Göğüs ağrısı olan hastalarda kararsız anjina pektorisi ayırt etmede end-tidal CO2'nin tanısal rolü

Öz

Amaç: Akut koroner sendrom (AKS) türlerinden biri olan kararsız angina pektoris (UAP), kalp dışı göğüs ağrısından (non-CCP) ayırt edilmesi zordur, bu nedenle doğru tanı için çeşitli stratejiler uygulanır. Bu çalışma, kardiyovasküler öyküsü olmayan göğüs ağrısı ile acil servise (AS) başvuran hastalarda non-invaziv olarak ölçülen end-tidal CO2'nin (ETCO2) UAP'yi saptayıp saptayamayacağını incelemeyi amaçlamaktadır. Yöntemler: Bu araştırma prospektif gözlemsel bir çalışma olarak yürütülmüştür. Bireyler, dahil etme ve hariç tutma kriterlerine göre iki gruba ayrıldı: CCP olmayan 75 hasta ve 75 UAP. Teşhis değeri kesimini tanımlamak için alıcı işletim özelliklerinin (ROC) analizlerinden yararlanılmıştır. Tek değişkenli regresyon analizi kullanılarak, UAP tahmini için ETCO2'nin olasılık oranı (%95 CI ile) hesaplandı. Bulgular: Araştırma popülasyonunun yaş ortalaması 61.2±11.3 olup, 34'ü kadın (%22.7), 116'sı erkektir (%77,3). Klinik özellikler ve laboratuvar parametreleri açısından gruplar arasında önemli farklılıklar yoktu. ETCO2 seviyeleri UAP grubunda CCP olmayan grupla karşılaştırıldığında önemli ölçüde daha düşüktü (p<0.001). ROC eğrisinin analizi, %78 duyarlılık ve %89 özgüllükle (EAA:0.81, p <0.001) azalmış bir ETCO2 <35'in UAP'yi öngördüğünü ortaya koydu. Ayrıca negatif prediktif değer %71.6, pozitif prediktif değer ise %79.4 olarak bulundu. UAP'li hastaların ETCO2 <35'e sahip olma olasılığı ÇKP olmayan hastalara göre 8.84 kat daha fazlaydı. Sonuç: UAP, göğüs ağrısı olan hastalarda non-invaziv bir parametre olarak ölçülen ETCO2 ile CCP olmayandan ayırt edilebilir.

Anahtar Kelimeler

• kararsız anjina
• soluk sonu karbondioksit
• kalp dışı göğüs ağrısı
• akut koroner sendrom
• koroner bakım ünitesi

The diagnostic role of end-tidal CO2 to distinguish unstable angina pectoris in patients with chest pain

Öz

Objective: Unstable angina pectoris (UAP), one of the acute coronary syndrome (ACS) types, is difficult to identify from non-cardiac chest pain (non-CCP), hence various strategies are applied for accurate diagnosis. This study aims to examine whether non-invasively measured end-tidal CO2 (ETCO2) can detect UAP in patients admitted to the emergency department (ED) with chest pain in the lack of a cardiovascular history. Methods: This research was conducted as a prospective observational study. The individuals were separated into two groups based on the inclusion and exclusion criteria: 75 patients with non-CCP and 75 UAP. Analyses of receiver operating characteristics (ROC) were utilized to define the diagnostic value cutoff. Using univariate regression analysis, the odds ratio of ETCO2 (with 95%CI) was computed for UAP prediction. Results: The mean age of the research population was 61.2±11.3 years, with 34 females (22.7%) and, 116 males (77.3%). There were no substantial differences across the groups regarding clinical characteristics and laboratory parameters. ETCO2 levels were substantially lower in the UAP group compared with the non-CCP group (p<0.001). Analysis of the ROC curve revealed that a decreased ETCO2 <35 predicted UAP with 78% sensitivity and 89% specificity (AUC:0.81, p <0.001). In addition, the negative predictive value was 71.6%, and the positive predictive value was 79.4%. Patients with UAP were 8.84 times more likely to have ETCO2 <35 than patients with non-CCP. Conclusion: UAP may be differentiated from non-CCP by ETCO2 measured as a non-invasive parameter in patients with chest pain.

Anahtar Kelimeler

• end-tidal carbon dioxide
• non-cardiac chest pain
• acute coronary syndrome
• coronary care unit
• unstable angina

Kaynakça

1. Collet, J. P., Thiele, H., Barbato, E., Barthélémy, O., Bauersachs, J., Bhatt, D. L., ... & Karia, N. (2021). 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). European heart journal, 42(14), 1289-1367.
2. Cornwell III, W. K., Baggish, A. L., Bhatta, Y. K. D., Brosnan, M. J., Dehnert, C., Guseh, J. S., ... & American Heart Association Exercise, Cardiac Rehabilitation, and SecondaryPrevention Committee of the Council on Clinical Cardiology; and Council on Arteriosclerosis, Thrombosis and Vascular Biology. (2021). Clinical implications for exercise at altitude among individuals with cardiovascular disease: a scientificstatement from the american heart association. Journal of the American Heart Association, 10(19), e023225.
3. Cury, R. C., Leipsic, J., Abbara, S., Achenbach, S., Berman, D., Bittencourt, M., ... &Blankstein, R. (2022). CAD-RADS™ 2.0–2022 Coronary Artery Disease-Reporting and Data System: An ExpertConsensusDocument of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR), and the North America Society of Cardiovascular Imaging (NASCI). Cardiovascular Imaging, 15(11), 1974-2001.
4. Crystal, G. J. (2015). Carbondioxide and the heart: physiology and clinical implications. Anesthesia &Analgesia, 121(3), 610-623.
5. Dong, L., &Mizota, T. (2022). In reply: Low levels of end-tidal carbondioxide during general anesthesia and postoperative mortality. CanadianJournal of Anesthesia/Journalcanadiend'anesthésie, 1-2. Finet, J. E., Van Iterson, E. H., &Tang, W. W. (2021). Invasive hemodynamic and metabolic evaluation of HFpEF. Current treatment options in cardiovascular medicine, 23, 1-24.
6. Ford, T. J., &Berry, C. (2020). Angina: contemporary diagnosis and management. Heart, 106(5), 387-398. Ghorbani, R., Blomberg, A., & Schmidt, F. M. (2018). Modeling pulmonary gasexchange and single-exhalationprofiles of carbonmonoxide. Frontiers in Physiology, 9, 927.
7. Ibanez, B., James, S., Agewall, S., Antunes, M. J., Bucciarelli-Ducci, C., Bueno, H., ... &Widimský, P. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. KardiologiaPolska (Polish Heart Journal), 76(2), 229-313.
8. İnan, G., Çetіnbіlek, P. H. K., & Gönüllü, H. (2022). Comparison of End-Tidal CarbonDioxide (ETCO2) Gradient and Vena Cava Collapsibility Index (VCCI) in Response to Intravenous Fluid Therapy in Patients with Moderate and Severe Dehydration and Acute Gastroenteritis. Prehospital and Disaster Medicine, 37(4), 474-479.

9. Javaudin, F., Her, S., Le Bastard, Q., De Carvalho, H., Le Conte, P., Baert, V., ... & GR-RéAC. (2020). Maximum value of end-tidal carbondioxideconcentrations during resuscitation as an indicator of return of spontaneouscirculation in out-of-hospital cardiac arrest. Prehospital Emergency Care, 24(4), 478-484.
10. Kaier, T. E., Twerenbold, R., Puelacher, C., Marjot, J., Imambaccus, N., Boeddinghaus, J., Nestelberger, T., Badertscher, P., Sabti, Z., Giménez, M. R., Wildi, K., Hillinger, P., Grimm, K., Loeffel, S., Shrestha, S., Widmer, D. F., Cupa, J., Kozhuharov, N., Miró, Ò., Martín-Sánchez, F. J., … Mueller, C. (2017). Direct Comparison of Cardiac Myosin-Binding Protein C With Cardiac Troponins for the Early Diagnosis of Acute Myocardial Infarction. Circulation, 136(16), 1495–1508. https://doi.org/10.1161/CIRCULATIONAHA.117.028084
11. Kargoli, F., Levsky, J., Bulcha, N., Mustehsan, M. H., Brown-Manhertz, D., Furlani, A., ... & Garcia, M. J. (2020). Comparison between anatomical and functional imaging modalities for evaluation of chest pain in the emergency department. The American Journal of Cardiology, 125(12), 1809-1814.
12. Kwong, J. L., Drennan, I. R., Turner, L., &Cheskes, S. (2023). Predefibrillation end-tidal CO2 and defibrillation success in out-of-hospital cardiac arrest: an observational cohort study. Emergency Medicine Journal, 40(1), 48-55.
13. Lawton, J. S., Tamis-Holland, J. E., Bangalore, S., Bates, E. R., Beckie, T. M., Bischoff, J. M., Bittl, J. A., Cohen, M. G., DiMaio, J. M., Don, C. W., Fremes, S. E., Gaudino, M. F., Goldberger, Z. D., Grant, M. C., Jaswal, J. B., Kurlansky, P. A., Mehran, R., Metkus, T. S., Jr, Nnacheta, L. C., Rao, S. V., … Zwischenberger, B. A. (2022). 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 145(3), e4–e17. https://doi.org/10.1161/CIR.0000000000001039
14. Long, B., Koyfman, A., &Vivirito, M. A. (2017). Capnography in the emergency department: a review of uses, waveforms, and limitations. The Journal of emergency medicine, 53(6), 829-842. Long, J., &Dippenaar, E. (2022). To whatextent is end-tidal carbondioxide a predictor of sepsis?. Journal of Paramedic Practice, 14(10), 425-431.
15. Mosing, M., Kutter, A. P., Iff, S., Raszplewicz, J., Mauch, J., Bohm, S. H., &Tusman, G. (2015). The effects of cardiac output and pulmonary arterial hypertension on volumetric capnography derived-variables during normoxia and hypoxia. Journal of clinical monitoring and computing, 29, 187-196.
16. Mueller, M., Jankow, E., Grafeneder, J., Schoergenhofer, C., Poppe, M., Schriefl, C., ... &Losert, H. (2022). The difference between arterial pCO2 and etCO2 after cardiac arrest–Outcome predictor or marker of unfavorableresuscitationcircumstances?. The American Journal of Emergency Medicine, 61, 120-126.
17. Norman, G. R., Sloan, J.A., Wyrwich, K.W. (2003). Interpretation of changes in health-related quality of life: the remarkableuniversality of half a standard deviation. Med Care, 41, 582–92.
18. Paiva, E. F., Paxton, J. H., &O’Neil, B. J. (2018). The use of end-tidal carbondioxide (ETCO2) measurement to guide management of cardiac arrest: a systematic review. Resuscitation, 123, 1-7.
19. Parr, M. S., Salehani, A., Ogilvie, M., EthanTabibian, B., Rahm, S., Hale, A. T., ... & Jones, J. G. (2022). The effect of procedural end-tidal CO2 on infarctexpansion during anterior circulationthrombectomy. InterventionalNeuroradiology, 15910199221143175.
20. Roffi, M., Patrono, C., Collet, J. P., Mueller, C., Valgimigli, M., Andreotti, F., ... &Windecker, S. (2015). 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. KardiologiaPolska (Polish Heart Journal), 73(12), 1207-1294.
21. Roos, A., Edgren, G., &Holzmann, M. J. (2022). Unstable Angina Pectoris With Myocardial Injury Versus Myocardial Infarction in the Era of High-Sensitivity Cardiac Troponin. The American Journal of Cardiology, 169, 32-41.
22. Smit, M., Coetzee, A. R., &Lochner, A. (2020). The pathophysiology of myocardial ischemia and perioperative myocardial infarction. Journal of Cardiothoracic and Vascular Anesthesia, 34(9), 2501-2512.
23. Sousa, M. L., Katira, B. H., Engelberts, D., Hsing, V., Schreiber, A., Jonkman, A. H., ... &Brochard, L. J. (2023). Mechanical ventilation in ARDS with an automaticresuscitator. Respiratory care, 68(5), 611-619.
24. Tilea, I., Varga, A., &Serban, R. C. (2021). Past, present, and future of blood biomarkers for the diagnosis of acute myocardial infarction—promises and challenges. Diagnostics, 11(5), 881.
25. Tremont, J. N. P., Caldas, R. A., Cook, N., Udekwu, P. O., &Moore, S. M. (2022). Low initial in-hospital end-tidal carbondioxidepredicts poor patient outcomes and is a useful trauma bay adjunct. The American Journal of Emergency Medicine, 56, 45-50.
26. Wertli, M. M., Dangma, T. D., Müller, S. E., Gort, L. M., Klauser, B. S., Melzer, L., ... &Burgstaller, J. M. (2019). Non-cardiac chest pain patients in the emergency department: Do physicians have a plan how to diagnose and treat them? A retrospective study. PLoS One, 14(2), e0211615.
27. Writing Committee, Kontos, M. C., de Lemos, J. A., Deitelzweig, S. B., Diercks, D. B., Gore, M. O., ... & Wright, L. J. (2022). 2022 ACC ExpertConsensusDecisionPathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. Journal of the American College of Cardiology, 80(20), 1925-1960.