Syncope on presentation is a surrogate for submassive and massive acute pulmonary embolism

INTRODUCTION

There are conflicting data regarding the prognostic value of syncope in patients with acute pulmonary embolism (APE).

METHODS

We retrospectively reviewed data of 552 consecutive adults with computed tomography pulmonary angiogram-confirmed APE to determine the correlates and outcome of the occurrence of syncope at the time of presentation.

RESULTS

Among 552 subjects with APE (mean age 54years, 47% men), syncope occurred in 12.3% (68/552). Compared with subjects without syncope, those with syncope were more likely to have admission systolic blood pressure<90mmHg (odds ratio (OR) 5.788, P<0.001), and an oxygen saturation<88% on room air (OR 5.560, P<0.001), right ventricular dilation (OR 2.480, P=0.006), right ventricular hypokinesis (OR 2.288, P=0.018), require mechanical ventilation for respiratory failure (OR 3.152, P=0.014), and more likely to receive systemic thrombolysis (OR 4.722, P=0.008). On multivariate analysis, syncope on presentation was an independent predictor of a massive APE (OR 2.454, 95% CI 1.109-5.525, P=0.03) after adjusting for patients' age, sex, requirement of antibiotics throughout hospitalization, peak serum creatinine, admission oxygen saturation<88% and admission heart rate>100bpm. There was no difference in mortality in cases with APE with or without syncope (P=0.412).

CONCLUSION

Syncope at the onset of pulmonary embolization is a surrogate for submassive and massive APE but is not associated with higher in-hospital mortality.

How Do We Balance the Long-Term Health of a Patient With the Short-Term Risk to the Physician?

BACKGROUND

There is a wide variation in practice patterns among emergency medicine physicians; many factors weigh into the medical decision-making process including the health of the patient as well as short-term risk to the physician.

OBJECTIVE

The objective of our discussion is to illustrate specific scenarios where medical decisions are focused on the physician's short-term risk, then to propose an approach to shifting the balance to the patient's long-term health.

METHODS

Using recent data on the evaluation, disposition, and outcomes of patients with low-risk chest pain in the emergency department, we calculate the risk of outpatient evaluation compared to the common practice of admission or observation.

RESULTS

Patients with low-risk chest pain and negative initial evaluation in the emergency department with 2 normal cardiac biomarkers, normal vital signs, and non-ischemic, interpretable ECGs, have an extremely low-risk of a short term clinically relevant adverse cardiac event. There is a suggestion of a higher patient risk from admission, prompting consideration that continued evaluation of the chest pain as an outpatient may be safer than admission or observation.

CONCLUSION

A test/intervention should be done if the risk of a missed diagnosis or adverse outcome is greater that the risk of the test/intervention. Involving the patient in the decision-making process may help to shift the management balance from the physician's short-term concern of their own risk, to the patient's long-term health.

Risk for Clinically Relevant Adverse Cardiac Events in Patients With Chest Pain at Hospital Admission

IMPORTANCE

Patients with potentially ischemic chest pain are commonly admitted to the hospital or observed after a negative evaluation in the emergency department (ED) owing to concern about adverse events. Previous studies have looked at 30-day mortality, but no current large studies have examined the most important information regarding ED disposition: the short-term risk for a clinically relevant adverse cardiac event (including inpatient ST-segment elevation myocardial infarction, life-threatening arrhythmia, cardiac or respiratory arrest, or death).

OBJECTIVE

To determine the incidence of clinically relevant adverse cardiac events in patients hospitalized for chest pain with 2 troponin-negative findings, nonconcerning initial ED vital signs, and nonischemic, interpretable electrocardiographic findings.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a blinded data review of 45,416 encounters obtained from a prospectively collected database enrolling adult patients admitted or observed with the following inclusion criteria: (1) primary presenting symptom of chest pain, chest tightness, chest burning, or chest pressure and (2) negative findings for serial biomarkers. Data were collected and analyzed from July 1, 2008, through June 30, 2013, from the EDs of 3 community teaching institutions with an aggregate census of more than 1 million visits. We analyzed data extracted by hypothesis-blinded abstractors.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite of life-threatening arrhythmia, inpatient ST-segment elevation myocardial infarction, cardiac or respiratory arrest, or death during hospitalization.

RESULTS

Of the 45,416 encounters, 11,230 met criteria for inclusion. Mean patient age was 58.0 years. Of the 11 230 encounters, 44.83% of patients arrived by ambulance and 55.00% of patients were women. Relevant history included hypertension in 46.00%, diabetes mellitus in 19.72%, and myocardial infarction in 13.16%. The primary end point occurred in 20 of the 11 230 patients (0.18% [95% CI, 0.11%-0.27%]). After excluding patients with abnormal vital signs, electrocardiographic ischemia, left bundle branch block, or a pacemaker rhythm, we identified a primary end point event in 4 of 7266 patients (0.06% [95% CI, 0.02%-0.14%]). Of these events, 2 were noncardiac and 2 were possibly iatrogenic.

CONCLUSIONS AND RELEVANCE

In adult patients with chest pain admitted with 2 negative findings for serial biomarkers, nonconcerning vital signs, and nonischemic electrocardiographic findings, short-term clinically relevant adverse cardiac events were rare and commonly iatrogenic, suggesting that routine inpatient admission may not be a beneficial strategy for this group.

Common eye disorders: six patients to treat, pitfalls to avoid

Primary care physicians have an important role in diagnosing and treating eye disorders--including dacryocystitis, blepharitis, and conjunctivitis--and in determining when ophthalmologic referral is needed. Fundus examination for diagnosis of glaucoma and diabetic eye complications should be a part of the routine examination in all adults. Patients with HIV or AIDS should be carefully monitored for cytomegalovirus retinitis. Children should be tested for amblyopia. Orbital cellulitis can have serious complications and must be vigorously treated. Finally, careful use of ophthalmologic topical agents, especially corticosteroid drops, is essential.

Common eye disorders: six patients to refer

Thorough ocular history taking and physical examination are essential to establish a diagnosis in patients presenting with eye conditions. Some conditions require ophthalmologic referral to avoid serious complications and even vision loss. These include corneal ulcers, retinal detachment, iritis, glaucoma, retinal artery occlusion, and endophthalmitis. Because primary open-angle glaucoma can have an insidious onset and cause irreversible damage, funduscopic examination should be a part of every complete physical examination.