BACKGROUND:  Evaluating high-sensitivity troponin I levels in emergency medicine is critical for diagnosing acute myocardial infarction (AMI). This study aims to evaluate the central laboratory versus bedside troponin I test in the emergency department of a tertiary care center.
METHODS:  This prospective observational study was conducted at Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India, from October to December 2023. Patient samples were analyzed in the central laboratory using the Dimension EXL 200 (Siemens® Healthcare Diagnostics Inc., Erlangen, Germany) as the gold standard test and through point-of-care testing using the TriageTrue® (Quidel Corporation, San Diego, CA) high-sensitivity troponin I kit, which was run on the Triage® MeterPro® device (Quidel Corporation, San Diego, CA). This device quantitatively determines troponin I in ethylenediaminetetraacetic acid-anticoagulated whole blood and plasma specimens. The results were compared. Statistical analysis was performed using SPSS version 18 (SPSS Inc., Chicago, IL). An unpaired t-test was performed to compare the difference in time taken using the two testing methods.
RESULTS:  The mean time for obtaining troponin I results was substantially shorter with bedside testing (14.91 minutes, standard deviation (SD) = 0.5) than with laboratory testing (119.1 minutes, SD = 5.03). Statistical analysis revealed a significant difference (t = -172.36, p < 0.001). A chi-square test was conducted to assess the disparity between the two testing methods, yielding a chi-square value of 32.64 and a p value of 0.00001, indicating a significant difference between bedside testing and laboratory testing.
CONCLUSIONS: The bedside high-sensitivity troponin I test offers a considerable advantage over laboratory testing regarding turnaround time within the emergency medicine department in India. This rapid diagnostic capability is crucial for timely management, which is beneficial for patients inconclusive of acute coronary syndrome-like non-ST segment elevation myocardial infarction (NSTEMI). It is also cost-effective. It also reduces the emergency boarding time and may reduce the number of unnecessary admissions in healthcare facilities.

There is a broad differential for new-onset cardiac dysrhythmia, and the rapid identification of the underlying cause of these cardiac emergencies can be lifesaving. Identifying wall motion abnormalities on point-of-care ultrasound (POCUS) is not a core echocardiography application for Emergency Medicine (EM) physicians. However, ruling in a regional wall motion abnormality can expedite patient-centered care and assist the busy EM physician in high-risk cases.

Non-ST-segment elevation myocardial infarction (NSTEMI) is associated with significant morbidity and mortality, occurring when the heart\'s need for oxygen cannot be met. It is defined by elevated cardiac biomarkers without ST-segment elevation and often carries a poorer prognosis than most ST-segment elevation events. NSTEMI usually results from severe coronary artery narrowing, transient occlusion, or microembolization of thrombus/atheromatous material. Patients with NSTEMI often have multiple comorbidities, which can worsen their prognosis and complicate treatment. This study aims to investigate the impact of comorbidities such as hypertension (HTN), diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), obesity, dyslipidemia, and smoking on patients with NSTEMI. The prevalence of each comorbidity is examined individually within the NSTEMI population to provide a clearer picture of how frequently these conditions co-occur with NSTEMI and how they affect the established NSTEMI treatment protocols.  This paper sheds light on the interaction between NSTEMI and commonly associated comorbidities through a comprehensive literature review and data analysis. This is critical for optimizing clinical decision-making and enhancing patient care, ultimately improving outcomes in this high-risk patient population.

Coxsackie B virus is primarily associated with fever, pharyngitis, and gastrointestinal symptoms, while myocarditis is rarely reported. We present a rare case of a 47-year-old male with a history of hypertension and obesity, who developed Coxsackie B virus-induced myositis, myocarditis, and polyarthralgia. The patient presented with worsening back pain radiating to his chest, migratory arthralgia, exertional dyspnea, and bilateral shoulder pain with arm weakness. Initial investigations revealed elevated creatinine kinase (CK) levels and troponin I, alongside a high white blood cell (WBC) count and C-reactive protein (CRP) levels. Given the patient\'s symptoms and uptrending troponin without EKG changes, there was a high concern for non-ST-elevation myocardial infarction (NSTEMI), leading to initial treatment with aspirin and IV heparin. However, further questioning revealed a recent sore throat and contact with an ill family member, prompting investigations for an infectious etiology. A viral panel confirmed Coxsackie B virus infection. The patient made a full recovery with supportive care. This case highlights the importance of considering viral causes, particularly the Coxsackie B virus, in patients presenting with muscle pain, cardiac symptoms, and joint pain. Comprehensive viral testing is crucial for early identification and appropriate management to prevent long-term complications. Understanding the mechanisms of Coxsackie B virus infection is essential for developing effective treatment strategies addressing both the viral infection and the inflammatory response.

Non-ST segment elevation myocardial infarction (NSTEMI) is an acute coronary syndrome event where myocardial ischemia is present, with an increase of cardiac troponins without an elevation of the ST segment. One of the fundamental measures used to diagnose or rule out acute coronary syndrome (ACS) is troponin levels in the blood. Troponin is a broad term used for the category of muscle contraction regulatory proteins and is commonly measured during ACS evaluation. Troponin I is only released by cardiac tissue, while some assay measurements will also pick up troponin released by skeletal muscle injury. This retrospective observational study was performed investigating troponin assays and how they relate to patient\'s outcomes. The troponin assays used in this Miami hospital where the database of patients was collected between 2018 and 2023 were troponin I (cTnI), the conventional troponin assay, and the newer high-sensitivity troponin I assay (hs-cTn). In this observational study patients who received an admitting diagnosis of NSTEMI corroborated by an independent cardiologist had their respective troponin assay levels included. Patients found to have ECG changes significant for non-ischemic pathologies, or echocardiogram findings suggestive of myocardial dysfunction not clinically correlated to an ACS were excluded from the study. A total of 75 patients were included in this study and the mean age was 75.97 ±14.72 years, with a presentation of chest pain, dyspnea and general weakness recorded in 59% (n = 45) of patients. The median time between troponin samples was 6.63 hours across both assays and hs-cTn showed a 4.99% increase in variation between samples while cTnI had a decrease of 2.53%. The study objective is to support whether there is a difference in rates of cardiac catheterization or mortality based on the type of troponin testing. There was no significant association found between, the type of troponin assay used during hospital admission, and the outcomes of catheterization and death (p > 0.009).

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital malformation. We present a case of an elderly patient with ALCAPA presenting with complete heart block and non-ST-elevation myocardial infarction years after diagnosis and surgical correction. An 81-year-old female with a history of ALCAPA presented to the emergency department with chest pain and progressive mental deterioration. She was bradycardic and hypotensive. An electrocardiogram revealed a complete heart block. Troponin was 4.04 ng/mL. She received atropine and underwent transcutaneous pacing. Left heart catheterization revealed complete occlusion of the mid-left circumflex artery, which was intervened with balloon angioplasty and chronic total occlusion of the right coronary artery. She was supported with temporary transvenous pacing, did not require further pacing support, and was discharged home. Previous records unearthed that in 1988 she had presented with syncope and was diagnosed with ALCAPA, filling from right-to-left collaterals with large and ectatic coronaries. At the time, she underwent surgical correction with excision of the left coronary from the pulmonary artery and reimplantation in the left coronary cusp along the posterior aorta. She had remained asymptomatic after her surgery until this presentation. ALCAPA is extremely rare in adults. Insufficient collaterals to the left ventricle cause inadequate blood supply, leading to ischemia in adults, predisposing them to arrhythmias and risk of sudden death. Adults with ALCAPA remain at increased risk of adverse cardiac events later in life, requiring long-term monitoring.

Coronary cameral fistulas (CCFs) are uncommon congenital or acquired anomalies characterized by abnormal connections between a coronary artery and a cardiac chamber. While often asymptomatic and incidentally detected, symptomatic presentations are rare, and symptoms may vary depending on the size and location of the fistula. We present the case of a 67-year-old female with complaints of intermittent typical cardiac chest pain and exertional dyspnea. Further evaluation revealed a CCF originating from the left anterior descending coronary artery and the left ventricle. Additionally, the patient was found to have pulmonary hypertension on right heart catheterization. This case highlights the importance of considering CCF in the differential diagnosis of chest pain, particularly in the presence of atypical symptoms and associated pulmonary hypertension (WHO Group 4). Further research is warranted to elucidate the optimal management strategies for symptomatic CCF, especially in cases complicated by pulmonary hypertension.

Patients with neurodevelopmental disorders (NDDs) encounter significant barriers to receiving quality health care, particularly for acute conditions such as non-ST segment elevation myocardial infarction (NSTEMI). This study addresses the critical gap in knowledge regarding in-hospital outcomes and the use of invasive therapies in this demographic. By analyzing data from the National Inpatient Sample database from 2011 to 2020 using the International Classification of Diseases, Ninth Edition (ICD-9) and Tenth Edition (ICD-10) codes, we identified patients with NSTEMI, both with and without NDDs, and compared baseline characteristics, in-hospital outcomes, and the application of invasive treatments. The analysis involved a weighted sample of 7,482,216 NSTEMI hospitalizations, of which 30,168 (0.40%) patients had NDDs. There were significantly higher comorbidity-adjusted odds of in-hospital mortality, cardiac arrest, endotracheal intubation, infectious complications, ventricular arrhythmias, and restraint use among the NDD cohort. Conversely, this group exhibited lower adjusted odds of undergoing left heart catheterization, percutaneous coronary intervention, or coronary artery bypass graft surgery. These findings underscore the disparities faced by patients with NDDs in accessing invasive cardiac interventions, highlighting the need for further research to address these barriers and improve care quality for this vulnerable population.

We present a case of a patient with inferior myocardial infarction (MI) and anomalous left main artery originating from the right coronary sinus. The left main artery and right coronary artery originated from the right coronary sinus but with separate ostia. The patient underwent revascularization of the right coronary artery with balloon angioplasty and a drug-eluting stent. Despite being rare, these anomalies can be life-threatening depending on the course of the artery, and when atherosclerotic disease is present, a revascularization strategy can be challenging. Knowing the existence of the left main artery anomaly is important to choose the right guide catheter to achieve successful cannulation and decrease the risk of complications, radiation exposure, and contrast usage.

UNASSIGNED: Cardiovascular disease (CVD) is the leading cause of mortality in kidney transplant (KT) patients. The perceived risk of contrast-induced nephropathy (CIN) may create a reluctance to perform coronary angiography in patients presenting with non-ST segment elevation myocardial infarction (NSTEMI).
UNASSIGNED: National Inpatient Sample (NIS) Database was used to sample individuals presenting with NSTEMI. Patients were stratified into KT and Non-KT cohorts. Outcomes included left heart catheterization rates, mortality, arrhythmias, acute kidney injury/acute renal failure (AKI/ARF), and extended length of hospital stay (ELOS) (>72 h). Propensity matching (1:1 ratio) and regression analyses were performed.
UNASSIGNED: Out of 336,354 patients with NSTEMI, 742 patients were in the KT group. KT patients were less likely to have LHC relative to non-KT patients (22.0 % vs 18.3 %); a difference that persisted on post-match analysis (27.1 % vs 19.4 %). On pre-match analysis, KT transplant patients that underwent LHC had lower mortality (10.3 % vs 0.7 %), AKI/ARF (44.6 % vs 27.9 %), arrhythmias (30.4 % vs 20.6 %) and lower ELOS (58.6 % vs 41.9 %). Post-match, KT cohort patient that underwent LHC had lower arrhythmias (OR:0.60[0.38-0.96]), AKI/ARF (OR = 0.51[0.34-0.77]), ELOS (OR:0.49[0.34-0.73]).
UNASSIGNED: KT patients underwent LHC much less frequently than their non-KT counterparts for NSTEMI. Coronary angiography and subsequent revascularization were associated with a significant decrease in morbidity and mortality. This theorized risk of CIN should not outweigh the benefit of LHC in KT patients.