Predictive value of high-sensitivity troponin for significant coronary artery disease in new-onset atrial fibrillation with rapid ventricular response.

BACKGROUND: High-sensitivity troponin-T (HS-cTnT) levels are often measured in patients presenting with atrial fibrillation (AF), with many subjected to unnecessary invasive assessments. The significance of a normal or mildly raised HS-cTnT in this context is poorly understood. This study aimed to determine the predictive value of HS-cTnT for significant coronary artery disease (CAD) in new AF with rapid ventricular response. We also compared the discriminative ability of HS-cTnT to suspected angina for significant CAD. METHODS: We examined patients presenting with new AF to two tertiary Irish centers in a defined period. Those included had HS-cTnT taken at presentation and subsequent ischemic evaluation. RESULTS: Of 5350 cases screened for inclusion, 281 were deemed eligible. Of these, 148 and 133 patients had a positive and negative index HS-cTnT, respectively. Of those with negative HS-cTnT, 13 (9.8%) had significant CAD versus 51 (34.5%) with positive HS-cTnT (P < 0.001). Positive Hs-cTnT status remained significant upon multivariate analysis (OR, 2.9; 95% CI, 1.37-6.14; P = 0.005). A similar model where HS-cTnT was replaced with suspected angina produced an OR of 1.64 (95% CI, 0.75-3.59; P = 0.213). A logistic model determined optimal cutoff value for HS-cTnT to be less than 30 ng/l, producing a negative predictive value of 91.8% and area under the receiver operative curve of 83.36. CONCLUSION: HS-cTnT exhibits potential as an effective screening biomarker to predict nonsignificant CAD in new rapid AF, allowing more targeted and rationalized ischemic testing. HS-cTnT may also be a more accurate predictor of significant CAD than clinically suspected stable angina.Graphical abstract: http://links.lww.com/MCA/A540.

Standardised aspiration first approach reduces materials used and cost of thrombectomy procedure in anterior circulation large vessel occlusion stoke.

PURPOSE: The aim of this study is to compare the volume of equipment and equipment costs in a cohort of consecutive patients with anterior circulation large vessel occlusion treated with a standardised aspiration first approach to those treated with a stent retriever first approach. METHODS: The equipment used in each case was recorded from a prospectively maintained equipment log. We then compared the volume of equipment used in each group. The cost of this equipment was calculated for each group based on local prices. Estimated equipment costs were then compared. RESULTS: Our patient cohort consisted of 127 consecutive patients who were treated with a non-standardised stent retriever first technique (group A), 127 consecutive patients who underwent a new standardised aspiration first technique (group B), and 126 consecutive patients reflecting more recent practise where an aspiration first approach has been an established practise in our department (group C).Standardised aspiration first approach results in reduced equipment usage in thrombectomy procedures. The total equipment cost per case in the stent retriever first group (group A) was significantly higher at €4726.4 ($4818.3) versus €3093.1 ($3153.2) in the aspiration first group (group B), a reduction of 34.6% and €2798.5 ($2852.9) in the current practise group (group C), a reduction of 40.8%. There was no statistically significant difference in cost between groups B and C (p = 0.57). CONCLUSION: The standardised aspiration first technique utilised a reduced volume of equipment and confers a 40.8% reduced cost per procedure compared to a stent retriever first approach.

Use of Flecainide in Stable Coronary Artery Disease: An Analysis of Its Safety in Both Nonobstructive and Obstructive Coronary Artery Disease.

BACKGROUND: Flecainide is a class IC antiarrhythmic drug that is contraindicated in patients who have a history of myocardial infarction, but its effect on mortality and risk of proarrhythmia in patients with stable obstructive and nonobstructive epicardial coronary artery disease (CAD) has not been assessed. OBJECTIVE: We sought to compare the safety of flecainide administration in patients who had angiographic evidence of either no or minimal CAD versus nonobstructive CAD, and those who underwent nuclear stress testing with perfusion defects versus those without perfusion defects. METHODS: We conducted a retrospective chart review of 348 patients who were treated with flecainide for at least 1 year duration and underwent evaluation for CAD with coronary angiography or myocardial perfusion imaging (MPI) stress testing within 3 months of initiating flecainide. We compared overall mortality and proarrhythmia between varying levels of CAD and perfusion defects. RESULTS: There was a similar 10-year survival between those with no or minimal CAD, nonobstructive CAD, and obstructive CAD (p = 0.6). Additionally, there was no difference in arrhythmia burden, including sustained ventricular tachycardias or frequent premature ventricular contractions (> 5% daily burden; p = 0.25). There was also no increase in mortality among those who had reversible perfusion defects >0% compared with those without, among subjects who underwent MPI (p = 0.14). On subgroup analysis, there was no increased risk in all-cause mortality with any specific coronary artery involvement, or with obstructive multivessel CAD (p = 0.89). CONCLUSION: Flecainide use is not associated with an increase in either all-cause mortality or ventricular arrhythmias in low-risk patients with stable nonobstructive CAD.

Screening for urinary tract colonisation prior to corticosteroid administration in acute multiple sclerosis relapses: Validation of an updated algorithm.

INTRODUCTION: To evaluate an updated algorithm in the detection of urinary tract infection (UTI) prior to high-dose corticosteroid treatment in acute relapses in multiple sclerosis (MS). This updated algorithm aimed to decrease the unnecessary use of antibiotics, whilst maintaining accuracy and safety. METHODS: Prospective cohort study of 471 consecutive patients with MS relapses in a hospital-based outpatient acute relapse clinic. 172 patients met exclusion criteria, leaving 299 patients for analysis. Patients underwent urine dipstick and were treated for UTI if 2 or more of: nitrites, leukocyte esterase and cloudy urine were positive. Patients with confirmed acute MS relapse were treated with high dose intravenous or oral methylprednisolone. RESULTS: Significant bacteriuria (>105 colony forming units/mL) was present in 33 (11%, 95% CI 8-15) patients. The algorithm sensitivity and specificity was 24% and 94% respectively; the negative predictive value was 91%. The overall accuracy of the algorithm was 87%. No adverse sequelae were identified in 25 patients who received high dose methylprednisolone in the presence of an untreated UTI. CONCLUSION: With an improved specificity, this updated algorithm addresses previous issues concerning the unnecessary prescription of antibiotics, whilst improving accuracy and maintaining safety.