Background: The non-ST elevation myocardial infarction (NSTEMI) guidelines of the European Society of Cardiology (ESC) recommend a 3h cardiac troponin determination in patients triaged to the observe-zone of the ESC 0/1h-algorithm; however, no specific cut-off for further triage is endorsed. Recently, a specific cut-off for 0/3h high-sensitivity cardiac troponin T (hs-cTnT) change (7ng/L) was proposed warranting external validation. Methods: Patients presenting with acute chest discomfort to the emergency department were prospectively enrolled into an international multicenter diagnostic study. Final diagnoses were centrally adjudicated by two independent cardiologists applying the 4th universal definition of MI, based on complete cardiac work-up, cardiac imaging and serial hs-cTnT. Hs-cTnT concentrations were measured at presentation, after 1h and 3h. The objective was to externally validate the proposed cut-off, and if necessary, derive and internally as well as externally validate novel 0/3h-criteria for the observe-zone of the ESC 0/1h-hs-cTnT-algorithm in an independent multicenter cohort. Results: Among 2076 eligible patients, application of the ESC 0/1h-hs-cTnT-algorithm triaged 1512 patients (72.8%) to either rule-out or rule-in of NSTEMI, remaining 564 patients (27.2%) in the observe-zone (adjudicated NSTEMI prevalence 120/564 patients, 21.3%). The suggested 0/3h-hs-cTnT-change of <7ng/L triaged 517 patients (91.7%) towards rule-out, resulting in a sensitivity of 33.3% (95%CI 25.5-42.2), missing 80 patients with NSTEMI, and ≥7ng/L triaged 47 patients towards rule-in (8.3%), resulting in a specificity of 98.4% (95%CI 96.8-99.2). Novel derived 0/3h-criteria for the observe-zone patients ruled-out NSTEMI with a 3h hs-cTnT concentration <15 ng/L and a 0/3h-hs-cTnT absolute change <4 ng/L, triaging 138 patients (25%) towards rule-out, resulting in a sensitivity of 99.2% (95%CI 96.0-99.9), missing 1 patient with NSTEMI. A 0/3h-hs-cTnT absolute change ≥6 ng/L triaged 63 patients (11.2%) towards rule-in, resulting in a specificity of 98% (95%CI 96.2-98.9) Thereby, the novel 0/3h-criteria reduced the number of patients in the observe zone by 36%, and the number of T1MI by 50%. Findings were confirmed in both internal and external validation. Conclusions: A combination of a 3h hs-cTnT concentration (<15 ng/L) and a 0/3h absolute change (<4 ng/L) is necessary to safely rule-out NSTEMI in patients remaining in the observe-zone of the ESC 0/1h-hs-cTnT-algorithm. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT00470587

We report a case of electrocardiographic signature of the Brugada syndrome in a 39-year-old patient with an overdose of diphenhydramine. He was found unconscious and hypotensive. His serum potassium concentration was 8.3 mEq/L and the ECG revealed a coved-type ST-segment elevation in leads V2-V3. These repolarization abnormalities neither normalize with the correction of the hyperkalemia nor with an intravenous infusion of isoproterenol. When he regained consciousness, he was admitted the toxic ingestion of diphenhydramine and progressively the ECG normalized. A negative flecainide test confirmed that the transient ECG abnormalities were the consequence of the drug overdose and ruled out the Brugada syndrome.

Aims Little is known about the epidemiology, clinical presentation, management, and outcome of acute pericarditis and myopericarditis. Methods and results The final diagnoses of acute pericarditis, myopericarditis, and non-ST-segment elevation myocardial infarction (NSTEMI) of patients presenting to seven emergency departments in Switzerland with acute chest pain were centrally adjudicated by two independent cardiologists using all information including serial measurements of high-sensitivity cardiac troponin T. The overall incidence of pericarditis and myopericarditis was estimated relative to the established incidence of NSTEMI. Current management and long-term outcome of both conditions were also assessed. Among 2533 chest pain patients, the incidence of pericarditis, myopericarditis, and NSTEMI were 1.9% (n = 48), 1.1% (n = 29), and 21.6% (n = 548), respectively. Accordingly, the estimated incidence of pericarditis and myopericarditis in Switzerland was 10.1 [95% confidence interval (95% CI) 9.3–10.9] and 6.1 (95% CI 5.6–6.7) cases per 100 000 population per year, respectively, vs. 115.0 (95% CI 112.3–117.6) cases per 100 000 population per year for NSTEMI. Pericarditis (85% male, median age 46 years) and myopericarditis (62% male, median age 56 years) had male predominance, and commonly (50% and 97%, respectively) resulted in hospitalization. No patient with pericarditis or myopericarditis died or had life-threatening arrhythmias within 30 days [incidence 0% (95% CI 0.0–4.8%)]. Compared with NSTEMI, the 2-year all-cause mortality adjusted hazard ratio of pericarditis and myopericarditis was 0.40 (95% CI 0.05–2.96), being 0.59 (95% CI 0.40–0.88) for non-cardiac causes of chest pain. Conclusion Pericarditis and myopericarditis are substantially less common than NSTEMI and have an excellent short- and long-term outcome. Clinical trial registration ClinicalTrial.gov, number NCT00470587, https://clinicaltrials.gov/ct2/show/NCT00470587.

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Josep Font 2019 Grant from Hospital Clinic de Barcelona Background Differences between female (F) and male (M) with coronary disease (CD) are related to time delays in detriment of women such as: hospital presentation, recognition of symptoms or an appropriate treatment. Further research based on sex and gender (S&G) is at important to confront the interplay of factors that shape health inequities. Purpose To do an analysis based on S&G of the admissions in the chest pain unit (CPU) of an emergency department (ED), comparing clinical features and also the physician’s initial diagnostic orientation after the first evaluation of the patients (FEoP) . Methods This is an observational descriptive unicentric study of consecutive cases. We retrospectively analysed all the cases admitted in a CPU from 2008-2019 and recorded the cardiovascular risk factors (cvrf), and the clinical and electrocardiographic (ECG) features. We also recorded the final diagnostic after all the management in the CPU and the FEoP [based on the clinical history, physical examination and ECG; before other complementary examinations like troponins (Tnc)]. The characteristics were compared according to sex (F or M). Results 41828 patients were included (42% F), with an older median age in F [Md (RIC) [65 (47-78) vs 59 (43-73)] y.o.; p &lt; 0,001]. We found a significant greater number of late presenters (≥12hours from symptoms onset) in F (41%vs37%;p &lt; 0,001). F were associated to greater rates of obesity, hypertension and previous heart failure; M had greater rates of diabetes mellitus, previous known coronary disease and smoke or cocaine use. When we considered the patients with typical chest pain (TCP), no significant differences based on S&G were found. Women’s ECG were more often interpreted as not having significant changes of ischemia. After the FEoP, the patients were classified as having an STEMI(♀1%vs♂2,5%;p &lt; 0,001), non-STEMI (♀4,3%vs♂5,4%;p &lt; 0,001) or non-diagnostic-ECG(93%). Among patients with non-diagnostic ECG, the physician’s initial diagnostic was a probable acute coronary syndrome (ACS) in 42% of cases. F were less likely to be considered as having an ACS (♀39%vs♂44,5%;p &lt; 0,001). This significant differences were maintained when:1) patients had ≥3cvrf [♀OR0,72; IC95%(0,63-0,83)]; 2)patients had ≥2cvrf [♀OR0,79; IC95% (0,74-0,86)]; 3)patients had TCP [♀OR 0,69; IC95% (0,64-0,74)]; 4)patients had ≥2cvrf and TCP [♀OR 0,72; IC95% (0,63-0,82)]. After the management in the CPU, a 14% of patients with non-diagnostic ECG were finally diagnosed with an ACS (36% if≥2cvrf and TCP). 3% of ACS were initially misdiagnosed (♀5%vs♂3% ;p &lt; 0,001). After a multivariate analysis F is an independent risk factor for an initial impression of non-ACS. Conclusions There is a gender gap in the first evaluation of chest pain with an underestimation of risk in women, not only by the patients who are more often late presenters, but also by the physicians, which entails a higher risk of being misdiagnosed or late diagnosed.

Introduction: The increasing burden on mental health has become a worldwide concern especially due to its substantial negative social and economic impact. The implementation of prevention actions and psychological interventions is crucial to mitigate these consequences, and evidence supporting its effectiveness would facilitate a more assertive response. Heart rate variability biofeedback (HRV-BF) has been proposed as a potential intervention to improve mental wellbeing through mechanisms in autonomic functioning. The aim of this study is to propose and evaluate the validity of an objective procedure to assess the effectiveness of a HRV-BF protocol in mitigating mental health symptoms in a sample of frontline HCWs (healthcare workers) who worked in the COVID-19 pandemic.Methods: A prospective experimental study applying a HRV-BF protocol was conducted with 21 frontline healthcare workers in 5 weekly sessions. For PRE–POST intervention comparisons, two different approaches were used to evaluate mental health status: applying (a) gold-standard psychometric questionnaires and (b) electrophysiological multiparametric models for chronic and acute stress assessment.Results: After HRV-BF intervention, psychometric questionnaires showed a reduction in mental health symptoms and stress perception. The electrophysiological multiparametric also showed a reduction in chronic stress levels, while the acute stress levels were similar in PRE and POST conditions. A significant reduction in respiratory rate and an increase in some heart rate variability parameters, such as SDNN, LFn, and LF/HF ratio, were also observed after intervention.Conclusion: Our findings suggest that a 5-session HRV-BF protocol is an effective intervention for reducing stress and other mental health symptoms among frontline HCWs who worked during the COVID-19 pandemic. The electrophysiological multiparametric models provide relevant information about the current mental health state, being useful for objectively evaluating the effectiveness of stress-reducing interventions. Further research could replicate the proposed procedure to confirm its feasibility for different samples and specific interventions.