Abstract

Undifferentiated chest pain is one of the most common reasons for emergency department attendance and admission to hospitals. Non-ST elevation acute coronary syndrome (NSTE-ACS) is an important cause of chest pain, and accurate diagnosis and risk stratification in the emergency department must be a clinical priority. In the future, the incidence of NSTE-ACS will rise further as higher sensitivity troponin assays are implemented in clinical practice. In this article, we review contemporary approaches for the diagnosis and risk stratification of NSTE-ACS during emergency care. We consider the limitations of current practices and potential improvements. Clinical guidelines recommend an early invasive strategy in higher risk NSTE-ACS. The Global Registry of Acute Coronary Events (GRACE) risk score is a validated risk stratification tool which has incremental prognostic value for risk stratification compared with clinical assessment or troponin testing alone. In emergency medicine, there has been a limited adoption of the GRACE score in some countries (e.g. United Kingdom), in part related to a delay in obtaining timely blood biochemistry results. Age makes an exponential contribution to the GRACE score, and on an individual patient basis, the risk of younger patients with a flow-limiting culprit coronary artery lesion may be underestimated. The future incorporation of novel cardiac biomarkers into this diagnostic pathway may allow for earlier treatment stratification. The cost-effectiveness of the new diagnostic pathways based on high-sensitivity troponin and copeptin must also be established. Finally, diagnostic tests and risk scores may optimize patient care but they cannot replace patient-focused good clinical judgment.

Abstract

To evaluate the relationship between mean apparent diffusion coefficient (ADC) and post-surgical Gleason scores. To determine the diagnostic accuracy of multiparametric magnetic resonance imaging (mp-MRI) on a 1.5 T magnet in distinguishing low, intermediate and high-grade prostate tumors. This is a retrospective institutional-review-board-approved, single-center study including 30 patients (median age, 60 years) who underwent mp-MRI before prostatectomy for prostate cancer. Using histological reports for guidance, the tumors were localized in ADC maps, and mean ADCs were measured and examined for correlation with Gleason scores. 2 patients had 2 measurable foci, so a total of 32 tumors were studied. The diagnostic accuracy of the mean ADC was assessed by using the area under the receiver operating characteristic curve (ROC). In the differentiation of tumors with a Gleason score of 6 from those with a Gleason score of at least 7, mean ADC yielded an AUC of 0.76 (95% confidence interval: 0.59, 0.93). In the differentiation of tumors with Gleason scores of 6 or 7 from those with a Gleason score of at least 8, mean ADC yielded an AUC of 0.94 (95% confidence interval: 0.86, 1.00). Mean ADC values may allow a correct assessment of the patient risk using a 1.5 T magnet without ERC.