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Uit Het Broek LG, Ort BBA, Vermeulen H, Pelgrim T, Vloet LCM, Berben SAA. Risk stratification tools for patients with syncope in emergency medical services and emergency departments: a scoping review. Scand J Trauma Resusc Emerg Med 2023; 31:48. [PMID: 37723535 PMCID: PMC10508018 DOI: 10.1186/s13049-023-01102-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 07/16/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Patients with a syncope constitute a challenge for risk stratification in (prehospital) emergency care. Professionals in EMS and ED need to differentiate the high-risk from the low-risk syncope patient, with limited time and resources. Clinical decision rules (CDRs) are designed to support professionals in risk stratification and clinical decision-making. Current CDRs seem unable to meet the standards to be used in the chain of emergency care. However, the need for a structured approach for syncope patients remains. We aimed to generate a broad overview of the available risk stratification tools and identify key elements, scoring systems and measurement properties of these tools. METHODS We performed a scoping review with a literature search in MEDLINE, CINAHL, Pubmed, Embase, Cochrane and Web of Science from January 2010 to May 2022. Study selection was done by two researchers independently and was supervised by a third researcher. Data extraction was performed through a data extraction form, and data were summarised through descriptive synthesis. A quality assessment of included studies was performed using a generic quality assessment tool for quantitative research and the AMSTAR-2 for systematic reviews. RESULTS The literature search identified 5385 unique studies; 38 were included in the review. We discovered 19 risk stratification tools, one of which was established in EMS patient care. One-third of risk stratification tools have been validated. Two main approaches for the application of the tools were identified. Elements of the tools were categorised in history taking, physical examination, electrocardiogram, additional examinations and other variables. Evaluation of measurement properties showed that negative and positive predictive value was used in half of the studies to assess the accuracy of tools. CONCLUSION A total of 19 risk stratification tools for syncope patients were identified. They were primarily established in ED patient care; most are not validated properly. Key elements in the risk stratification related to a potential cardiac problem as cause for the syncope. These insights provide directions for the key elements of a risk stratification tool and for a more advanced process to validate risk stratification tools.
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Affiliation(s)
- Lucia G Uit Het Broek
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands.
| | - B Bastiaan A Ort
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Hester Vermeulen
- Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Thomas Pelgrim
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Lilian C M Vloet
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Sivera A A Berben
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
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Clerico A, Zaninotto M, Aimo A, Musetti V, Perrone M, Padoan A, Dittadi R, Sandri MT, Bernardini S, Sciacovelli L, Trenti T, Malloggi L, Moretti M, Burgio MA, Manno ML, Migliardi M, Fortunato A, Plebani M. Evaluation of the cardiovascular risk in patients undergoing major non-cardiac surgery: role of cardiac-specific biomarkers. Clin Chem Lab Med 2022; 60:1525-1542. [PMID: 35858238 DOI: 10.1515/cclm-2022-0481] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/05/2022] [Indexed: 11/15/2022]
Abstract
Major adverse cardiovascular events are frequently observed in patients undergoing major non-cardiac surgery during the peri-operative period. At this time, the possibility to predict cardiovascular events remains limited, despite the introduction of several algorithms to calculate the risk of adverse events, mainly death and major adverse cardiovascular events (MACE) based on the clinical history, risk factors (sex, age, lipid profile, serum creatinine) and non-invasive cardiac exams (electrocardiogram, echocardiogram, stress tests). The cardiac-specific biomarkers natriuretic peptides (NPs) and cardiac troponins (cTn) have been proposed as additional tools for risk prediction in the peri-operative period, particularly for the identification of myocardial injury in patients undergoing major non-cardiac surgery. The prognostic information from the measurement of BNP/NT-proBNP and hs-cTn is independent and complementary to other important indicators of risk, also including ECG and imaging techniques. Elevated levels of cardiac-specific biomarkers before surgery are associated with a markedly higher risk of MACE during the peri-operative period. BNP/NT-proBNP and hs-cTn should be measured in all patients during the clinical evaluation before surgery, particularly during intermediate- or high-risk surgery, in patients aged >65 years and/or with comorbidities. Several questions remain to be assessed in dedicated clinical studies, such as how to optimize the management of patients with raised cardiac specific biomarkers before surgery, and whether a strategy based on biomarker measurement improves patient outcomes and is cost-effective.
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Affiliation(s)
- Aldo Clerico
- Scuola Superiore Sant'Anna e Fondazione CNR-Regione Toscana G. Monasterio, Pisa, Italy
| | - Martina Zaninotto
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova e Azienda Ospedaliera Universitaria di Padova, e Dipartimento di Medicina-Università di Padova, Padova, Italy
| | - Alberto Aimo
- Scuola Superiore Sant'Anna e Fondazione CNR-Regione Toscana G. Monasterio, Pisa, Italy
| | - Veronica Musetti
- Scuola Superiore Sant'Anna e Fondazione CNR-Regione Toscana G. Monasterio, Pisa, Italy
| | - Marco Perrone
- Dipartimento di Medicina Sperimentale, Università di Roma Tor Vergata, Roma, Italy
| | - Andrea Padoan
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova e Azienda Ospedaliera Universitaria di Padova, e Dipartimento di Medicina-Università di Padova, Padova, Italy
| | | | | | - Sergio Bernardini
- Dipartimento di Medicina Sperimentale, Università di Roma Tor Vergata, Roma, Italy
| | - Laura Sciacovelli
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova e Azienda Ospedaliera Universitaria di Padova, e Dipartimento di Medicina-Università di Padova, Padova, Italy
| | - Tommaso Trenti
- Dipartimento di Medicina di Laboratorio e Anatomia Patologica, Azienda Ospedaliera Universitaria e USL di Modena, Modena, Italy
| | - Lucia Malloggi
- Laboratorio Analisi, Azienda Ospedaliera-Universitaria di Pisa, Pisa, Italy
| | - Marco Moretti
- Medicina di Laboratorio, AOU Ospedali Riuniti Ancona, Ancona, Italy
| | | | | | - Marco Migliardi
- Laboratorio Analisi, Ospedale Ordine Mauriziano, Torino, Italy
| | | | - Mario Plebani
- Dipartimento di Medicina di Laboratorio-DIMED, Università di Padova, Padova, Italy
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Cediel G, Codina P, Spitaleri G, Domingo M, Santiago-Vacas E, Lupón J, Bayes-Genis A. Gender-Related Differences in Heart Failure Biomarkers. Front Cardiovasc Med 2021; 7:617705. [PMID: 33469552 PMCID: PMC7813809 DOI: 10.3389/fcvm.2020.617705] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/09/2020] [Indexed: 12/13/2022] Open
Abstract
Important differences in comorbidities and clinical characteristics exist between women and men with heart failure (HF). In particular, differences in the kinetics of biological circulating biomarkers—a critical component of cardiovascular care—are highly relevant. Most circulating HF biomarkers are assessed daily by clinicians without taking sex into account, despite the multiple gender-related differences observed in plasma concentrations. Even in health, compared to men, women tend to exhibit higher levels of natriuretic peptides and galectin-3 and lower levels of cardiac troponins and the cardiac stress marker, soluble ST2. Many biological factors can provide a reliable explanation for these differences, like body composition, fat distribution, or menopausal status. Notwithstanding, these sex-specific differences in biomarker levels do not reflect different pathobiological mechanisms in HF between women and men, and they do not necessarily imply a need to use different diagnostic cut-off levels in clinical practice. To date, the sex-specific prognostic value of HF biomarkers for risk stratification is an unresolved issue that future research must elucidate. This review outlines current evidence regarding gender-related differences in circulating biomarkers widely used in HF, the pathophysiological mechanisms underlying these differences, and their clinical relevance.
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Affiliation(s)
- Germán Cediel
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, CIBERCV, Autonomous University of Barcelona, Barcelona, Spain
| | - Pau Codina
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, CIBERCV, Autonomous University of Barcelona, Barcelona, Spain
| | - Giosafat Spitaleri
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, CIBERCV, Autonomous University of Barcelona, Barcelona, Spain
| | - Mar Domingo
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, CIBERCV, Autonomous University of Barcelona, Barcelona, Spain
| | - Evelyn Santiago-Vacas
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, CIBERCV, Autonomous University of Barcelona, Barcelona, Spain
| | - Josep Lupón
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, CIBERCV, Autonomous University of Barcelona, Barcelona, Spain
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, CIBERCV, Autonomous University of Barcelona, Barcelona, Spain
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Evidence on clinical relevance of cardiovascular risk evaluation in the general population using cardio-specific biomarkers. ACTA ACUST UNITED AC 2020; 59:79-90. [DOI: 10.1515/cclm-2020-0310] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/22/2020] [Indexed: 12/25/2022]
Abstract
Abstract
In recent years, the formulation of some immunoassays with high-sensitivity analytical performance allowed the accurate measurement of cardiac troponin I (cTnI) and T (cTnT) levels in reference subjects. Several studies have demonstrated the association between the risk of major cardiovascular events and cardiac troponin concentrations even for biomarker values within the reference intervals. High-sensitivity cTnI and cTnT methods (hs-cTn) enable to monitor myocardial renewal and remodelling, and to promptly identify patients at highest risk ofheart failure. An early and effective treatment of individuals at higher cardiovascular risk may revert the initial myocardial remodelling and slow down heart failure progression. Specific clinical trials should be carried out to demonstrate the efficacy and efficiency of the general population screening by means of cost-benefit analysis, in order to better identify individuals at higher risk for heart failure (HF) progression with hs-cTn methods.
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Cheng Y, Ou J, Tang B, Wang Q, Liang M, Wang Z, Wu Z. N-Terminal Pro-B-Type Natriuretic Peptide in Tricuspid Valve Replacement. Semin Thorac Cardiovasc Surg 2020; 32:801-810. [PMID: 32473963 DOI: 10.1053/j.semtcvs.2020.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 05/02/2020] [Indexed: 11/11/2022]
Abstract
The aim of the present study was to retrospectively investigate the prognostic value of N-terminal pro-brain natriuretic peptide (NT-proBNP) in tricuspid valve replacement (TVR). A total of 73 TVR patients who had NT-proBNP measured on the first postoperative morning during a period of 10 years from February 2008 to December 2018 were included in the study. The endpoint was postsurgery all-cause in-hospital mortality. The outcome-based cut-point optimization was performed using X-tile software. NT-proBNP with the maximum χ2 score and the minimum P value will be used as the optimal cut-point. Kaplan-Meier analysis and log-rank test were adopted to calculate and compare survival rates stratified by tertiles and the cut-point. Predictive capabilities of NT-proBNP were tested using univariable and multivariable Cox regression. Overall, 20 (27.3%) in-hospital deaths occurred. Postsurgery hospital stay was 21 days (interquartile range, 16-32 day). NT-proBNP were divided into low (<1262 pg/mL), medium (1262-4003 pg/mL), and high (≥4003 pg/mL) tertiles. The optimal cut-off point determined using X-tile was 3639 pg/mL. Kaplan-Meier analysis revealed a strong association between worse survival and elevated NT-proBNP expressed as tertiles (log-rank P = 0.002) and stratified by optimal cut point (log-rank P < 0.001). Multivariable Cox survival analysis demonstrated that NT-proBNP was a strong predictor of mortality (logNT-proBNP hazard ratio [HR], 2.11; 95% confidence interval [CI], 1.33-3.37; P = 0.002). In NT-proBNP tertiles model, multivariable Cox survival analysis showed that patients in the medium and high NT-proBNP tertiles had 6.32-fold (adjusted HR, 7.32; 95% CI, 0.76-70.69; P = 0.085) and 16.11-fold (adjusted HR, 17.11; 95% CI, 1.92-152.68, P = 0.011) increased risk for mortality, respectively, compared with patients in the low tertile. Elevated postoperative NT-proBNP level is a potential independent and strong in-hospital postsurgery mortality risk factor in TVR, thus may serve as a useful surrogate marker for risk-stratification.
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Affiliation(s)
- Yanmei Cheng
- Department of Cardiothoracic surgery ICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jingsong Ou
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Baiyun Tang
- Department of Cardiothoracic surgery ICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qianqian Wang
- Department of Epidemiology & Medical Statistics, Jishuitan Hospital, Beijing, China
| | - Mengya Liang
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhiping Wang
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhongkai Wu
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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