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In a randomized trial, patients with chest pain underwent a standard diagnostic evaluation with or without coronary CT angiography (CTA). The group assigned to CTA had a lower rate of death from coronary heart disease or nonfatal myocardial infarction at 5 years.

Background Studies have shown disparate results on the consequences of morphine use in ST-segment elevation myocardial infarction (STEMI). No study has evaluated alternative treatments that could be at least non-inferior to morphine without its potentially damaging consequences for myocardial function and platelet reactivity. The aim of this study was to evaluate whether nitrous oxide/oxygen plus intravenous acetaminophen (NOO-A) is non-inferior to morphine to control chest pain in STEMI patients. Methods This multicenter, open-label, cluster-randomized, controlled, non-inferiority study compared NOO-A with morphine in 684 prehospital patients with ongoing suspected STEMI of < 12 h duration and a pain rating score ≥ 4. The primary endpoint was the proportion of patients achieving pain relief (numeric rating score ≤ 3) after 30 min. Secondary safety endpoints included serious adverse events and death at 30 days. Results The median baseline pain score was 7.0 in both groups. The primary endpoint occurred in 51.7% of the NOO-A group and 73.6% of the morphine group (absolute risk difference − 21.7%; 95% confidence interval − 29.6 to − 13.8). At 30 days, the rate of serious adverse events was 16.0 and 18.8% in the NOO-A and morphine groups respectively (p = NS). The rate of death was 1.8% (NOO-A group) and 3.8% (morphine group) (p = NS). Conclusion Analgesia provided by NOO-A was inferior to morphine at 30 min in patients with acute STEMI in the prehospital setting. Rates of serious adverse events did not differ between groups. Trial registration ClinicalTrials.gov: NCT02198378 .

The Scottish Computed Tomography of the Heart (SCOT-HEART) trial demonstrated that management guided by coronary CT angiography (CCTA) improved the diagnosis, management, and outcome of patients with stable chest pain. We aimed to assess whether CCTA-guided care results in sustained long-term improvements in management and outcomes. SCOT-HEART was an open-label, multicentre, parallel group trial for which patients were recruited from 12 outpatient cardiology chest pain clinics across Scotland. Eligible patients were aged 18–75 years with symptoms of suspected stable angina due to coronary heart disease. Patients were randomly assigned (1:1) to standard of care plus CCTA or standard of care alone. In this prespecified 10-year analysis, prescribing data, coronary procedural interventions, and clinical outcomes were obtained through record linkage from national registries. The primary outcome was coronary heart disease death or non-fatal myocardial infarction on an intention-to-treat basis. This trial is registered at ClinicalTrials.gov (NCT01149590) and is complete. Between Nov 18, 2010, and Sept 24, 2014, 4146 patients were recruited (mean age 57 years [SD 10], 2325 [56·1%] male, 1821 [43·9%] female), with 2073 randomly assigned to standard care and CCTA and 2073 to standard care alone. After a median of 10·0 years (IQR 9·3–11·0), coronary heart disease death or non-fatal myocardial infarction was less frequent in the CCTA group compared with the standard care group (137 [6·6%] vs 171 [8·2%]; hazard ratio [HR] 0·79 [95% CI 0·63–0·99], p=0·044). Rates of all-cause, cardiovascular, and coronary heart disease death, and non-fatal stroke, were similar between the groups (p>0·05 for all), but non-fatal myocardial infarctions (90 [4·3%] vs 124 [6·0%]; HR 0·72 [0·55–0·94], p=0·017) and major adverse cardiovascular events (172 [8·3%] vs 214 [10·3%]; HR 0·80 [0·65–0·97], p=0·026) were less frequent in the CCTA group. Rates of coronary revascularisation procedures were similar (315 [15·2%] vs 318 [15·3%]; HR 1·00 [0·86–1·17], p=0·99) but preventive therapy prescribing remained more frequent in the CCTA group (831 [55·9%] of 1486 vs 728 [49·0%] of 1485 patients with available data; odds ratio 1·17 [95% CI 1·01–1·36], p=0·034). After 10 years, CCTA-guided management of patients with stable chest pain was associated with a sustained reduction in coronary heart disease death or non-fatal myocardial infarction. Identification of coronary atherosclerosis by CCTA improves long-term cardiovascular disease prevention in patients with stable chest pain. The Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Edinburgh and Lothian's Health Foundation Trust, British Heart Foundation, and Heart Diseases Research Fund.

Objective: Despite the availability of studies, there is a lack of available literature on the treatment of psychological and gastrointestinal causes of noncardiac chest pain (NCCP). Physiotherapeutic techniques involving diaphragmatic breathing, Jacobson’s relaxation and dynamic neuromuscular stabilization (DNS) could address these causes through the activation of parasympathetic system. Hence, this study aims to evaluate the combined effect of diaphragmatic breathing, Jacobson’s relaxation and DNS along with pharmacological therapy on patients with gastrointestinal and psychological causes of NCCP. Design: Randomized controlled trial. Setting: Cardiology OPD of a tertiary care hospital. Subjects: Eighty‐eight subjects with NCCP. Methods: The intervention group received diaphragmatic breathing, Jacobson’s relaxation technique, DNS and pharmacological treatment for 4 weeks. The control group was given pharmacological treatment with patient education. The Beck Depression Inventory (BDI) score, Hamilton Depression Rating Scale (HDRS) score, gastroesophageal reflux disease (GERD) questionnaire score and Numerical Pain Rating Scale (NPRS) score were measured at baseline and after 4 weeks of intervention. Results: The baseline characteristics and outcome measures were assessed, and no significant differences were noted in their mean values ( p > 0.05). After 4 weeks of intervention, a statistically significant difference was observed in BDI, HDRS, GERD questionnaire score and NPRS in both the groups ( p < 0.001). However, the GERD questionnaire and NPRS showed statistically significant decrease in the intervention group (GERD questionnaire: 28.39 ± 9.74 and NPRS: 4.57 ± 0.91) compared with the control group (GERD questionnaire: 35.54 ± 12.23 and NPRS: 4.95 ± 0.96) with p < 0.05. Conclusion: The diaphragmatic breathing exercises, Jacobson’s relaxation technique and DNS are beneficial for reducing GERD symptoms and pain in patients with NCCP. These techniques are safe and cost‐effective treatment for addressing the psychological and gastrointestinal causes of NCCP. These can be incorporated along with the pharmacological treatment to enhance the outcomes. However, future researches with long‐term follow‐ups are required. Trial Registration: Clinical Trials Registry ‐ India: CTRI/2025/02/081294

Background Approximately half of patients who seek care at Emergency Departments due to chest pain are diagnosed with Non-Cardiac Chest Pain (NCCP). Concerns for heart disease and misinterpretation of the symptoms increase cardiac anxiety and have a negative impact on patients' lives. Psychological interventions such as internet-delivered cognitive behavioral therapy (iCBT) are effective in treating psychological conditions such as anxiety, by helping patients to learn how to manage chest pain. Aims To evaluate the effects of a nurse-led iCBT program on cardiac anxiety and secondary outcomes, as bodily sensations, depressive symptoms, health-related quality of life and chest pain frequency in patients with NCCP at 6- and 12-month follow-up, and to explore predictors that can have impact on the effects of the iCBT program on psychological distress. Methods A longitudinal study of a Randomized Controlled Trial (RCT) evaluating the long-term effects of an iCBT program ( n  = 54) in patients with NCCP, compared to psychoeducation ( n  = 55). The primary outcome, cardiac anxiety was measured using the Cardiac Anxiety Questionnaire (CAQ), and the secondary outcomes were measured with The Body Sensations Questionnaire (BSQ), Patient Health Questionnaire-9 (PHQ-9), The EuroQol Visual Analog Scale (EQ-VAS) and a self-developed question to measure chest pain frequency. All measurements were performed before and after the intervention, and 3, 6 and 12 months after the intervention. Linear mixed model was used to test between-group differences in primary and secondary outcomes and multiple regression analysis was used to explore factors that may have an impact on the treatment effect of iCBT on cardiac anxiety. Results A total of 85% ( n  = 93/109) participants completed the 12-month follow-up. Mixed model analysis showed no statistically significant interaction effect of time and group between the iCBT and psychoeducation groups regarding cardiac anxiety over the 12-month follow-up. However, there was a statistically significant interaction effect of time and group ( p  = .009) regarding chest pain frequency favouring the iCBT group. In addition, we found a group effect in health-related quality of life ( p  = .03) favouring the iCBT group. The regression analysis showed that higher avoidance scores at baseline were associated with improvement in cardiac anxiety at 12-month follow-up. Conclusions Cardiac anxiety was reduced in patients with NCCP, but iCBT was not more effective than psychoeducation. Patients with a high tendency to avoid activities or situations that they believe could trigger cardiac symptoms may benefit more from psychological interventions targeting cardiac anxiety. Trial Registration The trial was registered at ClinicalTrials.gov NCT03336112 on 08/11/2017.

The ESCAPE (effectiveness and safety of chest pain assessment to prevent emergency admissions) randomised controlled trial of chest pain observation unit versus routine care 3 required prospective identification of all patients attending with acute chest pain; it thus provided an ideal opportunity for a descriptive study of the health care burden created by this problem. The chest pain nurses categorised each patient to: (1) ECG evidence of ACS (interpreted by the chest pain nurse): > 1 mm ST elevation or depression, or > 3 mm T wave inversion, in two or more consecutive leads; left bundle branch block; tachyarrhythmia (> 120 beats per minute); second or third degree heart block; (2) clinical diagnosis of probable ACS: prolonged (over one hour) or recurrent episodes of anginal type pain in a patient with known coronary heart disease (CHD) or a patient unable to undergo treadmill testing to rule out CHD; (3) suspected or proven non-ACS, life threatening pathology, such as pulmonary embolus, aortic dissection or pneumonia; (4) negligible risk of ACS or other life threatening pathology, such as pain only on chest wall movement, or age under 25 years; (5) undifferentiated chest pain: any patient not falling within the above categories The categories were applied sequentially, so patients were categorised according to the first definition that applied to them.

Noncardiac chest pain has a high prevalence and is associated with reduced quality of life, anxiety, avoidance of physical activity, and high societal costs. There is a lack of an effective, low-cost, easy to distribute intervention to assist patients with noncardiac chest pain. In this study, we aimed to investigate the effectiveness of internet-based cognitive behavioral therapy with telephone support for noncardiac chest pain. We conducted a randomized controlled trial, with a 12-month follow-up period, to compare internet-based cognitive behavioral therapy to a control condition (treatment as usual). A total of 162 participants aged 18 to 70 years with a diagnosis of noncardiac chest pain were randomized to either internet-based cognitive behavioral therapy (n=81) or treatment as usual (n=81). The participants in the experimental condition received 6 weekly sessions of internet-based cognitive behavioral therapy. The sessions covered different topics related to coping with noncardiac chest pain (education about the heart, physical activity, interpretations/attention, physical reactions to stress, optional panic treatment, and maintaining change). Between sessions, the participants also engaged in individually tailored physical exercises with increasing intensity. In addition to internet-based cognitive behavioral therapy sessions, participants received a brief weekly call from a clinician to provide support, encourage adherence, and provide access to the next session. Participants in the treatment-as-usual group received standard care for their noncardiac chest pain without any restrictions. Primary outcomes were cardiac anxiety, measured with the Cardiac Anxiety Questionnaire, and fear of bodily sensations, measured with the Body Sensations Questionnaire. Secondary outcomes were depression, measured using the Patient Health Questionnaire; health-related quality of life, measured using the EuroQol visual analog scale; and level of physical activity, assessed with self-report question. Additionally, a subgroup analysis of participants with depressive symptoms at baseline (PHQ-9 score ≥5) was conducted. Assessments were conducted at baseline, posttreatment, and at 3- and 12-month follow-ups. Linear mixed models were used to evaluate treatment effects. Cohen d was used to calculate effect sizes. In the main intention-to-treat analysis at the 12-month follow-up time point, participants in the internet-based cognitive behavioral therapy group had significant improvements in cardiac anxiety (-3.4 points, 95% CI -5.7 to -1.1; P=.004, d=0.38) and a nonsignificant improvement in fear of bodily sensations (-2.7 points, 95% CI -5.6 to 0.3; P=.07) compared with the treatment-as-usual group. Health-related quality of life at the 12-month follow-up improved with statistical and clinical significance in the internet-based cognitive behavioral therapy group (8.8 points, 95% CI 2.8 to 14.8; P=.004, d=0.48) compared with the treatment-as-usual group. Physical activity had significantly (P<.001) increased during the 6-week intervention period for the internet-based cognitive behavioral therapy group. Depression significantly improved posttreatment (P=.003) and at the 3-month follow-up (P=.03), but not at the 12-month follow-up (P=.35). Participants with depressive symptoms at baseline seemed to have increased effect of the intervention on cardiac anxiety (d=0.55) and health-related quality of life (d=0.71) at the 12-month follow-up. In the internet-based cognitive behavioral therapy group, 84% of the participants (68/81) completed at least 5 of the 6 sessions. This study provides evidence that internet-based cognitive behavioral therapy with minimal therapist contact and a focus on physical activity is effective in reducing cardiac anxiety and increasing health related quality of life in patients with noncardiac chest pain. ClinicalTrials.gov NCT03096925; http://clinicaltrials.gov/ct2/show/NCT03096925.

Patients with recurrent episodes of noncardiac chest pain (NCCP) experience cardiac anxiety as they misinterpret the pain to be cardiac related and avoid physical activity that they think could threaten their lives. Psychological interventions, such as internet-delivered cognitive behavioral therapy (iCBT), targeting anxiety can be a feasible solution by supporting patients to learn how to perceive and handle their chest pain. This study aims to evaluate the effects of a nurse-led iCBT program on cardiac anxiety and other patient-reported outcomes in patients with NCCP. Patients with at least two health care consultations because of NCCP during the past 6 months, and who were experiencing cardiac anxiety (Cardiac Anxiety Questionnaire score ≥24), were randomized into 5 weeks of iCBT (n=54) or psychoeducation (n=55). Patients were aged 54 (SD 17) years versus 57 (SD 16) years and were mainly women (32/54, 59% vs 35/55, 64%). The iCBT program comprised psychoeducation, mindfulness, and exposure to physical activity, with weekly homework assignments. The primary outcome was cardiac anxiety. The secondary outcomes were fear of bodily sensations, depressive symptoms, health-related quality of life, and chest pain frequency. Intention-to-treat analysis was applied, and the patients were followed up for 3 months. Mixed model analysis was used to determine between-group differences in primary and secondary outcomes. No significant differences were found between the iCBT and psychoeducation groups regarding cardiac anxiety or any of the secondary outcomes in terms of the interaction effect of time and group over the 3-month follow-up. iCBT demonstrated a small effect size on cardiac anxiety (Cohen d=0.31). In the iCBT group, 36% (16/44) of patients reported a positive reliable change score (≥11 points on the Cardiac Anxiety Questionnaire), and thus an improvement in cardiac anxiety, compared with 27% of (13/48) patients in the psychoeducation group. Within-group analysis showed further significant improvement in cardiac anxiety (P=.04) at the 3-month follow-up compared with the 5-week follow-up in the iCBT group but not in the psychoeducation group. iCBT was not superior to psychoeducation in decreasing cardiac anxiety in patients with NCCP. However, iCBT tends to have better long-term effects on psychological distress, including cardiac anxiety, health-related quality of life, and NCCP frequency than psychoeducation. The effects need to be followed up to draw more reliable conclusions. ClinicalTrials.gov NCT03336112; https://www.clinicaltrials.gov/ct2/show/NCT03336112.

Chest pain, a sudden and perilous symptom, is frequently encountered in the emergency department. Prompt and efficient first-aid measures and nursing interventions are crucial for effectively rescuing emergency patients experiencing chest pain. This study aims to investigate the impact of an enhanced emergency nursing process on the rescue outcomes of emergency patients with chest pain. A randomized controlled study was conducted. The research was conducted at Suzhou Hospital of Integrated Traditional Chinese and Western Medicine. A total of 90 emergency chest pain patients admitted between December 2021 and June 2022 were selected and divided into two groups, with 45 cases in each group. The control group received routine emergency nursing, while the observation group underwent an improved emergency nursing protocol. (1) Treatment initiation time, emergency rescue time, recovery time of vital signs, and hospital stay; (2) curative effect; (3) pain scores; (4) incidence of adverse events; and (5) patient satisfaction. Compared to the control group, the observation group exhibited shorter treatment initiation time, emergency rescue time, recovery time of vital signs, and hospital stay (P < .05). The effective rate in the observation group was higher (P < .05), and pain scores were lower at 30 min, 60 min, 120 min, and 240 min post-rescue (P < .05). The occurrence of adverse events was reduced in the observation group (P = .005), and patient satisfaction was higher at discharge (P < .05). The enhanced emergency nursing process effectively reduces the clinical rescue time for emergency patients with chest pain, enhances rescue efficiency, seizes crucial opportunities for saving lives, and improves patient satisfaction. These findings have significant positive implications for clinical applications.