1
|
Clinical risk scores versus simple integrated clinical judgment in patients with suspected acute coronary syndromes. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The clinical utility of clinical risk scores in patients presenting with suspected acute coronary syndromes to the emergency department (ED) is uncertain.
Purpose
We aimed to directly compare the performance of three established clinical risk scores to simple integrated clinical judgment (ICJ) of the treating ED physician.
Methods
Thirty day major adverse cardiac events (MACE) including all-cause death, life-threatening arrhythmia, cardiogenic shock, acute myocardial infarction (AMI, including the index event), and unstable angina requiring urgent coronary revascularization were centrally adjudicated by two independent cardiologists in patients presenting to the emergency department (ED) with acute chest discomfort in an international multicenter study (12 centres in 5 European countries). ICJ for the likelihood that an ACS is the cause of acute chest discomfort was quantified by the treating ED physician using a visual analogue scale at 90 minutes after patient's presentation to the ED. At this time, the ED physician had obtained the patient history, physical examination including vital signs, the 12-lead electrocardiogram at presentation, and the first local (hs)-cTn measurement. We directly compared the prognostic performance of the HEART-score, the GRACE-score, and the T-MACS decision aid to simple integrated clinical judgment (ICJ) of the treating ED physician. We also assessed the safety for rule-out of MACE at 30-days.
Results
Among 4551 eligible patients, 1110/4551 patients (24.4%) had at least one MACE within 30 days. Prognostic accuracy as quantified by the area under the receiver-operating characteristics curve was 0.85 (95% CI, 0.84–0.87) for the HEART-score, 0.85 (95% CI, 0.84–0.87) for the GRACE-score, 0.79 (95% CI, 0.77–0.80) for the TIMI decision aid, and 0.87 (95% CI, 0.85–0.88) for ICJ (Figure). The HEART-score identified 1893/4551 (41.6%) patients as low-risk with an NPV of 96.0% (95% CI, 95.0–96.8), the GRACE score identified 1542/4551 (33.9%) patients as low-risk with an NPV of 97.0% (95% CI, 96.0–97.7), the TIMI score identified 2157/4551 (47.4%) patients as low-risk with an NPV of 93.1% (95% CI, 91.9–94.1), and simple ICJ identified 1743/4551 (38.3%) patients as low-risk with an NPV of 95.6% (95% CI, 94.5–96.5).
Conclusion
The simple ICJ of the treating physician performed well for the prediction of 30-day MACE and might be an alternative to the well-validated HEART-score, GRACE-score, and T-MACS decision aid.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): The study was supported by research grants from the the Swiss Heart Foundation and the University of Basel.
Collapse
|
2
|
Performance of high-sensitivity cardiac troponin T versus I for the early diagnosis of myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Clinical practice guidelines assume that both cardiac troponin (cTn) T and cTnI concentrations reflect identical pathophysiological processes and are equally effective in the detection of myocardial injury. However, there are differences between cTnT and cTnI that have been reported.
Purpose
The aim of this study was to directly compare the diagnostic performance of high-sensitivity cardiac troponin (hs-cTn) T versus hs-cTnI for the early diagnosis of acute myocardial infarction (MI).
Methods
In a prospective multicentre study, diagnostic and prognostic accuracies of hs-cTnT and I were analyzed in consecutive patients presenting to the emergency department with acute chest pain. The final diagnosis was adjudicated by two independent cardiologists using all information pertaining to the individual patient according to the fourth universal definition of MI. Adjudication of the final diagnoses was performed twice: once using serial measurements of hs-cTnT and once using hs-cTnI. Furthermore, the clinical performance of hs-cTnT/I when embedded in the European Society of Cardiology (ESC) 0/1h-algorithm was assessed.
Results
Among 5087 consecutive patients (median [Interquartile range, IQR] age 61 [49.0, 74.0] years, 33.2% female), 951 (18.7%) and 901 patients (17.7%) had an adjudicated final diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI) when using serial measurements of hs-cTnT and hs-cTnI for adjudication, respectively. Diagnostic accuracy was very high for both hs-cTnT and hs-cTnI and comparable when using hs-cTnT for adjudication (hs-cTnT: area under the curve [AUC] 0.93 [95% CI 0.92–0.94] versus hs-cTnI AUC 0.93 [95% CI 0.92–0.94]; p=0.891). However, when using serial measurements of hs-cTnI for adjudication, diagnostic accuracy was significantly higher for hs-cTnI (AUC 0.93 [95% CI 0.92–0.94] versus AUC 0.94 [95% CI 0.94–0.95], p<0.001; Figure 1). This was confirmed in subgroup analyses including early presenter (≤3h), patients with renal failure, known coronary artery disease and elderly (≥70 years). However, both assays performed excellent with very high safety for rule-out and high accuracy for rule-in MI when embedded in the ESC 0/1h-algorithm. Prognostic accuracies for 730-day all-cause mortality and cardiovascular death were significantly higher for hs-cTnT compared to hs-cTnI (Figure 2).
Conclusions
While there seem to be differences between hs-cTnT and hs-cTnI in their diagnostic and prognostic performance, clinical relevance needs to be further evaluated since both assays performed excellent when embedded in their respective early triage algorithms.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Swiss National Foundation, Swiss Heart Foundation
Collapse
|
3
|
Association of accompanying dyspnea with diagnoses and outcome of patients presenting with suspected acute coronary syndromes. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The presence of accompanying dyspnea is routinely assessed and common in chest pain patients with suspected acute coronary syndromes (ACS), but its impact on differential diagnoses, diagnostic work-up and outcome is incompletely understood.
Purpose
To determine the association of accompanying dyspnea with diagnoses, diagnostic work-up, and outcome of patients presenting with suspected ACS to the emergency department (ED).
Methods
We prospectively enrolled unselected patients presenting to the ED with chest pain as the main symptom suggestive of ACS in an international multicenter study. Final diagnoses were adjudicated by two independent cardiologists using all information including cardiac imaging. Patients were stratified by the presence or absence of self-reported dyspnea. The primary diagnostic endpoint was the differential diagnosis. The secondary diagnostic endpoint was the performance of high-sensitivity cardiac troponin (hs-cTn) and the European Society of Cardiology (ESC) 0/1h-algorithms for the diagnosis of myocardial infarction (MI). The primary prognostic endpoint was all-cause mortality at two years.
Results
Among 6045 patients, 2892/6045 (48%) had accompanying dyspnea. Final diagnoses in patients with versus without dyspnea were different (overall p<0.001), but prevalence of ACS was comparable (MI 22.4% vs. 21.9%, p=0.602, unstable angina 8.7% vs. 7.9%, p=0.291). In contrast, patients with dyspnea more often had cardiac, non-coronary disease (15.3% vs. 10.2%, p<0.001). Diagnostic accuracy of high-sensitivity cardiac troponin (hs-cTn)T/I concentrations at presentation for the diagnosis of MI was high and not affected by the presence of dyspnea (area under the curve 0.89–0.91 in both groups). The ESC 0/1h-algorithms performed excellent in both groups with negative predictive values >99.4%. The presence of dyspnea was associated with all-cause death at two years (hazard ratio [HR] 2.487 [95% CI, 2.001–3.091, p<0.001) and remained an independent predictor after adjustment for covariates at baseline (HR 1.813 [95% CI, 1.453–2.261, p=0.001]). Overall mortality rates were higher in patients with dyspnea at two years (9.0% vs. 3.7%, p<0.001).
Conclusion
Accompanying dyspnea was not associated with a higher prevalence of ACS but with cardiac, non-coronary disease such as heart failure. While the safety of the diagnostic work-up was not affected, accompanying dyspnea was associated with and an independent predictor for two-year all-cause mortality.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): Swiss Heart Foundation, University of Basel.
Collapse
|
4
|
0/1h-algorithm using a new high-sensitivity cardiac troponin I assay for early diagnosis of myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The clinical performance of the novel high-sensitivity cardiac troponin I EXL (hs-cTnI-EXL) assay is unknown so far.
Purpose
We aimed to validate the clinical performance of the hs-cTnI-EXL assay and to derive and validate an hs-cTnI-EXL-specific 0/1h-algorithm for the early diagnosis of myocardial infarction (MI).
Methods
This multicenter study included patients presenting to the emergency department with symptoms suggestive of myocardial infarction. Central adjudication of final diagnoses was performed by two independent cardiologists using all clinical information including cardiac imaging twice: first, using serial hs-cTnI-Architect (primary analysis) and second, using serial hs-cTnT-Elecsys (secondary analysis) concentrations in addition to those clinically used (hs)-cTn. Hs-cTnI-EXL was measured at presentation and at 1h. The primary objective was to directly compare diagnostic accuracy quantified by the area under the receiver-operating-characteristic curve (AUC) of hs-cTnI-EXL, hs-cTnI-Architect and hs-cTnT-Elecsys. Secondary objectives included the derivation and validation of an hs-cTnI- EXL-specific 0/1h-algorithm.
Results
MI was the adjudicated final diagnosis in 204/1454 (14%) patients. At presentation, the AUC for hs-cTnI-EXL was 0.94 (95% CI, 0.93–0.96), being comparable to hs-cTnI-Architect (0.95; 95% CI, 0.93–0.96) and hs-cTnT-Elecsys (0.93; 95% CI, 0.91–0.95; Figure 1). In the derivation cohort (n=813), an optimal hs-cTnI-EXL-0/1h-algorithm was rule-out of MI with <9ng/L if onset of chest pain >3h or <9ng/L & 0h-1h-change <5ng/L, and rule-in with ≥160ng/L or 0h-1h-change ≥100ng/L. In the validation cohort (n=345), this hs-cTnI-EXL-0/1h-algorithm also performed well: rule-out in 56% of patients, negative predictive value 99.5% (95% CI, 97.1–99.9), sensitivity 97.8% (95% CI, 88.7–99.6), rule-in in 9% of patients, positive predictive value 83.3% (95% CI, 66.4–92.7), specificity 98.3% (95% CI, 96.1–99.3; Figure 2). Secondary analyses confirmed the findings using adjudication including serial measurements of hs-cTnT-Elecsys.
Conclusions
Hs-cTnI-EXL has comparable diagnostic performance to the currently best-validated hs-cTnT/I assays.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Swiss National Foundation, Swiss Heart Foundation
Collapse
|
5
|
[Current situation of sepsis care in Spanish emergency departments]. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2022; 35:192-203. [PMID: 35103453 PMCID: PMC8972694 DOI: 10.37201/req/150.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/28/2021] [Accepted: 12/10/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To describe the approach to the patients with suspected sepsis in the Spanish emergency department hospitals (ED) and analyze whether there are differences according to the size of the hospital and the number of visits to the emergency room. METHODS Structured survey of those responsible for the 282 public EDs that serve adults 24 hours a day, 365 days a year. It was asked about assistance and management in the emergency room in the care of patients with suspected sepsis. The results are compared according to hospital size (large ≥ 500 beds vs medium-small <500) and influx to the emergency room (discharge ≥ 200 visits / day vs medium-low <200). RESULTS A total of 250 Spanish EDs responded (89%). Sepsis protocols are available in 163 (65%) EDs median weekly sepsis treated ranged from 0-5 per week in 39 (71%) ED, 6-10 per week in 10 (18%), 11-15 per week in 4 (7%), and more than 15 activations per week in 3 centers (3.6%). The criteria used for sepsis diagnosis were the qSOFA/SOFA in 105 (63.6%) of the hospitals, SIRS in 6 (3.6%), while in 49 (29.7%) they used both criteria simultaneously. In 79 centers, the sepsis diagnosis was computerized, and in 56 there were tools to help decision-making. 48% (79 of 163) of the EDs had data on bundles compliance. In 61% (99 of 163) of EDs there was training in sepsis and in 56% (55 of 99) it was periodic. Considering the size of the hospital, large hospitals participated more frequently as recipients of patients with sepsis and had an infectious, sepsis and short-stay unit, a microbiologist and infectious disease specialist on duty. CONCLUSIONS Most EDs have sepsis protocols, but there is room for improvement. The computerization and development of alerts for diagnosis and treatment still have a long way to go in EDs.
Collapse
|
6
|
Derivation and validation of a novel 3-hour pathway for the observe-zone of the ESC 0/1h-algorithm. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The latest non-ST elevation myocardial infarction (NSTEMI) guidelines from the European Society of Cardiology (ESC) recommend a 3h cardiac troponin determination in patients triaged to the observe-zone of the ESC 0/1h-algorithm; however, no specific cut-off for further triage is endorsed.
Purpose
To derive and internally, as well as externally, validate a novel 3-hour pathway for the observe-zone of the ESC 0/1h-algorithm.
Methods
In an ongoing multicentre international diagnostic study, we prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of myocardial infarction (MI). Final diagnoses were centrally adjudicated by two independent cardiologists applying the 4th universal definition of MI, based on complete cardiac work-up including cardiac imaging, serial high sensitivity cardiac troponin T (hs-cTnT) sampling and 90-day follow-up information. High sensitivity-cTnT concentrations were measured at presentation and after 1 and 3 hours. The primary outcome was safety, quantified by the sensitivity and NPV for early rule out of NSTEMI. External validation was performed in an independent multicentre international study.
Results
Among 2076 eligible patients, application of the ESC 0/1h-algorithm triaged 1512 patients (72.8%) to either rule-out or rule-in of NSTEMI, remaining 564 patients (27.2%) in the observe-zone (adjudicated NSTEMI prevalence 120/564 patients, 21.3%). The novel derived 3h-pathway for the observe-zone patients ruled-out NSTEMI with a 3h hs-cTnT concentration <15 ng/L and a 0/3h-hs-cTnT absolute change <4 ng/L, triaging 138 patients (25%) towards rule-out, resulting in a sensitivity of 99.2% (95% CI 96.0–99.9) and a NPV of 99.3% (95% CI 95.4–99.9). A 0/3h-hs-cTnT absolute change ≥6 ng/L ruled-in 63 patients (11.2%), resulting in a specificity of 98% (95% CI 96.2–98.9) and a PPV of 85.7% (95% CI75.0–92.3). The novel 3h-pathway reduced the number of patients in the observe zone by 36%, and the number of T1MI by 50% (Figure 1). Findings were confirmed in both internal and external validation.
Conclusions
A novel derived pathway combining a 3h hs-cTnT concentration <15 ng/L and a 0/3h absolute change <4 ng/L allowed to very safely rule-out NSTEMI in patients remaining in the observe-zone of the ESC 0/1h-algorithm.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Swiss Heart FoundationThe Swiss National Science Foundation Figure 1
Collapse
|
7
|
Early diagnosis of acute myocardial infarction in patients with a history of percutaneous coronary intervention. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Recurrence of acute chest pain after percutaneous coronary intervention (PCI) is common. The early detection of acute myocardial infarction (AMI) as a possible cause of acute chest pain can be challenging in patients with a history of PCI due to e.g. pre-existing electrocardiographic abnormalities. It is unknown, whether high-sensitivity cardiac troponin T (hs-cTnT) concentrations and hs-cTnT-based rapid algorithms perform equally well in patients with a history of PCI.
Purpose
To investigate the impact of prior PCI on the diagnostic performance of hs-cTnT concentrations for early rule-out and rule-in of AMI.
Methods
In an ongoing multicentre international study, we prospectively enrolled unselected patients presenting to the emergency department (ED) with symptoms suggestive of AMI. Final diagnoses were centrally adjudicated by two independent cardiologists using all available medical records obtained during clinical care including 90 day follow-up information and cardiac imaging. High-sensitivity cTnT concentrations at presentation and after 1h were compared against the adjudicated final diagnosis. Patients were stratified according to the presence or absence of previous PCI.
Results
Among 5536 patients (1313 with and 4223 without previous PCI), incidence of AMI was significantly higher in patients with previous PCI (26.3% versus 21.4%; p<0.001). Patients with prior PCI and a final diagnoses other than AMI had significantly higher concentrations of hs-cTnT at presentation to the ED (median 9ng/l [IQR 6 to 15.8] vs 5.5ng/l [IQR 3 to 10]; p<0.001). However, in patients with final adjudicated diagnosis of AMI, hs-TnT concentrations at presentation were lower in patients with previous PCI (median 46ng/l [IQR 23 to 94] vs 55ng/l [IQR 25 to 175]; p=0.003). The diagnostic accuracy of hs-cTnT was high in patients with history of PCI, but significantly lower compared to patients without PCI (AUC 0.91 [95% CI 0.89–0.92] versus AUC 0.94 [95% CI 0.94–0.95]; p<0.001, respectively). When applying the ESC 0/1-algorithm among patients with previous history of PCI, the rule out pathway showed also very high safety in patients with a history of PCI (sensitivity 99.2 [95% CI 97.2–99.8] and negative predictive value 99.6 [95% CI 98.5–99.9]). However, the efficacy of the ESC 0/1h-algorithm for early rule out of NSTEMI was lower in the PCI group compared to no PCI (45.2% vs 65.1%; P<0.001, respectively), triaging more patients to the observe zone (36.8% versus 18.8%; p<0.001). Time to discharge from the ED was significantly longer in patients with prior PCI (334 min vs 290 min; p<0.001). When stratified for index AMI, patients with history of PCI waited longer for a final diagnoses of AMI (285 vs 217 min; p<0.001).
Conclusions
History of PCI impacts on the diagnostic performance of hs-cTnT. Although the ESC 0/1h-algorithm still performs very safe when applied to patients with a history of PCI, its efficacy is significantly reduced.
Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation, the KTI, the Stiftung für kardiovaskuläre Forschung Basel the University of Basel and the University Hospital Basel
Collapse
|
8
|
Incidence, characteristics and prognosis of different cardiac etiologies underlying cardiac syncope. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Cardiac syncope has been shown to carry the highest hazard for all-cause death compared to other causes of syncope including vasovagal and orthostatic syncope. However, little is known about the incidence, characteristics and prognosis of different cardiac etiologies underlying cardiac syncope.
Purpose
To evaluate the incidence, characteristics and prognosis of different cardiac etiologies underlying cardiac syncope.
Methods
We enrolled patients presenting to the emergency department (ED) with syncope in a large prospective international multicentre study. The cause of syncope (cardiac vs non-cardiac) including the detailed cardiac aetiology (if cardiac) was centrally adjudicated by two independent cardiologists based on detailed in-hospital as well as outpatient cardiac work-up during 360 days following presentation. Cardiac syncope was classified into four groups: bradyarrhythmia, tachyarrhythmia, structural disease and other (cardiopulmonary and great vessels), as recommended in the ESC Syncope Guidelines. All-cause death during 2-years follow-up was the primary outcome.
Results
Among 2025 patients presenting with syncope to the ED, cardiac syncope was the final adjudicated diagnoses in 318 (15.7%) patients. The incidence rate of all-cause death among cardiac syncope patients was 103 cases per 1000 person-years. Bradyarrhythmia was the most frequent primary cause of cardiac syncope (n=146, 45.9%) followed by tachyarrhythmia (n=75, 23.6%), structural disease (n=64, 20.1%) and other cardiac (n=26, 8.2%). Patients were 37% female with a median age of 77 years (IQR 67–83) showing no statistically significant difference between subgroups. Clinical characteristics differed significantly among the four subgroups. E.g. syncope occurred during exercise in 12 patients (8.2%) with bradyarrhythmia, 10 patients (13.3%) with tachyarrhythmia, 16 patients (25%) with structural disease, and 5 patients (19%) with other cardiac (p<0.01). Likely of most importance, long-term mortality differed significantly among the four different cardiac subgroups. The multivariable-adjusted hazard ratios (HR) among patients with bradyarrhythmia, tachyarrhythmia, structural disease and other cardiac as compared to patients with vasovagal syncope, the HR were 1.3 (95% CI 0.7–2.5), 4.6 (95% CI 2.3–9.1), 3.1 (95% CI 1.5–6.4) and 5.9 (95% CI 2.3–15.2), respectively (Figure 1).
Conclusions
Bradyarrhythmia, tachyarrhythmia, and structural cardiac disease are the dominant causes of cardiac syncope. Interestingly, with the appropriate therapy initiated long-term mortality of bradyarrhythmia is comparable to that of vasovagal syncope, while long-term mortality of tachyarrhythmia and structural cardiac disease were substantially increased 3 to 5 fold.
Figure 1. Kaplan-Meier curve
Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Swiss National Science Foundation, the Swiss Heart Foundation, the Stiftung für kardiovaskuläre Forschung Basel, the University of Basel and the University Hospital Basel.
Collapse
|
9
|
Analysis of risk factors associated with recurrence of acute pericarditis in patients diagnosed in the emergency room. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Around 5% of patients consulting to the emergency room (ER) for non-ischemic thoracic pain are diagnosed of acute pericarditis (AP). The good prognosis of this pathology is well known, with a mortality of 1% and a low incidence of serious complications, which has led the research to focus on recurrences. Female sex, corticoid treatment and treatment adherence are related with higher risk of recurrence. Colchicine has been associated with less recurrences.
Purpose
To analyse the factors associated with recurrence after the diagnosis of AP in the ER of a third-level hospital.
Methods
Retrospective review of ER consultations oriented as AP, prospectively documented during 10 years (2008–2018). In 2019, a follow up was done in order to identify the recurrences and to search for associated factors (univariate and multivariate analysis).
Results
610 patients were diagnosed of AP, 175 (29%) recurrences were documented. Factors associated with an increased risk of recurrence were: previous AP, immunosuppression or history of autoimmune disease, fever or increased acute-phase reactants (CRP; ESR), hospitalization and corticoid treatment. Factors associated with less risk of recurrence were: age, non-steroidal anti-inflammatory drug (NSAID) treatment and idiopatic/viral etiology. No association with sex or colchicine treatment was identified. Multivariate analysis identified 3 factors that were independently associated with the risk of recurrence in a direct way: previous history of AP, [OR (IC95%): 2.09 (1.11–3.92)]; increased CRP [OR (IC95%): 1.09 (1.03–1.15)]; hospitalization [OR (IC95%): 2.65 (1.07–6.58)]. 2 factors were inversely associated with the risk of recurrence: age [OR (IC95%): 0.98 (0.96–0.99)]; NSAID treatment [OR (IC95%): 0.56 (0.32–0.97)].
Conclusions
29% of the patients were readmitted to the ER for an AP recurrence. Previous AP, increased CRP and the need of hospitalization were associated with a higher risk of recurrence. Age and NSAID treatment, on the other hand, were associated with less risk of recurrence.
Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Ajuts per la Recerca Josep Font
Collapse
|
10
|
External validation of a clinical decision rule to identify patients at low risk for acute coronary syndrome who do not need objective coronary artery disease testing. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Rapid high-sensitivity cardiac troponin (hs-cTn) based algorithms have substantially improved the early rule-out of acute myocardial infarction (AMI) and thereby facilitated the selection of patients eligible for outpatient management. However, it remains unclear, which patients after rule-out of AMI should still undergo objective anatomic or functional cardiac testing for the detection of relevant coronary artery disease. A pilot study has derived a clinical decision rule for the selection of patients who do not need objective anatomic or functional cardiac testing for coronary artery disease (“No Objective Testing” (NOT) rule).
Purpose
To externally validate the performance of the NOT-rule in a multicentre study.
Methods
Patients presenting to the ED with symptoms suggestive of an acute coronary syndrome (ACS) were enrolled in a large prospective international multicentre study at 12 study sites in five European countries. Two independent cardiologists centrally adjudicated the final diagnosis using all clinical data including cardiac imaging and at least 90-day follow-up. The NOT-rule is applied in patients, in whom a 2h accelerated diagnostic protocol (using hs-cTnI concentrations at 0h/2h and ECG data) has ruled-out AMI and based on clinical variables. In brief, the first rule is a weighted score derived from independent predictors of ACS that classifies patients as low-risk if they score ≤4 points. The second rule was simplified and ruled patients out if they were younger than 50 years, had no history of an AMI or known CAD, and no prescribed nitrates. The third rule equals the second except nitrate use was omitted. Primary objective was the safety and efficacy of the NOT-rules for rule-out of major adverse cardiac events (MACE) including AMI, unstable angina pectoris, urgent or emergency revascularisation or cardiovascular death at 30-days of follow-up. Secondary objective was the safety and efficacy for rule-out of MACE at 2-years.
Results
Out of 3188 enrolled patients, 2162 (68%) had hs-cTnI concentrations at 0h and 2h below the 99th centile as well as a non-diagnostic ECG and were therefore eligible for the analysis. MACE at 30-days occurred in 302 (14%) patients. The second and third rule offered highest safety and efficacy for rule-out of MACE at 30-days. Both identified 492 (23%) patients at low-risk with a sensitivity of 99.7% (95% CI 98.2–99.9%) and a negative predictive value (NPV) of 99.8% (95% CI 98.6–99.9%). One MACE was missed within 30-days (revascularisation of a one-vessel CAD). Sensitivity 98.9% (95% CI 97.1–99.7%) and NPV 99.2% (95% CI 97.8–99.7) were also very high for 1-year MACE, as well as 2-year MACE 98.4% (95% CI 96.5–99.4%) and 98.4% (95% CI 96.5–99.3%), respectively.
Conclusions
The NOT rules proved to be a safe tool that identifies nearly one-fourth of patients at very low risk for MACE, who may not need objective anatomic or functional cardiac testing for coronary artery disease.
Performance of NOT rules
Funding Acknowledgement
Type of funding source: Other. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation, the KTI, the European Union, the Stiftung für kardiovaskuläre Forschung Basel, the University of Basel, the University Hospital Basel
Collapse
|
11
|
Specific sex and gender factors of pericarditis in women. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Pericarditis is relatively common in clinical practice and may present as an isolated disease or as a manifestation of a systemic disease. There is an important sex-gap in the evidence on cardiovascular diseases, whereas it is unclear if there are sex-specific differences in the features of patients with acute pericarditis (AP).
Objective
The aim of this study was to evaluate the presence of specific sex and gender factors of pericarditis in women.
Material and methods
We retrospectively included all consecutive patients admitted with acute pericarditis (AP) in an emergency department (ED) of a tertiary care center between 2008 and 2018. Patients without acute pericarditis diagnosis criteria were excluded. We collected patients' baseline characteristics and management data. Recurrence and complicated related to AP at 30-days and 1-year follow-up were assessed.
Results
A total of 729 patients (mean age 42±17.2 years, 33% females) were analyzed. Women were older than men (47.5 yo vs 40 yo, P<0.001). Univariate analysis showed that women presented more prevalence of obesity (11% vs 5%, P<0.01) and chronic kidney disease (6% vs 3%, P<0.05) with previous autoimmune disease (15% vs 3%, P<0.001), and previous immunosuppressive treatment more frequent (15% vs 7%, P<0.01). Women presented more delayed time between beginnings of symptoms until first medical attendance (70 min vs 41 min, P<0.01). No difference was found either echocardiography findings or blood test values. Autoimmune AP was more prevalent in women than men (9% vs 1%, P<0.001). Hence, corticosteroids treatment was more used in women (12% vs 4,5%, P<0.001). In multivariate analysis, six factors were found as specific gender factors of pericarditis in women: Age (OR: 1.02, 95% CI: 1.01–13.2, P<0.01), obesity (OR: 2.27, 95% CI: 1.15–4.49; P<0,05), smoker (OR: 0.39, 95% CI: 0.25–0.59, P<0.001), previous autoimmune disease (OR: 4,29, 95% CI: 1,77–13,21; P<0,01); electrocardiogram diagnosis criteria (OR: 0,18, 95% CI: 0,6–0,52; P<0,001); Autoimmune etiology (adjusted OR: 11,78, 95% CI: 1,99–69,64; P<0,01). No difference was found in recurrence of AP in 30-days and 1-year follow-up (12% vs 13%, P>0.05; 14% vs 13%. P>0.05; respectively).
Conclusion
In our cohort, women with AP attended ED later than men and were less likely to present with typical AP changes in the electrocardiogram. Moreover, women are more commonly affected by specific forms of pericarditis related to autoimmune disease. However, follow-up did not show differences related to gender.
Funding Acknowledgement
Type of funding source: None
Collapse
|
12
|
Clinical risk scores and integrated clinical judgment in patients with suspected acute coronary syndrome. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Clinical risk scores are recommended for formal risk stratification in patients presenting with suspected acute coronary syndrome (ACS). It is unknown, whether these scores still provide additional value in the era of high-sensitivity cardiac troponin (hs-cTn) compared to simple integrated clinical judgment.
Purpose
To evaluate the diagnostic and prognostic performance of integrated clinical judgment compared to clinical risk scores.
Methods
We prospectively enrolled patients presenting to the emergency department with symptoms suggestive of ACS such as acute chest discomfort. The primary prognostic endpoint was the composite of 30-day major adverse cardiac events (MACE) including all-cause death, life-threatening arrhythmia, cardiogenic shock, acute myocardial infarction (AMI, including the index event), and urgent coronary revascularization and was adjudicated by two independent cardiologists. The performance of five well-established formal risk scores (T-MACS, HEART, GRACE, TIMI, and EDACS) for the prediction of 30-day MACE was directly compared with simple integrated clinical judgment for the ACS likelihood by the treating ED physician. Integrated clinical judgment was quantified using a visual analogue scale at 90 minutes after patient's presentation to the ED. The primary diagnostic endpoint was index AMI.
Results
Among 2031 patients, 417/2031 patients (20.5%) had at least one MACE within 30 days. Prognostic accuracy for 30-day MACE quantified by the area under the receiver-operating characteristics curve (AUC) was 0.87 (95% CI 0.85–0.89) for T-MACS, 0.87 (95% CI 0.85–0.89) for HEART, 0.84 (95% CI 0.82–0.86) for GRACE, 0.81 (95% CI 0.79–0.83) for TIMI, 0.75 (95% CI 0.73–0.78) for EDACS, versus 0.89 (95% CI 0.87–0.91) for simple integrated clinical judgment (p<0.01 versus GRACE, TIMI, and EDACS; Figure 1). Similarly, diagnostic accuracy was 0.92 (95% CI 0.90–0.94) for T-MACS, 0.89 (95% CI 0.87–0.90) for HEART, 0.88 (95% CI 0.86–0.89) for GRACE, 0.80 (95% CI 0.78–0.82) for TIMI, 0.74 (95% CI 0.72–0.77) for EDACS, versus 0.89 (95% CI 0.88–0.91) for simple integrated clinical judgment (p<0.01 versus GRACE, TIMI, and EDACS).
Conclusion
None of the formal clinical risk scores outperformed simple integrated clinical judgment for ACS in the prediction of 30-day MACE or the diagnosis of AMI. Therefore, in the era of hs-cTn testing as part of integrated clinical judgment, clinical risk scores seem to no longer provide incremental value.
Figure 1. Diagnostic accuracy for MACE at 30-days
Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): Swiss National Science Foundation, Swiss Heart Foundation
Collapse
|
13
|
Validation of the FAINT risk score in a large prospective international multicenter study. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Risk stratification of older patients presenting to the Emergency Department (ED) with syncope remains an unmet clinical need. The FAINT Score was derived in a large American cohort in an attempt to predict 30-day serious cardiac outcomes in patients >60y.o. While a FAINT score of 0 showed high sensitivity to exclude death and serious outcomes at 30 days in the derivation cohort, it remains unvalidated.
Methods
We validated the FAINT score (History of heart failure, history of arrhythmia, initial ECG result abnormal, elevate NT-proBNP, elevated hs-troponin T) in a large prospective international multicenter study recruiting patients 40 years presenting to the ED with syncope within the last 12 hours in eight countries on three continents. Main outcome measure was 30-day serious cardiac events or mortality. We assessed the performance and calibration of the FAINT score for validation and compared it to the OESIL score (Age >64y, cardiovascular disease history, syncope without prodromes, abnormal ECG).
Results
1885 patients were eligible for this validation analysis. 169 (8.9%) patients experienced 30-day serious adverse events.
A FAINT score of 0 was present for 378 patients (20% of the cohort) and allowed for a sensitivity of 0.97 to rule out adverse events and death at 30-days. A FAINT score of 0 or 1 was present for 626 patients (33% of the cohort) and allowed for a sensitivity of 0.92.
The area under the receiver operating characteristic curve (AUC) for the FAINT score was 0.75 (95%, Confidence Interval (CI) 0.72–0.79), which was comparable to the performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) or high-sensitivity Troponin T (hs-cTnT) alone, which are two biomarkers used in the FAINT score. The score did not outperform the OESIL score.
A calibration curve showed that the score was extremely well calibrated for low-risk patients.
Conclusion
This is the first validation of the FAINT score in a large international syncope cohort. The safety of a FAINT score of 0 or 1 was good and comparable to the results obtained in the derivation cohort. While the score is suitable to highlight low-risk patients and calibrates well in an external cohort, its discrimination for higher risk patients is not better than biomarkers alone or an older, less complex risk score.
Figure 1. Area under the Receiver Operating Curve (ROC) for the FAINT score and for NT-proBNP and hs-cTnT as continuous markers as well as for the OESIL score. CI = Confidence Interval.
Funding Acknowledgement
Type of funding source: Public hospital(s). Main funding source(s): University Hospital Basel, Switzerland
Collapse
|
14
|
Early diagnosis of myocardial infarction in patients presenting late after chest pain onset. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The European Society of Cardiology (ESC) recommends the clinical use of the 0/1h-algorithms in patients with suspected acute coronary syndrome (ACS) to rule-out or rule-in non-ST elevation myocardial infarction (NSTEMI). However, the diagnostic performance of the ESC 0/1h-algorithms was only validated in patients presenting within 12 hours after chest pain onset (=early presenters) to the emergency department (ED). To this date, evidence regarding their performance in patients with chest pain onset >12h (=late presenters) is lacking.
Purpose
To evaluate the diagnostic performance of the ESC 0/1h-algorithms in late presenters.
Methods
We prospectively enrolled patients presenting to the ED with symptoms suggestive of ACS such as acute chest discomfort. Two independent cardiologists adjudicated the final diagnoses based on all available clinical information including serial hs-cTn concentrations, follow-up information and cardiac imaging. Hs-cTnT/I concentrations at 0h and 1h were measured in a blinded fashion. The primary diagnostic endpoint was the diagnostic performance of the hs-cTnT/I ESC 0/1h-algorithms in patients presenting late after chest pain onset compared to those presenting early. Diagnostic performance was quantified by safety of rule-out (sensitivity and negative predictive value), accuracy of rule-in (specificity and positive predictive value), and efficacy (proportion of patients) classified as rule-out or rule-in within 1 hour after presentation to the ED. The primary prognostic endpoint was all-cause mortality after 30-days and two-years in patients in whom NSTEMI was ruled-out by the ESC 0/1h-algorithms.
Results
Among 4733 patients, 308/4733 (7%) presented late to the ED. The ESC hs-cTnT 0/1h-algorithm ruled-out 185/308 (60%) of late presenters with a sensitivity of 100% (95% CI, 93.7–100) and a negative predictive value (NPV) of 100% (95% CI, 98.0–100). Sixty-one of 308 (20%) were ruled-in with a specificity of 95.2 (95% CI, 91.8–97.2) and a positive predictive value (PPV) of 80.3% (95% CI, 68.7–88.4). The remaining 62/308 (20%) were classified as observe with a NSTEMI prevalence of 13%. In comparison, 59% of early presenters were ruled-out (sensitivity 99.3% [95% CI, 98.4–99.7]; NPV 99.8 [99.5–99.9]), 17% were ruled-in (specificity 96.2 [95% CI, 95.5–96.8]; PPV 81.4 [95% CI, 78.4–84.0]), and 45% were classified as observe. Late presenters in whom NSTEMI was ruled-out had 30-day and two-year survival rates of 100% and 98.2%, respectively. Similar findings were made for the ESC hs-cTnI 0/1h-algorithm.
Conclusion
The ESC hs-cTnT/I algorithms also provide excellent diagnostic performance for early triage and specifically safe rule-out of NSTEMI in patients presenting late after chest pain onset to the ED.
Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): Swiss Heart Foundation, Swiss National Science Foundation
Collapse
|
15
|
External validation of a suggested extension of the ESC 0/1h-algorithm for early rule out of myocardial infarction. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The European Society of Cardiology (ESC) high sensitivity cardiac troponin T 0/1h-algorithm has substantially improved the management of patients with suspected acute myocardial infarction (AMI) by triaging about 75% of patients to rapid rule-out and/or rapid rule-in. However, about 25% of patients remain in the “observe-zone”, and the optimal management of these patients is unknown. Recently, a pilot single center study with a low prevalence of AMI suggested that an absolute change of less than 7ng/L between the 0h and 3h hs-cTnT concentration would allow to help in the evaluation of patients in the observe-zone and allow triage towards rule-out with very high negative predictive value [NPV].
Purpose
To externally validate this suggested modification of the ESC 0/1h-algorithm for early rule out of AMI.
Methods
In an ongoing multicentre international study, we prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of MI. Final diagnoses were centrally adjudicated by two independent cardiologists using all available medical records obtained during clinical care including 90 day follow-up information and cardiac imaging. High sensitivity-cTnT (Elecsys) concentrations were measured at presentation and after 1 and 3 hours. The primary outcome was safety, quantified by the sensitivity and NPV for early rule out of NSTEMI.
Results
Among 1633 enrolled patients with available 0, 1 and 3h hs-cTnT concentrations, NSTEMI was the adjudicated final diagnosis in 337 (20.6%) patients. The ESC 0/1h-algorithm ruled out 918 (56.2%) patients, with a sensitivity of 98.8% (95% confidence interval [CI], 97.0–99.5) and a NPV of 99.6% (95% CI, 98.9–99.8). A total of 428 patients (26.2%) remained in the observe zone. After applying the suggested 0–3 hour absolute change cut-off criteria of 7ng/L, 393 (92.0%) additional patients from the observe zone were triaged towards ruled out. However, the safety of this triage step was poor with 62 patients with NSTEMI missed, resulting in a sensitivity of 33.3% and a NPV of 84.2% for rule-out.
Conclusions
The suggested 0/3h absolute change cut-off of 7ng/L for patients remaining in the observe zone of the ESC 0/1h-algorithm does NOT allow safe rule-out of AMI and should therefore NOT be implemented into routine clinical care.
Figure 1
Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation, the Stiftung für kardiovaskuläre Forschung Basel, the University of Basel and the University Hospital Basel
Collapse
|
16
|
Abstract
Abstract
Background
Lately, the novel high-sensitivity cardiac troponin I (hs-cTnI) Access assay was developed. Its clinical performance in patients presenting with chest pain to the emergency department (ED) is unknown.
Purpose
To clinically validate the novel hs-cTnI-Access assay and to derive and validate an assay specific 0/1h-algorithm accordingly to the European Society of Cardiology (ESC) recommendations.
Methods
In a prospective international multicentre study we enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI). Final diagnoses were centrally adjudicated by two independent cardiologists including all clinical information including cardiac imaging twice: first, using serial hs-cTnT (Elecsys, primary analysis) and second, using hs-cTnI (Architect, secondary analysis) measurements in addition to the clinically used (hs)-cTn. Hs-cTnI-Access was measured at presentation and at 1h. Primary objective was a direct comparison of diagnostic accuracy as quantified by the area under the receiver-operating-characteristic curve (AUC) of hs-cTnI-Access versus the two established hs-cTn assays (hs-cTnT-Elecsys, hs-cTnI-Architect). Secondary objectives included the derivation and internal validation of an hs-cTnI-Access specific 0/1h-algorithm.
Results
AMI was the adjudicated final diagnosis in 243/1579 (15.4%) patients. The AUC at presentation for hs-cTnI-Access was 0.95 (95% CI, 0.94–0.96), significantly higher as hs-cTnI-Architect (0.92 [95% CI, 0.91–0.94; p<0.001]), and comparable to hs-cTnT-Elecsys (0.94 [95% CI, 0.93–0.95; p=0.12]) Applying the derived hs-cTnI-Access 0/1h-algorithm (derivation cohort n=686) to the internal validation cohort (n=680), 60% of patients were ruled-out (sensitivity 98.9% [95% CI, 94.3–99.8]), and 15% of patients were ruled-in (specificity 95.9% [95% CI, 94.0–97.2]). Patients ruled-out by the 0/1h-algorithm had a survival rate of of 100% after 30-days and 98.4% after two years of follow up. Findings were confirmed in the secondary analyses using the adjudication including serial measurements of hs-cTnI (Architect).
Performance of the 0/1h-algorithm
Conclusions
Diagnostic accuracy of the novel hs-cTnI-Access assay is excellent and at least comparable to the two established hs-cTn assays. The assay-specific 0/1h-algorithm allows a safe rule-out and accurate rule-in of MI in about 75% of patients within 1-hour after presentation to the ED. Survival of patients ruled-out by the 0/1h-algorithm was very high.
Acknowledgement/Funding
Swiss National Science Foundation, the Swiss Heart Foundation, the KTI, the European Union, the Stiftung für kardiovaskuläre Forschung Basel
Collapse
|
17
|
P6354Decreased beneficial effects of oral heart failure medications in patients with acute decompensated heart failure and hyperglycemia: results from an international observational cohort. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Hyperglycemia is common, regardless of diabetes mellitus (DM), and is associated with increased mortality in patients with acute heart failure (AHF). Current oral heart failure (HF) medications improve the outcome in patients with AHF. However, the relationships between HF medications, admission glucose levels, and prognosis in AHF patients remained unknown.
Purpose
This study sought to investigate the effect of oral HF medications on relationships between hyperglycemia at admission and 1-year all-cause mortality in patients with AHF.
Methods
From the GREAT (Global Research on Acute Conditions Team) registry, 13840 patients presenting with AHF whose admission glucose levels were available were included and followed up for 1-year all-cause mortality. Hyperglycemia was defined as a glucose levels of ≥7 mmol/L for patients without history of DM and ≥10 mmol/L for those with history of DM. Patients with hypoglycemia (defined as a glucose levels of ≤4 mmol/L, n=193, 1.4%) were excluded in this analysis.
Results
There were 6418 (%) patients with hyperglycemia and 7229 (%) patients with normoglycemia. One-year mortality was higher in patients with hyperglycemia than those with normoglycemia (1911 [30%] and 1821 [25%], respectively). Even after adjustment, the risk for 1-year mortality was significantly higher in hyperglycemia (HR 1.14, 95%-CI 1.04–1.26, P=0.008) compared with normoglycemia. Detrimental effects of hyperglycemia on 1-year mortality were more severe in de novo AHF patients than in patients with history of HF (p for interaction 0.004). Oral HF medications (beta blockers and/or angiotensin converting enzyme inhibitors/angiotensin receptor blockers) at discharge were effective in AHF patients with normoglycemia regardless of history of HF. Oral HF medications at discharge are very effective in de novo AHF patients with hyperglycemia and less effective in acute decompensated HF patients with hyperglycemia (Figure).
HF medications and 1-year mortality
Conclusions
Hyperglycemia at admission is associated with increased risk for 1-year mortality. Current oral HF medications are effective in most of subgroups, though they were less effective in patients with acute decompensated HF and hyperglycemia. These patients might need more aggressive therapies to improve outcomes.
Acknowledgement/Funding
This work was supported by a research fellowship from Japan Heart Foundation (E.A.)
Collapse
|
18
|
P1656Incremental value of interleukin-6 and C-reactive protein to the MEESSI acute heart failure risk score. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The MEESSI-acute heart failure (AHF) risk score has high accuracy in the prediction of 30-day mortality in patients presenting with AHF and may be considered the current gold standard for this indication.
Purpose
As the original MEESSI model does not include measurements of inflammatory biomarkers, the impact of interleukin-6 or C-reactive protein (CRP) on the model's goodness of fit is unknown.
Methods
In a prospective multicenter diagnostic study the presence of AHF was centrally adjudicated by two independent cardiologists among patients presenting with acute dyspnea to the ED. The MEESSI-AHF risk score was calculated using a recalibrated model containing 12 independent risk factors. The incremental value of interleukin-6 and CRP was examined by the use of logistic regression analysis and enter method variable selection with an entry criterion of p<0.05. Goodness of fit tests were performed to measure the updated model's discrimination and calibration.
Results
In 1247 patients with adjudicated AHF, the MEESSI-AHF risk score was calculated. Of these, 1113 patients (89.3%) had available measurements of interleukin-6 and CRP. In the logistic regression analysis both biomarkers had a highly significant impact on the MEESSI model (p<0.001, respectively). Compared to the original MEESSI-Model (c-statistic, 0.79 (95% CI, 0.75–0.83)) the addition of interleukin-6 (c-statistic, 0.81 (95% CI, 0.77–0.85)) or CRP (c-statistic, 0.83 (95% CI, 0.79–0.86)) significantly improved the model's discrimination (p=0.022 and p=0.011, respectively). When assessing the cumulative mortality, the gradient in 30-day mortality over six predefined risk groups was increased by addition of interleukin-6 or CRP. 30-day mortality rates in the lowest and highest risk groups of the original model were 0.4% and 32.5% compared to 0% and 34.9% in the model updated with interleukin-6 and 0.6% and 37.6% in the model updated with CRP. All compared models showed good overall calibration (Hosmer-Lemeshow p=0.302 (original model), p=0.136 (model updated by interleukin-6) and p=0.902 (model updated by CRP)).
Discrimination original_updated
Conclusion
There is significant incremental value of interleukin-6 and CRP to the MEESSI score as indicated by the improved goodness of fit compared to the original model.
Acknowledgement/Funding
European Union, the Swiss National Science Foundation, the Swiss Heart Foundation, the Cardiovascular Research Foundation Basel,
Collapse
|
19
|
P4538Effect of risk of malnutrition on 30-day mortality among older patients with acute heart failure in emergency departments. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
There is a need to explore the risk of malnutrition as a modifiable prognostic factor in order to establish routine screening of malnutrition in the emergency setting among older patients with acute heart failure (AH.
Objectives
To determine the impact of risk of malnutrition on 30-day mortality risk among older patients attended for AHF in the Emergency Department (ED).
Methodology
We performed a secondary analysis of the OAK-3 Registry including all consecutive patients ≥65 years attended with AHF in 16 Spanish EDs over a 2-month period (January-February 2016). Risk of malnutrition was defined by the Mini Nutritional Assessment Short Form (MNA-SF) <12 points. Unadjusted and adjusted logistic regression models were used to assess the association between risk of malnutrition and 30-day mortality.
Results
We included 749 patients (mean age: 85 (SD 6); 55.8% females). Risk of malnutrition was observed in 594 (79.3%) patients. The rate of 30-day mortality was 8.8%. After adjusting for MEESSI-AHF risk score clinical categories (model 1) and after adding all variables showing a significantly different distribution among groups (model 2), the risk of malnutrition was an independent factor associated with 30-day mortality (adjusted OR by model 1=3.4; 95% CI 1.2–9.7; p=0.020 and adjusted OR by model 2=3.2; 95% CI 1.1–9.2; p=0.030) compared to normal nutritional status.
Conclusions
The risk of malnutrition assessed by the MNA-SF is associated with 30-day mortality in older patients attended with AHF in EDs. Routine screening of risk of malnutrition may help emergency physicians in decision-making and establishing a care plan.
Acknowledgement/Funding
Spanish Ministry of Health and FEDER (PI 18/00456, PI 18/00393, PI 17/00972, PI17/1732, PI15/00773, PI15/01019, and PI11/01021)
Collapse
|
20
|
3305Validation of a novel high-sensitivity cardiac troponin i assay for early diagnosis of acute myocardial infarction. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The novel high-sensitivity cardiac troponin I (hs-cTnI)-Vitros assay was developed recently. Before its possible implementation into routine clinical care for triage of chest pain patients, its performance needs clinical validation.
Purpose
To clinically validate hs-cTnI-Vitros and to derive and validate an assay-specific 0/1h-algorithm following the European Society of Cardiology (ESC) recommendations.
Methods
In a prospective international multicentre study (12 centres in 5 European countries) we enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI). Final diagnoses were centrally adjudicated by two independent cardiologists including all clinical information including cardiac imaging twice: first, using serial hs-cTnT (Elecsys, primary analysis) and second, using hs-cTnI (Architect, secondary analysis) measurements in addition to the clinically used (hs)-cTn. Hs-cTnI-Vitros was measured at presentation and at 1h in a blinded fashion. Primary objective was direct comparison of diagnostic accuracy as quantified by the area under the receiver-operating-characteristic curve (AUC) of hs-cTnI-Vitros versus the two established hs-cTn assays (hs-cTnT-Elecsys, hs-cTnI-Architect). Secondary objectives included the derivation and validation of a hs-cTnI-Vitros specific 0/1h-algorithm.
Results
AMI was the adjudicated final diagnosis in 158/1231 (13%) patients. The AUC at presentation for hs-cTnI-Vitros was 0.95 (95% CI, 0.93–0.96), and significantly higher as hs-cTnT-Elecsys (0.94 [95% CI, 0.92–0.95; p=0.01]) and hs-cTnI-Architect (0.92 [95% CI, 0.90–0.94; p<0.001]). Applying the derived hs-cTnI-Vitros 0/1h-algorithm (derivation cohort n=519) to the validation cohort (n=520), 53% of patients were ruled-out (sensitivity 100% [95% CI, 98.6–100]), and 14% of patients were ruled-in (specificity 95.6% [95% CI, 93.4–97.2]). Patients ruled-out by the 0/1h-algorithm had a survival rate of 99.8% at 30-days and 98.7% at 2-years. Findings were confirmed in the secondary analyses using the adjudication including serial measurements of hs-cTnI (Architect).
ROC Curves for the 3 hs-cTn assays at 0h
Conclusions
The novel hs-cTnI-Vitros assay has even higher diagnostic accuracy as the current gold-standards hs-cTnT and hs-cTnI. The hs-cTnI-Vitros specific 0/1h-algorithms allows a safe rule-out and accurate rule-in of AMI in about 70% of patients within 1h after presentation to the ED.
Acknowledgement/Funding
Swiss National Science Foundation, the Swiss Heart Foundation, the KTI, the European Union, the Stiftung für kardiovaskuläre Forschung Basel
Collapse
|
21
|
|
22
|
P2714Diagnostic accuracy of a novel ultra-sensitive cardiac troponin I assay compared to high-sensitivity cardiac troponin T and I for the early diagnosis of myocardial infarction. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
23
|
P5595Clinical effect of sex-specific cutoff values of high-sensitivity cardiac troponin I in suspected myocardial infarction. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p5595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
24
|
P4612Validation of a score for early discrimination of patients with type 2 myocardial infarction. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p4612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
25
|
P3437External validation of the MEESSI acute heart failure risk score. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
26
|
P6461One-hour rule-out and rule-in of acute myocardial infarction using a novel ultra-sensitive cardiac troponin I assay. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p6461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
27
|
P6454Comparing the prognostic value of ultra-sensitive cardiac troponin I versus high-sensitivity cardiac troponin T and I among patients with suspected myocardial infarction. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p6454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
28
|
P4836Sex-specific symptoms in the early diagnosis of syncope. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p4836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
29
|
P828Direct comparison of three 0/1h-algorithms for rapid rule-out and rule-in of acute myocardial infarction using one ultra-sensitive and two high-sensitivity cardiac troponin assays. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy564.p828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
30
|
P3436The J-curve relationship between admission glucose level and 1-year mortality in patients with acute heart failure: results from an international observational cohort. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
31
|
P4678Impact of the U.S. FDA regulatory approach not to report high-sensitivity cardiac troponin T concentrations below 6 ng/l on the ESC 0/1-hour algorithm for rule-out/in of acute myocardial infarction. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx504.p4678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
32
|
P82824-hour patterning of different syncope etiologies in patients presenting to the emergency department. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx501.p828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
33
|
P5585Diagnosis of acute myocardial infarction in patients presenting with left bundle branch block. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx493.p5585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
34
|
2271Validation of the European Society of Cardiology 0/1-hour algorithm for rule-out and rule-in of acute myocardial infarction. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx502.2271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
35
|
P468Natural history of syncope: insights from the BASEL IX study. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx501.p468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
36
|
P4696One-hour rule-out and rule-in of acute myocardial infarction using a novel high-sensitivity cardiac troponin I assay. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx504.p4696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
37
|
P2328Performance of the ESC 0/1-hour algorithm for rapid rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin I in patients with impaired and normal renal function. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx502.p2328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
38
|
P1491Gender related differences in long-term outcomes of acute heart failure patients from different geographic regions. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx502.p1491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
39
|
P469Pro-hormones in the early diagnosis of cardiac syncope. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx501.p469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
40
|
52Effect of pre-test probability on diagnostic and prognostic performance of high-sensitivity cardiac troponin for acute myocardial infarction. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx501.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
41
|
Retraction: The improvement of large High-Density Lipoprotein (HDL) particle levels, and presumably HDL metabolism, depend on effects of low-carbohydrate diet and weight loss. EXCLI JOURNAL 2016; 15:570. [PMID: 27932940 PMCID: PMC5138495 DOI: 10.17179/excli2016-570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 09/19/2016] [Indexed: 02/05/2023]
Abstract
[This retracts the article DOI: 10.17179/excli2015-642.].
Collapse
|
42
|
The improvement of large High-Density Lipoprotein (HDL) particle levels, and presumably HDL metabolism, depend on effects of low-carbohydrate diet and weight loss. EXCLI JOURNAL 2016; 15:166-76. [PMID: 27103896 PMCID: PMC4834750 DOI: 10.17179/excli2015-642] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 02/10/2016] [Indexed: 02/05/2023]
Abstract
Depressed levels of atheroprotective large HDL particles are common in obesity and cardiovascular disease (CVD). Increases in large HDL particles are favourably associated with reduced CVD event risk and coronary plaque burden. The objective of the study is to compare the effectiveness of low-carbohydrate diets and weight loss for increasing blood levels of large HDL particles at 1 year. This study was performed by screening for body mass index (BMI) and metabolic syndrome in 160 consecutive subjects referred to our out-patient Metabolic Unit in South Italy. We administered dietary advice to four small groups rather than individually. A single team comprised of a dietitian and physician administered diet-specific advice to each group. Large HDL particles at baseline and 1 year were measured using two-dimensional gel electrophoresis. Dietary intake was assessed via 3-day diet records. Although 1-year weight loss did not differ between diet groups (mean 4.4 %), increases in large HDL particles paralleled the degree of carbohydrate restriction across the four diets (p<0.001 for trend). Regression analysis indicated that magnitude of carbohydrate restriction (percentage of calories as carbohydrate at 1 year) and weight loss were each independent predictors of 1-year increases in large HDL concentration. Changes in HDL cholesterol concentration were modestly correlated with changes in large HDL particle concentration (r=0.47, p=.001). In conclusion, reduction of excess dietary carbohydrate and body weight improved large HDL levels. Comparison trials with cardiovascular outcomes are needed to more fully evaluate these findings.
Collapse
|
43
|
[Some considerations on the analysis of publications in clinical neurology in different European countries over the period 2000-2009]. Rev Neurol 2012; 54:510-511. [PMID: 22492106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
|
44
|
Liquid ecstasy intoxication: clinical features of 505 consecutive emergency department patients. Emerg Med J 2011; 28:462-6. [DOI: 10.1136/emj.2008.068403] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
45
|
Comparison between exclusively school teacher-based and mixed school teacher and healthcare provider-based programme on basic cardiopulmonary resuscitation for secondary schools. Emerg Med J 2009; 26:648-52. [DOI: 10.1136/emj.2008.062992] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
46
|
[The possibilities of fibrinolytic treatment within the first three hours following a stroke: is there a ceiling?]. Rev Neurol 2007; 45:316-7. [PMID: 17876744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
|
47
|
A Primary Care Physician Seeing Patients in a Fast Track Area: Effect on Effectiveness, Efficiency, and Perceived Care Quality. Ann Emerg Med 2005. [DOI: 10.1016/j.annemergmed.2005.06.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
48
|
Basic cardiopulmonary resuscitation program for high school students (PROCES): How many concepts and skills remain one year later? Ann Emerg Med 2004. [DOI: 10.1016/j.annemergmed.2004.07.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
49
|
Basic cardiopulmonary resuscitation program for high school students (PROCES): Results from the pilot program. Ann Emerg Med 2004. [DOI: 10.1016/j.annemergmed.2004.07.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
50
|
Histological and biochemical assessment of mitochondrial function in dermatomyositis. Rheumatology (Oxford) 1998. [DOI: 10.1093/rheumatology/37.10.1047] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|