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Study objectives: To test the short- and long-term performance of a simple algorithm to detect or rule out acute coronary artery disease (CAD) in patients referred with acute chest pain (CP). Design: Prospective, multicenter study with 30-day and 1-year follow-ups. Setting: Emergency and coronary care units of two university hospitals and four affiliated teaching hospitals in a suburban region of northern Switzerland. Patients: One hundred sixty-one consecutive patients referred with acute CP with a high CAD risk profile underwent exercise testing (ET) within 24 h if results of two troponin tests and ECG remained normal within 6 h. The patients were discharged if ET results were negative or underwent angiography if the results were positive. Measurements and results: The primary end point was survival free of death, myocardial infarction (MI), and acute coronary syndrome, as well as the correct diagnosis of CAD in need of revascularization. Failure of the algorithm included events not predicted and false-positive ET results. Symptom-limited ET was performed in 142 patients, and stress imaging was performed in 17 patients. Discharge within 24 h was possible in 76%. Angiography in 21 patients showed no CAD in 4 patients, whereas revascularization was necessary in 17 patients. During follow-up, three patients had an MI (one fatal) and two patients had unstable angina, for an event rate of 3.1%/yr. Overall sensitivity of the algorithm to detect CAD was 71%, whereby six of seven false-positive ET results were due to exercise-induced CP without ECG changes. More importantly, the negative predictive value was 96.4%, indicating that this simple algorithm failed to identify only 3.6% of patients at risk for future events. Conclusions: Discharge within 24 h after onset of acute CP in high-risk CAD patients is safe, irrespective of CAD history, if ECG findings remain unchanged and troponin test results are normal within 6 h, and if results of adequate ET are negative. [ABSTRACT FROM AUTHOR]

Study objectives: To define the prognostic value of stress testing (STRT) in patients ≥75 years of age. Design: Multicenter prospective randomized trial. Setting: Tertiary care centers. Patients: Two hundred ninety-two patients of the Trial of Invasive vs Medical Treatment of Elderly Patients aged ≥75 years with chronic angina despite receiving two or more antianginal drugs were prospectively observed for 1 year. Intervention: STRT (88% exercise ECG; 12% pharmacologic stress imaging) was performed if possible, and ischemia was diagnosed using current guidelines. Death for any reason and nonfatal myocardial infarction were outcome events. Results: Patients who could perform STRT (148 patients) were younger, had a lower risk profile, received less medication, and had less severe angina than patients who could not perform STRT (144 patients). The 1-year mortality rate was only 1.4% in patients with negative STRT results (72 patients) compared to 5.3% in patients with positive STRT results (76 patients) and 13.7% in patients who had not undergone STRT due to unstable symptoms (95 patients). The corresponding 1-year rates of death/infarction were 2.8%, 15.8%, and 26.3%, respectively. After adjustment for baseline differences, mortality rates were no longer significantly different. However, compared to patients with negative STRT results, infarction and death/infarction rates remained higher in patients with provocable ischemia (hazard ratio [HR], 8.9 [p = 0.04]; HR, 6.1 [p = 0.02], respectively) and in patients without STRT due to unstable angina (HR, 11.8 [p = 0.02]; HR, 8.6 [p = .004], respectively). Conclusions: STRT in elderly patients is feasible and provides important prognostic information for their future management. Patients with negative STRT results after receiving therapy have a good prognosis, and their conditions may be managed conservatively. [ABSTRACT FROM AUTHOR]

Presents a case of an 85-year-old man with a lung mass. Case history; Chest radiographic finding; Medical history; Vital signs; Laboratory tests; Medications; Pulmonary tissue reaction to lipid material; Common cause of exogenous lipoid pneumonia.