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INTRODUCTION AND OBJECTIVES: Ruling out pulmonary embolism (PE) through a combination of clinical assessment and D-dimer level can potentially avoid excessive use of computed tomography pulmonary angiography (CTPA). We aimed to compare the diagnostic accuracy of the standard approach based on the Wells and Geneva scores combined with a standard D-dimer cut-off (500 ng/ml), with three alternative strategies (age-adjusted and the YEARS and PEGeD algorithms) in patients admitted to the emergency department (ED) with suspected PE. METHODS: Consecutive outpatients admitted to the ED who underwent CTPA due to suspected PE were retrospectively assessed. Sensitivity, specificity, positive and negative predictive values, likelihood ratios and diagnostic odds ratios were calculated and compared between the different diagnostic prediction rules. RESULTS: We included 1402 patients (mean age 69±18 years, 54% female), and PE was confirmed in 25%. Compared to the standard approach (p<0.001), an age-adjusted strategy increased specificity with a non-significant decrease in sensitivity only in patients older than 70 years. Compared to the standard and age-adjusted approaches, the YEARS and PEGeD algorithms had the highest specificity across all ages, but were associated with a significant decrease in sensitivity (p<0.001), particularly in patients aged under 60 years (sensitivity of 81% in patients aged between 51 and 60 years). CONCLUSION: Compared to the standard approach, all algorithms were associated with increased specificity. The age-adjusted strategy was the only one not associated with a significant decrease in sensitivity compared to the standard approach, enabling CTPA requests to be reduced safely.
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The main objective of this consensus statement from the Portuguese Society of Cardiology, the Portuguese Society of Gynecology, the Portuguese Society of Obstetrics and Maternal-Fetal Medicine, Portuguese Society of Contraception, Portuguese Association of General Practice and Family Medicine is to improve cardiovascular care for women. It includes a brief review of the state-of-the-art of cardiovascular diseases in women and of the links to other fields such as Gynaecology, Obstetrics and Endocrinology. It also provides final recommendations to help clinicians working in care of women's health.
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Cardiología , Enfermedades Cardiovasculares , Humanos , Femenino , Sociedades MédicasRESUMEN
INTRODUCTION: Functional class is an important predictor of prognosis in chronic heart failure (CHF). However, it is often subjective and poorly reproducible. OBJECTIVE: We sought to identify diagnostic markers of high functional class. METHODS: We prospectively studied 37 patients with symptomatic CHF and ejection fraction<40%. The study protocol included clinical evaluation, echocardiography (M-mode, 2D, Doppler and tissue Doppler) and laboratory tests including copeptin, vasopressin and NT-proBNP. We compared patients in NYHA class II with those in NYHA class>II. Overall mortality was assessed at 18 months. RESULTS: Mortality was higher in the more advanced symptomatic stages (p<0.05). Patients in NYHA class>II had higher creatinine, copeptin and NT-proBNP levels (p<0.05). E/E', E-septum distance, pulmonary artery systolic pressure (PASP) and inferior vena cava (IVC) dimensions were also significantly greater (p<0.05). The biomarkers copeptin (area under the curve [AUC]=0.76, p<0.01) and NT-proBNP (AUC=0.81, p<0.01) and the echocardiographic parameters PASP (AUC=0.88, p<0.01) and IVC inspiratory diameter (AUC=0.91, p<0.01) showed the best performance for diagnosis of functional class>II. In multivariate regression analysis only PASP and serum creatinine were independent predictors of NYHA functional class>II. CONCLUSION: Copeptin and NT-proBNP have high sensitivity and specificity in the diagnosis of functional classes with prognostic impact and may be useful in defining a standardized functional classification. The structural and hemodynamic echocardiographic changes associated with NYHA class>II were left ventricular filling pressure, PASP and central venous pressure.
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Glicopéptidos/sangre , Insuficiencia Cardíaca Sistólica/sangre , Anciano , Biomarcadores/sangre , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Índice de Severidad de la EnfermedadRESUMEN
Acute myocarditis is often misdiagnosed, and its evolution is not always benign; correct and prompt diagnosis is therefore essential. We report the case of a 62-year-old woman with chest pain after a stressful event and ST-segment elevation on the electrocardiogram, in whom urgent cardiac catheterization showed normal coronary arteries and left ventricular apical ballooning, suggesting takotsubo syndrome. However, cardiac magnetic resonance imaging showed lesions typical of acute myocarditis, thus suggesting this diagnosis. We highlight the diagnostic difficulty in patients with chest pain, elevated troponin and normal coronary arteries, and the key role of cardiac magnetic resonance in differential diagnosis.
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Imagen por Resonancia Magnética , Miocarditis/diagnóstico , Cardiomiopatía de Takotsubo/diagnóstico , Diagnóstico Diferencial , Femenino , Humanos , Persona de Mediana EdadRESUMEN
Despite constant medical evolution, the reimbursement policy of Portuguese National Health Service (NHS) for the study and risk stratification of coronary heart disease has remained unchanged for several decades. Lack of adjustment to contemporary clinical practice has long been evident. However, the recent publication of the European Guidelines for diagnosis and treatment of chronic coronary syndromes further highlighted this gap and the urgent need for a change. Prompted by these Guidelines, the Working Group on Nuclear Cardiology, Cardiac Magnetic Resonance and Cardiac CT, the Working Group on Echocardiography and the Working Group on Stress Pathophysiology and Cardiac Rehabilitation of the Portuguese Society of Cardiology, began a process of joint reflection on the current limitations and how these recommendations could be applied in Portugal. To this end, the authors suggest that the new imaging methods (stress echocardiogram, cardiac computed tomography and cardiac magnetic resonance), should be added to exercise treadmill stress test and myocardial perfusion scintigraphy in the available exam portfolio within the Portuguese NHS. This change would allow full adoption of European guidelines and a better use of tests, according to clinical context, availability and local specificities. The adoption of clinical guidance standards, based on these assumptions, would translate into a qualitative improvement in the management of these patients and would promote an effective use of the available resources, with potential health and financial gains.