revascularization (CR) in patients with acute coronary syndrome (ACS) and multivessel disease (MVD) is still debated. The safety and efficacy of immediate and staged CR (ICR vs. SCR) in this patient group were thus compared., Methods and Results: PubMed, Embase, and CENTRAL were systematically searched to identify randomized controlled trials of CR strategies for MVD. Studies comparing cardiovascular benefits between ICR and SCR in ACS patients with MVD were included. Short- and long-term outcomes were compared using random-effect risk ratios (RRs). The analysis included seven studies with 3445 patients. The ICR and SCR groups showed comparable risks of all-cause death at 1 year (RR: 1.18; 95% CI: 0.72 to 1.95), but the risk increased at 1 month in ICR patients (RR: 2.35; 95% CI: 1.12 to 4.91). ICR reduced the risk of myocardial infarction (MI, RR: 0.54; 95% CI: 0.33 to 0.90) and target vessel revascularization (TVR, RR: 0.62; 95% CI: 0.45 to 0.85) at 1 year., Conclusion: The all-cause death rates were comparable between ICR and SCR strategies. CR at index procedure could reduce MI and TVR rates at 1 year (46% and 38%, respectively). Future studies need to obtain more precise evidence and identify the cardiovascular benefits of these two strategies., Clinical Trial Number: Not applicable., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Angiopoietin-like protein 2 (Angptl2) is a cytokine that is released to stimulate inflammation and accelerate atherogenesis. Our study sought to assess the predictive significance of serum Angptl2 in individuals diagnosed with acute coronary syndrome (ACS) and determine whether it can enhance prognostic performance beyond the GRACE risk score., Methods: We recruited a total of 1060 patients with ACS in a consecutive manner. The levels of Angptl2 in serum were analyzed at baseline. The subjects were then followed up for 12 months to monitor the occurrence of major adverse cardiovascular events (MACE)., Results: The level of serum Angptl2 showed a positive correlation with the GRACE score (r = 0.54, p < 0.001). Survival analysis revealed that increased levels of serum Angptl2 were associated with higher occurrence of the composite of MACE (log-rank p < 0.001) and its specific components (log-rank p = 0.011 for all-cause death, p = 0.007 for non-fatal myocardial infarction and p < 0.001 for revascularization respectively). Throughout the follow-up period, 163 instances (15.4%) of endpoint events were documented. In terms of MACE, both serum Angptl2 levels (HR: 1.178, 95% CI: 1.058-1.313, p = 0.003) and the GRACE risk score (HR: 1.181, 95% CI: 1.007-1.385, p = 0.041) emerged as significant predictors following Cox multivariate adjustment. Additionally, the addition of serum Angptl2 to the GRACE score improved the predictive capacity for prognosis [increase in area under the receiveroperating characteristic curve (AUC) from 0.740 to 0.794, p = 0.020; net reclassification improvement (NRI) = 0.401, p = 0.001; integrated discrimination improvement (IDI) = 0.022, p = 0.008]., Conclusion: Serum Angptl2 might be a useful prognostic biomarker and combining serum Angptl2 with the GRACE score increased the efficacy of prognosis prediction in ACS patients., Trial Registration: Not applicable., Competing Interests: Declarations. Ethics approval and consent to participate: The study was approved by the Ethics Committee of Nanjing First Hospital, Nanjing Medical University (No.2019-053) and was performed in accordance with the ethical standards outlined in the Declaration of Helsinki. All participants provided written informed consent to participate in the study. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)