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Chapter 013. Chest Discomfort (Part 7)

Unpublished data from Brigham and Women's Hospital Chest Pain Study, 1997–1999 Markers of myocardial injury are often obtained in the emergency department evaluation of acute chest discomfort. The most commonly used markers are creatine kinase (CK), CK-MB, and the cardiac troponins (I and T). Rapid bedside assays of the cardiac troponins have been developed and shown to be sufficiently accurate to predict prognosis and guide management. Some data support the use of other markers, such as serum myoglobin, C-reactive protein (CRP), placental growth factor, myeloperoxidase, and B-type natriuretic peptide (BNP); their roles are the subject of ongoing research. Single values. | Chapter 013. Chest Discomfort Part 7 Unpublished data from Brigham and Women s Hospital Chest Pain Study 1997-1999 Markers of myocardial injury are often obtained in the emergency department evaluation of acute chest discomfort. The most commonly used markers are creatine kinase CK CK-MB and the cardiac troponins I and T . Rapid bedside assays of the cardiac troponins have been developed and shown to be sufficiently accurate to predict prognosis and guide management. Some data support the use of other markers such as serum myoglobin C-reactive protein CRP placental growth factor myeloperoxidase and B-type natriuretic peptide BNP their roles are the subject of ongoing research. Single values of any of these markers do not have high sensitivity for acute myocardial infarction or for prediction of complications. Hence decisions to discharge patients home should not be made on the basis of single negative values of these tests. Provocative tests for coronary artery disease are not appropriate for patients with ongoing chest pain. In such patients rest myocardial perfusion scans can be considered a normal scan reduces the likelihood of coronary artery disease and can help avoid admission of low-risk patients to the hospital. Promising early results suggest that 64-slice CT and cardiac MRI may be of sufficient accuracy for diagnosis of coronary disease that these technologies may become widely used for patients with acute chest pain in whom the diagnosis is not clear. Clinicians frequently employ therapeutic trials with sublingual nitroglycerin or antacids or in the stable patient seen in the office setting a proton pump inhibitor. A common error is to assume that a response to any of these interventions clarifies the diagnosis. While such information is often helpful the patient s response may be due to the placebo effect. Hence myocardial ischemia should never be considered excluded solely because of a response to antacid therapy. Similarly failure of nitroglycerin to