The Predictive Role of Lactate in the Emergency Department in Patients with Severe Dyspnea

Objective

An accurate identification of patients at the need for prioritized diagnostics and care are crucial in the emergency department (ED). Blood gas (BG) analysis is a widely available laboratory test, which allows to measure vital parameters, including markers of ventilation and perfusion. The aim of our analysis was to assess whether blood gas parameters in patients with dyspnea at an increased risk of respiratory failure admitted to the ED can predict short-term outcomes.

Methods

The study group eventually consisted of 108 patients, with available BG analysis. The clinical and laboratory parameters were retrospectively evaluated, and three groups were distinguished-arterial blood gas (ABG), venous blood gas (VBG), and mixed blood gas. The primary endpoint was short-term, all-cause mortality during the follow-up of median (quartile 1-quartile 3) 2 (1-4) months. The independent risk factors for mortality that could be obtained from blood gas sampling were evaluated.

Results

The short-term mortality was 35.2% (38/108). Patients who died were more frequently initially assigned to the red triage risk group, more burdened with comorbidities, and the median SpO2 on admission was significantly lower than in patients who survived the follow-up period. In the multivariable analysis, lactate was the strongest independent predictor of death, with 1 mmol/L increasing all-cause mortality by 58% in ABG (95% CI: 1.01-2.47), by 80% in VBG (95% CI: 1.13-2.88), and by 68% in the mixed blood gas analysis (95% CI: 1.22-2.31), what remained significant in VBG and mixed group after correction for base excess. In each group, pH, pO2, and pCO2 did not predict short-term mortality.

Conclusions

In patients admitted to the ED due to dyspnea, at risk of respiratory failure, lactate levels in arterial, venous, and mixed blood samples are independent predictors of short-term mortality.

Sacubitril/valsartan for cardioprotection in breast cancer (MAINSTREAM): design and rationale of the randomized trial

AIMS

In recent years, survival in patients with breast cancer has increased. Despite the improvement in outcomes of those patients, the risk of treatment-related cardiotoxicity remains high, and its presence has been associated with a higher risk of treatment termination and thus lower therapeutic efficacy. Prior trials demonstrated that a preventive initiation of heart failure drugs, including the renin-angiotensin-aldosterone inhibitors, might reduce the risk of treatment-related cardiotoxicity. However, to date, no study investigated the efficacy of sacubitril/valsartan, a novel antineurohormonal drug shown to be superior to the previous therapies, in the prevention of cardiotoxicity in patients with early-stage breast cancer, which is the aim of the trial.

METHODS AND RESULTS

MAINSTREAM is a randomized, placebo-controlled, double-blind, multicentre, clinical trial. After the run-in period, a total of 480 patients with early breast cancer undergoing treatment with anthracyclines and/or anti-human epidermal growth factor receptor 2 drugs will be randomized to the highest tolerated dose of sacubitril/valsartan, being preferably 97/103 mg twice daily or placebo in 1:1 ratio. The patients will be monitored, including routine transthoracic echocardiography (TTE) and laboratory biomarker monitoring, for 24 months. The primary endpoint of the trial will be the occurrence of a decrease in left ventricular ejection fraction by ≥5% in TTE within 24 months. The key secondary endpoints will be the composite endpoint of death from any cause or hospitalization for heart failure, as well as other imaging, laboratory, and clinical outcomes, including the occurrence of the cancer therapy-related cardiac dysfunction resulting in the necessity to initiate treatment. The first patients are expected to be recruited in the coming months, and the estimated completion of the study and publication of the results are expected in December 2027, pending recruitment.

CONCLUSIONS

The MAINSTREAM trial will determine the efficacy and safety of treatment with sacubitril/valsartan as a prevention of cardiotoxicity in patients with early breast cancer (ClinicalTrials.gov number: NCT05465031).

Mallampati Score Is an Independent Predictor of Active Oxygen Therapy in Patients with COVID-19

Mallampati score has been identified and accepted worldwide as an independent predictor of difficult intubation and obstructive sleep apnea. We aimed to determine whether Mallampati score assessed on the first patient medical assessment allowed us to stratify the risk of worsening of conditions in patients hospitalized due to COVID-19. A total of 493 consecutive patients admitted between 13 November 2021 and 2 January 2022 to the temporary hospital in Pyrzowice were included in the analysis. The clinical data, chest CT scan, and major, clinically relevant laboratory parameters were assessed by patient-treating physicians, whereas the Mallampati score was assessed on admission by investigators blinded to further treatment. The primary endpoints were necessity of active oxygen therapy (AOT) during hospitalization and 60-day all-cause mortality. Of 493 patients included in the analysis, 69 (14.0%) were in Mallampati I, 57 (11.6%) were in Mallampati II, 78 (15.8%) were in Mallampati III, and 288 (58.9%) were in Mallampati IV. There were no differences in the baseline characteristics between the groups, except the prevalence of chronic kidney disease (p = 0.046). Patients with Mallampati IV were at the highest risk of AOT during the hospitalization (33.0%) and the highest risk of death due to any cause at 60 days (35.0%), which significantly differed from other scores (p = 0.005 and p = 0.03, respectively). Mallampati IV was identified as an independent predictor of need for AOT (OR 3.089, 95% confidence interval 1.65−5.77, p < 0.001) but not of all-cause mortality at 60 days. In conclusion, Mallampati IV was identified as an independent predictor of AOT during hospitalization. Mallampati score can serve as a prehospital tool allowing to identify patients at higher need for AOT.

Is the last before-death alert remote monitoring transmission in patients with heart failure life-threatening?

BACKGROUND

Remote monitoring (RM) of cardiac implantable electronic devices (CIED) allows for a regular analysis of the occurrence of arrhythmias and functioning of the devices.

AIMS

To date, no study investigated the characteristics of the alert-triggered ultimate transmissions before death, which was the aim of the present analysis.

METHODS

Patients monitored remotely in our center, whose baseline characteristics were obtained from the COMMIT-HF Registry (NCT02536443) were analyzed and divided according to the occurrence of alert transmissions during the RM. In patients who had an alert transmission, the last transmission was analyzed. All RM data were obtained from the software provided by four RM manufacturers.

RESULTS

Of 1271 patients with CIEDs which transmitted at least one message to the RM center, 198 (15.6%) had no alert transmissions, while 1073 (84.4%) had at least one alert transmission. Respective mortality in patients with and without alerts during RM was 29.7% and 12.6%, respectively. In patients who had ever an alert, the last recorded transmission before death was scheduled in 166 patients and alert-triggered in 152 patients. The most frequent alert-triggered last transmissions were atrial fibrillation/flutter (39.4%) and ventricular tachyarrhythmias (26.8%). The median period from the last alert-triggered transmission to death was 10 days.

CONCLUSION

This is the first analysis of the ultimate RM transmissions delivered by CIEDs before death. In approximately 85% of RM patients with CIEDs, at least one alert transmission occurred during the RM, and in patients who had ever an alert, almost half of the last transmissions before death were alert-triggered.

Serum uric acid is an independent risk factor of worse mid- and long-term outcomes in patients with non-ST-segment elevation acute coronary syndromes

BACKGROUND

The data on the association between serum uric acid (sUA) concentration and outcomes in patients with an ACS are inconsistent and do not focus on patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). The aim of this study was to analyze an association of sUA concentration on admission and outcomes in those patients.

METHODS

Data from the prospective, single-center registry of patients hospitalized due to NSTE-ACS from January 2006 to December 2016 were analyzed retrospectively. The population was divided into quartiles according to the baseline sUA. The primary outcome was the incidence of all-cause death, non-fatal myocardial infarction, stroke and ACS-driven revascularization at 36 months.

RESULTS

Total of 2,824 patients with sUA measured on admission were included in this analysis with a median sUA of 352 µmol/L (5.92 mg/dL). Patients with higher sUA were older and more burdened with cardiovascular risk factors and history of coronary events. The prevalence of multivessel coronary artery disease and left main stenosis was significantly higher in patients with higher sUA. Elevated sUA concentration was associated with significantly worse short-, mid- and long-term outcomes. All-cause mortality was significantly higher in each analyzed period. In the multivariable analysis, sUA elevation was identified as an independent predictor of all-cause mortality at 12-month and 36-month follow-up.

CONCLUSIONS

Elevated baseline sUA concentration was independently associated with worse mid- and long-term outcomes in patients with NSTE-ACS. Baseline sUA concentration could identify patients with NSTE-ACS at higher risk of more dismal prognosis.

The clinical value of the routine analysis of cardiac implantable electronic devices after the patient's death in a tertiary cardiovascular center

INTRODUCTION

The postmortem interrogation of cardiac implantable electronic devices (CIEDs) has not been regularly practiced yet. We presumed that it can provide data not only on the mechanism of the patient's death but also on possible device malfunctions contributing to its occurrence.

OBJECTIVES

The study aimed to determine the usefulness of the explantation and interrogation of CIEDs after the patient's death in routine clinical practice, when combined with autopsy findings and clinical follow‑up starting from the time after device implantation.

PATIENTS AND METHODS

Between August 24, 2008 and August 30, 2018, all patients who underwent autopsy in the tertiary cardiovascular center or partner facilities had the device explanted and interrogated by the qualified electrophysiologist. Clinical characteristics obtained at the time of device implantation and patients' death were obtained from medical records. Device interrogation results were then combined with autopsy report and clinical data.

RESULTS

Out of 1200 autopsied patients, the device was removed and analyzed in 61 individuals. Clinical characteristics from the time of implantation and patients' death were available in 53 (86.7%) and 49 (80.3%) patients, respectively. Device‑related concerns, undetected during patients' hospital stay, were noted in 6 cases (6.1%) and included 3 programming and 3 hardware issues.

CONCLUSIONS

To our knowledge, this is the first study to date to combine the clinical follow‑up of patients before death and on admission at the end of life, autopsy results, and postmortem CIED interrogation. Having implemented the device interrogation, we found 6 CIED‑related events potentially associated with patients' death, which were not detected before its occurrence.

Post mortem pro life - Should we analyse the implantable devices after death? A systematic review

AIM

Post-mortem interrogation of the cardiac implantable electronic devices (CIEDs) in combination with autopsy findings can provide additional information regarding device functioning after implantation or the mechanism of death. The aim of the study is to review the available data on the post-mortem interrogation of CIEDs and its possible clinical implications.

METHODS AND RESULTS

A systematic review of the published studies has been performed. Out of 762 unique citations 14 have been retained for final analysis. Post-mortem CIED interrogation reliably detects both serious device malfunctions and lead disorders but also improper device programming. As the need for CIED implantation is growing in the low-income countries, currently available data on battery longevity of devices explanted and destined for re-use have been reviewed.

CONCLUSIONS

Post-mortem CIED interrogation provides a unique opportunity to explore different mechanisms of death, often unavailable for distinction during regular in-hospital observation or in autopsy analysis.