High-sensitivity cardiac troponin T in detecting obstructive coronary artery disease in hemodialysis patients listed for kidney transplantation.

BACKGROUND: Cardiovascular diseases are the leading cause of morbidity and mortality in patients with end-stage renal disease. AIMS: This study aimed to assess the prognostic value of high-sensitivity cardiac troponin T (hs-cTnT) in identifying patients with obstructive coronary artery disease (CAD) among patients on hemodialysis listed for kidney transplantation. METHODS: The study prospectively enrolled consecutive adult hemodialysis patients listed for kidney transplantation. They underwent laboratory tests and a standardized set of imaging and functional tests, including coronary angiography, according to patient characteristics. RESULTS: The study included 100 consecutive patients (72 men)at a median age of 56.5 years. Ultimately, 48% of the patients were diagnosed with obstructive CAD. Age and plasma hs-cTnT levels predicted the diagnosis of obstructive CAD (OR, 1.13; 95% CI, 1.08-1.20; P < 0.001 and OR, 1.03; 95% CI, 1.01-1.05; P = 0.001, respectively). The calculated cut-off value for age was 53 years, which showed sensitivity of 87.5% and specificity of 76.9% for obstructive CAD diagnosis. The calculated value for hs-cTnT was 0.067 ng/ml, which showed sensitivity of 61.4% and specificity of 82.2% for the detection of obstructive CAD. In patients aged >52 years, 79.2% were diagnosed with obstructive CAD. However, in the group of patients ≤52 years and with hs-cTnT >0.069 ng/ml, the incidence of obstructive CAD was significantly higher than in the group with hs-cTnT level ≤0.069 ng/ml. CONCLUSIONS: Baseline hs-cTnT level is a useful prognostic biomarker in the diagnosis of obstructive CAD in hemodialysis patients listed for kidney transplantation.

Plasma Troponins Identify Patients with Very Low-Risk Acute Pulmonary Embolism.

INTRODUCTION: Although in the non-vitamin K oral anticoagulants (NOAC) era majority of low-risk acute pulmonary embolism (APE) patients can be treated at home, identifying those at very low risk of clinical deterioration may be challenging. We aimed to propose the risk stratification algorithm in sPESI 0 point APE patients, allowing them to select candidates for safe outpatient treatment. MATERIALS AND METHODS: Post hoc analysis of a prospective study of 1151 normotensive patients with at least segmental APE. In the final analysis, we included 409 sPESI 0 point patients. Cardiac troponin assessment and echocardiographic examination were performed immediately after admission. Right ventricular dysfunction was defined as the right ventricle/left ventricle ratio (RV/LV) > 1.0. The clinical endpoint (CE) included APE-related mortality and/or rescue thrombolysis and/or immediate surgical embolectomy in patients with clinical deterioration. RESULTS: CE occurred in four patients who had higher serum troponin levels than subjects with a favorable clinical course (troponin/ULN: 7.8 (6.4-9.4) vs. 0.2 (0-1.36) p = 0.000). Receiver operating characteristic (ROC) analysis showed that the area under the curve for troponin in the prediction of CE was 0.908 (95% CI 0.831-0.984; p < 0.001). We defined the cut-off value of troponin at >1.7 ULN with 100% PPV for CE. In univariate and multivariate analysis, elevated serum troponin level was associated with an increased risk of CE, whereas RV/LV > 1.0 was not. CONCLUSIONS: Solely clinical risk assessment in APE is insufficient, and patients with sPESI 0 points require further assessment based on myocardial damage biomarkers. Patients with troponin levels not exceeding 1.7 ULN constitute the group of "very low risk" with a good prognosis.

Electrocardiogram, Echocardiogram and NT-proBNP in Screening for Thromboembolism Pulmonary Hypertension in Patients after Pulmonary Embolism.

Background: The annual mortality of patients with untreated chronic thromboembolism pulmonary hypertension (CTEPH) is approximately 50% unless a timely diagnosis is followed by adequate treatment. In pulmonary embolism (PE) survivors with functional limitation, the diagnostic work-up starts with echocardiography. It is followed by lung scintigraphy and right heart catheterization. However, noninvasive tests providing diagnostic clues to CTEPH, or ascertaining this diagnosis as very unlikely, would be extremely useful since the majority of post PE functional limitations are caused by deconditioning. Methods: Patients after acute PE underwent a structured clinical evaluation with electrocardiogram, routine laboratory tests including NT-proBNP and echocardiography. The aim of this study was to verify whether the parameters from echocardiographic or perhaps electrocardiographic examination and NT-proBNP concentration best determine the risk of CTEPH. Results: Out of the total number of patients (n = 261, male n = 123) after PE who were included in the study, in the group of 155 patients (59.4%) with reported functional impairment, 13 patients (8.4%) had CTEPH and 7 PE survivors had chronic thromboembolic pulmonary disease (CTEPD) (4.5%). Echo parameters differed significantly between CTEPH/CTEPD cases and other symptomatic PE survivors. Patients with CTEPH/CTEPD also had higher levels of NT-proBNP (p = 0.022) but concentration of NT-proBNP above 125 pg/mL did not differentiate patients with CTEPH/CTEPD (p > 0.05). Additionally, the proportion of patients with right bundle brunch block registered in ECG was higher in the CTEPH/CTED group (23.5% vs. 5.8%, p = 0.034) but there were no differences between the other ECG characteristics of right ventricle overload. Conclusions: Screening for CTEPH/CTEPD should be performed in patients with reduced exercise tolerance compared to the pre PE period. It is not effective in asymptomatic PE survivors. Patients with CTEPH/CTED predominantly had abnormalities indicating chronic thromboembolism in the echocardiographic assessment. NT-proBNP and electrocardiographic characteristics of right ventricle overload proved to be insufficient in predicting CTEPH/CTEPD development.

A Novel Doppler TRPG/AcT Index Improves Echocardiographic Diagnosis of Pulmonary Hypertension after Pulmonary Embolism.

BACKGROUND: We hypothesized that a Doppler index, the ratio of tricuspid regurgitation peak gradient (TRPG) to pulmonary ejection acceleration time (AcT), improves the assessment of the echocardiographic probability of pulmonary hypertension in the identification of CTEPH and chronic thromboembolic pulmonary disease (CTED) in symptomatic patients after PE. Doppler echocardiography is recommended as the initial imaging tool for the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE). METHODS: We analyzed the data from 845 consecutive PE (468 women; 61 ± 18 years) survivors who completed at least 6 months of anticoagulation therapy. Here, 555 patients (325 women; 66 ± 16 years) reporting functional impairment (FI) underwent transthoracic echocardiography. We included 506 patients (297 women; age 63.4 ± 16.6 years) in whom both AcT and TRPG were available into the current study. The presence of a minimum of intermediate echocardiographic probability of PH necessitated the diagnosis of CTEPH. RESULTS: Echocardiography revealed a high echocardiographic probability of PH in 69 (13.6%) and intermediate echocardiographic probability in 109 (21.5%) patients. CTEPH was diagnosed in 35 (6.9%) patients and CTED in 22 (4.3%) patients. TRPG/AcT was significantly higher in the combined CTEPH + CTED group than in those with other causes of FI (0.412 (0.100-2.197) vs. 0.208 (0.026-0.115), p < 0.001), and the area under the receiver operating characteristic curve of the TRPG/AcT for CTEPH + CTED was 0.804 (95% confidence interval (CI): 0.731-0.876). Importantly, multiple logistic regression showed that TRPG/AcT is a significant predictor of CTEPH + CTED after considering echocardiographic probability (odds ratio = 1.51, 95% CI: 1.25-1.91, p < 0.001). Conditional inference trees analysis revealed that TRPG/AcT > 0.595 identified patients with CTEPH or CTED with a positive predictive value of 78.6% and negative predictive value of 92.7%. CONCLUSIONS: A Doppler index TRPG/AcT improves the assessment of symptomatic PE survivors. TRPG/AcT > 0.6 indicates a high probability of CTEPH or CTED, whereas TRPG/AcT < 0.6 allows for the safe exclusion of CTEPH + CTED in patients with a low echocardiographic probability of PH.

Assessment of pulmonary embolism severity and the risk of early death.

Currently, venous thromboembolism, including deep vein thrombosis and acute pulmonary embolism (PE), is globally the third most frequent acute cardiovascular syndrome with rising incidence rates. The clinical presentation of PE is heterogenous: from incidental findings on imaging studies to sudden cardiac death. Hemodynamic instability identifies patients at high risk of early mortality. In hemodynamically stable patients, further stratification into intermediate- and low-risk categories is advised, preferably using a combined risk assessment strategy based on clinical parameters, laboratory findings, and imaging markers. Treatment should be tailored to the risk of early death, with more aggressive treatments reserved for patients at higher risk of complications. This review offers an update on the current strategies for assessing PE severity and the risk of early death and discusses developments in predicting mortality risk in patients with PE.

, , ACUTE PULMONARY EMBOLISM BY AMNIOTIC FLUID - A RARE COMPLICATION OF PERINATAL PERIOD THAT SHOULD NOT BE FORGOTTEN.

OBJECTIVE: Amniotic fluid embolism (AFE) is a diagnostically challenging type of pulmonary embolism that occurs when amniotic fluid enters maternal circulation during delivery or postpartum. This obstetric complication is very rare but characterized by high mortality rate. The main symptoms are dyspnea, cardiovascular collapse, disseminated intravascular coagulation (DIC) and even sudden cardiac death. The aim of the article is to draw attention to AFE as a rare but possible and catastrophic complication of perinatal period. The authors present a 28-year-old woman who was admitted to obstetric ward during the first stage of labour. The patient developed sudden deterioration of her medical state with acute respiratory distress symptoms. An emergency cesarean section was performed, complicated by excessive bleeding. After a detailed assessment of the patient's condition and evaluation of the results of additional tests, we diagnosed AFE as the cause of the patient's deterioration. CONCLUSION: Conclusions: The case study shows how unpredictable, unpreventable and dangerous is AFE. It is still one of the main causes of maternal deaths in developed countries. Four diagnostic criteria proposed by the Society for Maternal-Fetal Medicine (SMFM) may accelerate diagnosis. AFE as a medical emergency, requires immediate multidisciplinary response and aggressive treatment. The initial medical care may be facilitated by the application of the general guidelines recommended by SMFM. The case report also emphasizes the need for further research on this disease, in particular on early detection and prevention.

Left ventricular diastolic dysfunction and diseases severity contribute to impaired exercise capacity in systemic lupus erythematosus.

OBJECTIVES: Patients with systemic lupus erythematosus (SLE) have a higher risk of myocardial involvement, which can result in ventricular dysfunction. The aim of our study was to estimate potential relationship between exercise capacity assessed by six minute walk test (6MWT) and echocardiographic parameters of left and right ventricular function in SLE patients. METHODS: We prospectively studied 66 SLE patients (57 F, age 44 (20-75) years) and 27 age matched healthy subjects. In addition to routine evaluation, 6MWT and transthoracic echocardiography including LV diastolic dysfunction parameters (E/A, E/É) were performed. RESULTS: While E/A was similar in both groups, E/E' was higher in patients with SLE than in controls, 7.5 (4-22) vs 6.8 (1.6-9.4), p = 0.018. The mean 6MWT distance was significantly shorter in SLE (561.6 ± 150.7 vs 682.6 ± 98.1 m, p < 0.002). Among SLE patients only 53 (80.3%) were capable to walk at least 450 m, while in controls 27 (100%) (p = 0.013). We observed significant correlations between 6MWT distance and SLICC/ACR-DI (rho=-0.44, p < 0.001), E/A (rho = 0.30, p = 0.004), E/E' (rho=-0.36, p < 0.001) in SLE patients. Univariable logistic regression models revealed that SLICC/ACR-DI, E/E', tricuspid regurgitant peak gradient (TRPG), and right ventricular systolic pressure (RVSP) were associated with 6MWT distance lower than < 450 m. ROC curves shown high predictive value of E/E' ratio, TRPG, RVSP in the prediction for 6MWT distance < 450 m. CONCLUSION: Impaired exercise tolerance seems to result mainly from the severity of SLE and LV diastolic dysfunction.

Non-invasive early exclusion of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the InShape II study.

BACKGROUND: The current diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE) is unacceptably long, causing loss of quality-adjusted life years and excess mortality. Validated screening strategies for early CTEPH diagnosis are lacking. Echocardiographic screening among all PE survivors is associated with overdiagnosis and cost-ineffectiveness. We aimed to validate a simple screening strategy for excluding CTEPH early after acute PE, limiting the number of performed echocardiograms. METHODS: In this prospective, international, multicentre management study, consecutive patients were managed according to a screening algorithm starting 3 months after acute PE to determine whether echocardiographic evaluation of pulmonary hypertension (PH) was indicated. If the 'CTEPH prediction score' indicated high pretest probability or matching symptoms were present, the 'CTEPH rule-out criteria' were applied, consisting of ECG reading and N-terminalpro-brain natriuretic peptide. Only if these results could not rule out possible PH, the patients were referred for echocardiography. RESULTS: 424 patients were included. Based on the algorithm, CTEPH was considered absent in 343 (81%) patients, leaving 81 patients (19%) referred for echocardiography. During 2-year follow-up, one patient in whom echocardiography was deemed unnecessary by the algorithm was diagnosed with CTEPH, reflecting an algorithm failure rate of 0.29% (95% CI 0% to 1.6%). Overall CTEPH incidence was 3.1% (13/424), of whom 10 patients were diagnosed within 4 months after the PE presentation. CONCLUSIONS: The InShape II algorithm accurately excluded CTEPH, without the need for echocardiography in the overall majority of patients. CTEPH was identified early after acute PE, resulting in a substantially shorter diagnostic delay than in current practice.

Evaluation of the InterTAK Diagnostic Score in differentiating Takotsubo syndrome from acute coronary syndrome. A single center experience.

BACKGROUND: The aim of this study was to evaluate the usefulness of a novel clinical score - the InterTAK Diagnostic Score in differentiating Takotsubo syndrome (TTS) from acute coronary syndrome (ACS). METHODS: Medical records of 40 consecutive patients with ACS and 20 patients with TTS were managed and retrospectively analyzed at the documented center. Each patient was evaluated using the Inter- TAK Diagnostic Score. To illustrate the diagnostic ability of the score, a receiver operating characteristic (ROC) curve was performed. RESULTS: Takotsube syndrome patients were more often female compared to the ACS group (70% vs. 27.5%, p = 0.002), an emotional trigger was more prevalent among the TTS group (65% vs. 7.5%, p < 0.001). The area under the curve (AUC) for the score was 0.885 (95% confidence interval [CI] 0.78-0.97). Using a cut-off value of 45 points, the sum of sensitivity and specificity was the highest. However, when patients with a score of ≥ 50 were diagnosed as TTS, 85% were diagnosed correctly. When patients with score ≤ 31 were diagnosed as ACS, 92% were diagnosed correctly. CONCLUSIONS: The InterTAK Diagnostic Score might help in differentiating TTS from ACSs with high sensitivity and specificity. This finding requires further investigation to confirm its clinical utility.