Acute heart failure in elderly patients admitted to the emergency department with acute dyspnea: a multimarker approach diagnostic study.

BACKGROUND AND IMPORTANCE: Diagnosing acute heart failure (AHF) is difficult in elderly patients presenting with acute dyspnea to the emergency department. OBJECTIVES: To assess the diagnostic accuracy of NT-proBNP, high-sensitivity cardiac troponin-I (Hs-cTnI), soluble ST2 (ST2), galectin-3 and CD146 alone and in combination for diagnosing AHF in elderly patients presenting with acute dyspnea to the emergency department. DESIGN, SETTINGS AND PARTICIPANTS: This was a prospective, multicenter study performed between September 2016 and January 2020, including elderly patients presenting with acute dyspnea to the emergency department of 6 French hospitals. INTERVENTION: Measurement of NT-proBNP, hs-cTnI, ST2, galectin-3 and CD146. OUTCOME MEASURE AND ANALYSIS: The reference standard, AHF, was adjudicated by two independent physicians based on ED and hospitalization clinical, biological (excluding biomarkers), radiological and echocardiography data (performed by a cardiologist in the cardiology department specifically for this study). Three exploratory methods (two using a cross-sectional approach with logistic regression and counting all biomarker combinations, and one using a sequential approach with gray zone optimizations) were applied to create comprehensive combinations of the 5 biomarkers for measuring diagnostic accuracy. MAIN RESULTS: Two hundred thirty-eight patients (median age of 85 years, IQR = 8) were analyzed, and 110 (46%) were diagnosed with AHF. The accuracies of NT-proBNP, CD146, hs-cTnI, galectin-3, and ST2 were 0.72 [95% confidence interval (CI) 0.66-0.77], 0.63 (95% CI 0.57-0.69), 0.59 (95% CI 0.53-0.65), 0.55 (95% CI 0.49-0.61) and 0.51 (95% CI 0.45-0.57), respectively. Regardless of the approach used or how the 5 biomarkers were combined, the best accuracy for diagnosing AHF (0.73, 95% CI 0.67-0.78) did not differ from that of NT-proBNP alone. CONCLUSION: In this study, NT-proBNP alone exhibited the best diagnostic accuracy for diagnosing AHF in elderly patients presenting with acute dyspnea to the emergency departments. None of the other biomarkers alone or combined improved the accuracy compared to NT-proBNP, which is the only biomarker to use in this setting.

Simple Aspiration versus Drainage for Complete Pneumothorax: A Randomized Noninferiority Trial.

Rationale: Management of first episodes of primary spontaneous pneumothorax remains the subject of debate. Objectives: To determine whether first-line simple aspiration is noninferior to first-line chest tube drainage for lung expansion in patients with complete primary spontaneous pneumothorax. Methods: We conducted a prospective, open-label, randomized noninferiority trial. Adults aged 18-50 years with complete primary spontaneous pneumothorax (total separation of the lung from the chest wall), recruited at 31 French hospitals from 2009 to 2015, received simple aspiration (n = 200) or chest tube drainage (n = 202) as first-line treatment. The primary outcome was pulmonary expansion 24 hours after the procedure. Secondary outcomes were tolerance of treatment, occurrence of adverse events, and recurrence of pneumothorax within 1 year. Substantial discordance in the numerical inputs used for trial planning and the actual trial rates of the primary outcome resulted in a reevaluation of the trial analysis plan. Measurement and Main Results: Treatment failure occurred in 29% in the aspiration group and 18% in the chest tube drainage group (difference in failure rate, 0.113; 95% confidence interval [CI], 0.026-0.200). The aspiration group experienced less pain overall (mean difference, -1.4; 95% CI, -1.89, -0.91), less pain limiting breathing (frequency difference, -0.18; 95% CI, -0.27, -0.09), and less kinking of the device (frequency difference, -0.05; 95% CI, -0.09, -0.01). Recurrence of pneumothorax was 20% in this group versus 27% in the drainage group (frequency difference, -0.07; 95% CI, -0.16, +0.02). Conclusions: First-line management of complete primary spontaneous pneumothorax with simple aspiration had a higher failure rate than chest tube drainage but was better tolerated with fewer adverse events. Clinical trial registered with www.clinicaltrials.gov (NCT01008228).

Late diagnosis of isolated congenitally corrected transposition of the great arteries in a 92-year old woman.

We report the case of a 92-year old woman with congenitally corrected transposition of the great arteries (CCTGA). The case is remarkable as the CCTGA had remained undiagnosed until the diagnosis was made when the patient was aged 70 years, and had 10 pregnancies without heart failure.

Real-time myocardial contrast echocardiography for pharmacologic stress testing: is quantitative estimation of myocardial blood flow reserve necessary?

BACKGROUND: Little is known about the diagnostic accuracy of quantitative real-time myocardial contrast echocardiography (MCE) as an adjunct to stress testing. This study was performed to evaluate the agreement between MCE and technetium 99m-sestamibi single photon emission computed tomography (SPECT) for detection of perfusion defects and to investigate whether quantitative assessment of myocardial perfusion can increase the diagnostic value of MCE. METHODS: MCE was performed at rest and during peak adenosine stress in 50 unselected patients undergoing SPECT imaging. Concordance between the 2 methods was assessed using kappa statistics. MCE images were analyzed quantitatively, measuring peak intensity (A) and maximal rise of signal intensity (beta). Myocardial blood flow reserve was estimated by calculating the ratios of A(adenosine)/A(baseline) (A reserve), beta(adenosine)/beta(baseline) (beta reserve), and A x beta(adenosine)/A x beta(baseline) (A x beta reserve). RESULTS: Visual analysis of MCE agreed well with SPECT (kappa = 0.67) with sensitivity of 64%, specificity of 97%, and overall accuracy of 87%. Quantitative analysis showed that peak signal intensity A significantly increased under adenosine stress in SPECT-normal segments (2.6 +/- 1.9 vs 3.0 +/- 1.6 dB, P <.0001), tendencially decreased in reversible (3.0 +/- 2.0 vs 2.4 +/- 1.2 dB, P =.07) and remained unchanged in fixed (0.9 +/- 0.9 vs 0.8 +/- 0.9 dB) defects. beta Increased markedly under adenosine in normal segments (0.4 +/- 0.4 vs 1.4 +/- 1.3, P <.0001) but not in segments with reversible or fixed defects. Receiver operating characteristic showed that beta reserve and A x beta reserve, but not A reserve, are sensitive parameters for detecting perfusion defects with areas under the curve of 0.84, 0.85, and 0.61, respectively. Cut-off values of 1.9 and 2.3, respectively, for beta and A x beta reserve yielded sensitivity rates of 79% and 80%, specificity rates of 75% and 78%, and overall accuracy rates of 76% and 79%, respectively. CONCLUSION: Quantitative estimation of myocardial blood flow reserve by MCE parameters corresponds to the evaluation of myocardial perfusion by nuclear imaging and can increase the sensitivity but not the overall accuracy of contrast echocardiography.