Triaging patients with suspicious chest pain

N Engl J Med2012;367:299-308OpenUrlCrossRefMedline

Coronary computed tomographic angiography (CCTA) is one option for patients with suspicious chest pain who have no ischaemic changes on an electrocardiogram and a negative troponin test. CCTA is good at ruling out acute coronary syndromes in these patients and worked faster than more traditional strategies in a recent trial. Adults who had CCTA went home 7.6 hours earlier on average than controls who had a mix of tests (or none), including stress echocardiography and single photon emission computed tomography. The authors recruited 1000 patients from nine US emergency departments. Just 75 had an acute coronary syndrome diagnosed at the index visit. Eight more cases emerged in the month after discharge—six of them after standard evaluation at the index visit⇑.

So, CCTA helps rule out acute coronary syndromes faster than standard triage. But it does have drawbacks, including more radiation, more tests, and more interventions downstream, says an editorial (p 375). Do patients with no history, a non-ischaemic electrocardiogram, and a negative troponin test need any further testing at all? They have a low risk of major cardiovascular events, and there is no evidence that more tests reduce that risk any further. An assessment based on age, sex, and history of cardiovascular disease should be enough if followed by an outpatient appointment a few weeks later. The patients in this study had a mean age of 54 years and about half were women.

Drug resistant HIV rises in eastern and southern Africa

Lancet2012; doi:10.1016/S0140-6736(12)61038-1

The prevalence of drug resistant HIV-1 is rising fast in some parts of sub-Saharan Africa, according to a global study of more than 26 000 untreated adults. The prevalence of resistant mutations rose fastest in eastern countries, from an estimated 1.0% before the scale-up of antiretroviral treatment to an estimated 7.4% …