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Background/introduction Type 4a myocardial infarction (MI) occurs when myocardial injury is combined with either symptoms suggestive of myocardial ischaemia, new left bundle branch block, angiographic loss of patency of a major artery or imaging suggestive of new loss of myocardium. Myocardial injury is defined as a rise of >5 x 99th upper reference limit (URL) of 14 ng/l (i.e. >70 ng/l) for highly sensitive troponin T (hsTnT) at 6 h if hsTnT was normal at baseline or >20% rise from 0 to 6 h if hsTnT was >14 ng/l at baseline. Aim To assess the prognostic value of biomarkers of myocardial injury following elective percutaneous coronary intervention (PCI). Design A cohort of 209 patients were included of whom 144 (68.9%) were male, mean age was 68.8 years, 28 (13.4%) were smokers, 31 (14.8%) were diabetic, 199 (95.2%) had hypercholesterolaemia and 138 (66.0%) had hypertension. Methods We evaluated hsTnT, heart-type fatty acid-binding protein (H-FABP), troponin I (TnI), creatine kinase MB type (CKMB), myoglobin, glycogen phosphorylase BB (GPBB) and carbonic anhydrase III (CA III) at 0, 4, 6 and 24 h following elective PCI. Patients were followed up at 1 year to assess for major adverse clinical events (MACE). Results Myocardial injury was observed in 37 (17.7%) patients. Median hsTnT/H-FABP at 4 h were most predictive. MACE was noted in 6 (2.9%) patients, 3 had type 4a MI post PCI, P = 0.036. Discussion/conclusions Median 4 h hsTnT/H-FABP were most predictive of myocardial injury following PCI. H-FABP and hsTnT were predictive of MACE.

We prospectively evaluated a rapid-access chest pain clinic in terms of clinical diagnoses, outcomes, morbidity and mortality at 3 months follow-up in patients, and cost-effectiveness. All patients seen at the clinic from February 1999 to December 2000 were assessed. Referring doctors indicated the management they would have provided had the clinic been unavailable, to allow a cost-effectiveness analysis. Overall, 709 patients were referred, 471 (66%) from General Practitioners, 212 (30%) from Accident and Emergency doctors and 26 (4%) from other sources. All had recent onset, or increasing frequency of ischaemic-type chest pain (excluding those with suspected myocardial infarction or rest chest pain angina). Fifty-one (7%) had acute coronary syndromes, 119 (17%) had stable ischaemic heart disease, 144 (20%) had possible ischaemic heart disease, and 395 (56%) were considered to have non-ischaemic symptoms. Some 70% of patients were seen within 24 h. Only 57 patients (8%) were admitted. Had the clinic been unavailable, 160 patients would have been admitted. Out-patient cardiology appointments were arranged for 116 patients (16%), and 429 patients (60%) were discharged directly. Follow-up data at 3 months were obtained from 565/567 eligible patients (99.6%). No major cardiac events (death/myocardial infarction) occurred in those with non-ischaemic chest pain. There were five deaths (including one due to cancer) and three patients had a myocardial infarction (event rate 1%). There were eleven readmissions for angina: six were in patients with acute coronary syndromes, and four of these six were awaiting revascularization. The estimated net saving was pound 58/patient. A rapid-access chest pain clinic offers a prompt, safe and cost-effective service in a challenging group of patients.