Prognostic value of plasma lactate levels among patients with acute pulmonary embolism: the thrombo-embolism lactate outcome study.

STUDY OBJECTIVE: We investigate the prognostic value of plasma lactate levels in patients with acute pulmonary embolism. METHODS: We studied adult patients with symptomatic, objectively confirmed pulmonary embolism presenting to a single emergency department. Plasma lactate and troponin I levels were tested at presentation. We considered lactate values greater than or equal to 2 mmol/L and troponin I values greater than or equal to 0.10 ng/mL to be abnormal. Right-sided ventricular dysfunction was assessed by echocardiography. Primary endpoint was all-cause death occurring on or before 30 days after presentation. Secondary endpoints were the composite of all-cause death and clinical deterioration (defined as progression to shock, mechanical ventilation, or cardiopulmonary resuscitation) and death caused by pulmonary embolism. We tested the association between lactate level greater than or equal to 2 mmol/L and the endpoints using Cox proportional hazards regression analysis. RESULTS: Of the 270 patients included in the study, the mean age was 73 years (SD 12.7 years) and 151 (55.9%) were women. Twelve patients (4.4%) showed shock or hypotension (shock or systolic arterial pressure <100 mm Hg) at presentation, 109 (40.4%) had right-sided ventricular dysfunction, 93 (34.4%) showed troponin I level greater than or equal to 0.10 ng/mL, and 81 (30%) showed lactate level greater than or equal to 2 mmol/L. Seventeen patients (6.3%) died, 12 (4.4%) because of pulmonary embolism, and 37 (13.7%) reached the composite endpoint. Patients with lactate level greater than or equal to 2 mmol/L showed higher mortality (17.3%; 95% confidence interval [CI] 11.9% to 20%) than patients with a lower level (1.6%; 95% CI 0.8% to 1.9%). Plasma lactate level was associated with all-cause death (hazard ratio 11.67; 95% CI 3.32 to 41.03) and the composite endpoint (hazard ratio 8.14; 95% CI 3.83 to 17.34) independent of shock or hypotension, right-sided ventricular dysfunction, or elevation of troponin I values. CONCLUSION: Patients with pulmonary embolism and elevated plasma lactate level are at high risk of death and adverse outcome, independent of shock or hypotension, or right-sided ventricular dysfunction or injury markers.

Abnormal troponin level as short-term predictor of poor outcome in acute atrial fibrillation.

BACKGROUND: The link between minor troponin (cardiac troponin I [cTnI]) elevations and atrial fibrillation (AF) is still debated. METHODS: A total of 948 patients with AF lasting less than 48 hours participated in the study and were required to undergo 1-month and 12-month follow-up. The exclusion criteria were represented by younger than 18 years, the presence of hemodynamic instability, or severe comorbidity. Primary end point was the composite of ischemic vascular events inclusive of stroke, acute coronary syndrome, revascularization, and death. RESULTS: In the short term, 4 patients (5%) of 78 with abnormal cTnI reached the primary end point (P = .001 vs others). Conversely, in the long term, 13 patients (17%) with abnormal cTnI, 21 (10%) with known ischemic vascular disease, and 50 (5%) aged patients (75 ± 10 years) reached the primary end point (P < .001, P < .001, and P = .002, respectively). At multivariate analysis, abnormal cTnI (hazard ratio [HR], 2.84; 95% confidence interval, 1.38-5.84; P = .005), known ischemic vascular disease (HR, 2.03; 95% confidence interval, 1.11-3.70; P = .021), and age (HR, 1.05; 95 confidence interval, 1.02-1.08; P = .002) were predictors of the primary end point. Minimal or minor cTnI elevation (<0.45 or ≥ 0.45 ng/mL, respectively) showed no differences when associated with the primary end point. The C-statistic demonstrated the significant prognostic value of older age and known ischemic vascular disease, beyond troponin. Clinical parameters inclusive of heart rate, blood pressure, and risk factors for arteriosclerosis showed no relationship with adverse events. Readmission rate did not differ between groups. CONCLUSIONS: In patients with acute AF, minor cTnI elevations link to short-term adverse events. Known ischemic vascular disease and older age showed prognostic value only in the long term.

Short- and long-term cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram.

AIM: The aim of this study is to evaluate incidence of adverse cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram (ECG) and initial troponin. METHODS: Prospective, nonrandomized study enrolled low-risk patients with normal ECG and troponin on admission who underwent observation and/or stress testing by unstandardized clinical judgment. Patients who experienced recurrent angina or positive ECGs or positive troponins during observation or patients with positive stress testing were admitted; otherwise, they were discharged. END POINT: The end points are cardiac events at short- and long-term follow-up including cardiovascular death, myocardial infarction, unstable angina, and revascularization. RESULTS: Of 5656 patients considered, 1732 with ischemic ECG were initially admitted and, therefore, excluded from the analysis; 2860 with pleuritic chest pain and normal ECG were discharged; 1064 with visceral chest pain and normal ECG were enrolled. Patients with known coronary disease (45%) were older and likely presented known vascular disease. Patients with known vascular disease, older age, female sex, diabetes mellitus, and lower chest pain score were likely managed with observation. In patients with known coronary disease as compared with patients without, overall cardiac events account for 35% vs 14%, respectively (P < .001), as follows: in-hospital, 23% vs 10%, (P < .001); 1 month, 4% vs 2% (P = .133); and 9.9 ± 4.9 months, 8% vs 2%, respectively (P < .001). CONCLUSIONS: One-third of patients with chest pain with known coronary disease, negative ECG, and biomarkers were subsequently found to have adverse cardiac events. The value of this research for an emergency medicine audience could be extended to all clinicians and general practitioners beyond cardiologists.

Risk scores prognostic implementation in patients with chest pain and nondiagnostic electrocardiograms.

BACKGROUND: Several risk scores are available for prognostic purpose in patients presenting with chest pain. AIM: The aim of this study was to compare Grace, Pursuit, Thrombolysis in Myocardial Infarction (TIMI), Goldman, Sanchis, and Florence Prediction Rule (FPR) to exercise electrocardiogram (ECG), decision making, and outcome in the emergency setting. METHODS: Patients with nondiagnostic ECGs and normal troponins and without history of coronary disease underwent exercise ECG. Patients with positive testing underwent coronary angiography; otherwise, they were discharged. End point was the composite of coronary stenosis at angiography or cardiovascular death, myocardial infarction, angina, and revascularization at 12-month follow-up. RESULTS: Of 508 patients considered, 320 had no history of coronary disease: 29 were unable to perform exercise testing, and finally, 291 were enrolled. Areas under the receiver operating characteristic curves for Grace, Pursuit, TIMI, Goldman, Sanchis, and FPR were 0.59, 0.68, 0.69, 0.543, 0.66, and 0.74, respectively (P < .05 FPR vs Goldman and Grace). In patients with negative exercise ECG and overall low risk score, only the FPR effectively succeeded in recognizing those who achieved the end point; in patients with high risk score, the additional presence of carotid stenosis and recurrent angina predicted the end point (odds ratio, 12 and 5, respectively). Overall, logistic regression analysis including exercise ECG, coronary risk factors, and risk scores showed that exercise ECG was an independent predictor of coronary events (P < .001). CONCLUSIONS: The FPR effectively succeeds in ruling out coronary events in patients categorized with overall low risk score. Exercise ECG, nonetheless being an independent predictor of coronary events could be considered questionable in this subset of patients.

Clinical management of atrial fibrillation: early interventions, observation, and structured follow-up reduce hospitalizations.

BACKGROUND: Novel facilities such as an intensive observation unit and an outpatient clinic could result in improving management of patients presenting with atrial fibrillation (AF). METHODS: This observational study enrolled 3475 patients. Group 1 (1120 patients; years 2004-2005) was managed with standard approach; group 2 (992 patients; years 2006-2007) was managed with additional intensive observation; group 3 (1363 patients; years 2008-2009) was managed with additional intensive observation and outpatient clinic. Primary end point was admission to hospital. Secondary end points included modalities of rhythm conversion and administration of class IC vs class III antiarrhythmic drugs in patients with AF lasting less than 48 hours. RESULTS: Lack of rhythm control, comorbidities, diabetes, and age were independent predictors of hospitalization. Admissions significantly decreased from group 1 (50%) to 2 (38%) and to 3 (24%) (P < .001). Interestingly, more than a quarter of patients in group 3 were referred to the outpatient clinic for short-term follow-up, eventually avoiding admission. Patients with AF lasting less than 48 hours (n = 2189) and without structural heart disease (n = 1685) achieved sinus rhythm in 89% of cases and were discharged. In these patients, early administration of antiarrhythmic drugs of class IC and III gained sinus rhythm in 80% and 20%, respectively (P < .001). Spontaneous conversion occurred in 26%; electrical, 17%; and pharmacological, 57%. CONCLUSIONS: In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations. Patients without structural heart disease treated with antiarrhythmic drugs achieved sinus rhythm in 89% of cases, mostly with class IC drugs.

Early discharge of patients with pulmonary embolism in daily clinical practice: A prospective observational study comparing clinical gestalt and clinical rules.

OBJECTIVES: To estimate the efficiency and safety of clinicians' gestalt in the identification of patients with pulmonary embolism (PE) candidates for early discharge and to compare the efficiency and safety of clinical gestalt with that of the Pulmonary Embolism Severity Index (PESI), the simplified PESI (sPESI) and the Hestia criteria (HC). METHODS: Consecutive adult patients presenting to the emergency department of four Italian hospitals with confirmed diagnosis of PE were included. Data for PESI, sPESI and HC assessment were prospectively collected. Patients were managed according to the clinical gestalt of the attending physician, independent of the results of PESI, sPESI and HC. Efficiency was defined as the prevalence of candidates to early discharge. The primary safety measure was the incidence of a composite of venous thromboembolic recurrence, major haemorrhage or all-cause mortality within 30 days. RESULTS: Out of 547 included patients, 178 (32.5%) were judged to be at low risk and discharged within 48 h from presentation. HC identified a higher proportion (41.7%) whereas both PESI (24.1%) and sPESI (18.3%) identified a lower proportion of candidates for early discharge when compared to clinical gestalt (P < 0.01 for all). The incidence of the safety outcome was 2.8% in early-discharged patients according to clinical gestalt and 2.3%, 3.0% and 2.6% in candidates to early discharge according to PESI, sPESI and HC, without differences between strategies. CONCLUSIONS: In our cohort, clinical gestalt identified one-third of PE patients for early discharge. Among different strategies HC showed the highest efficiency sharing similar safety with the other strategies.

Role of masked coronary heart disease in patients with recent-onset atrial fibrillation and troponin elevations.

BACKGROUND: Patients with recent-onset atrial fibrillation (AF) and cardiac troponin I (cTnI) elevations show poor outcomes. Coronary heart disease might be a cause, consequence, or an innocent bystander. OBJECTIVE: The aim of this study was to recognize and treat coronary heart disease to avoid adverse events. METHODS: Patients with recent-onset AF participated in the study. The exclusion criteria were acute coronary syndrome and severe comorbidities. Patients managed with standard care (group 1, n=1086, years 2010-2011) were compared with patients managed with tailored care inclusive of echocardiography and stress testing when required (group 2, n=1055, years 2012-2013). ENDPOINT: The endpoint was a composite of ischemic vascular events including stroke, acute coronary syndrome, revascularization and cardiovascular death at 6 months of follow-up. RESULTS: Of 4008 patients considered, 2141 were enrolled; 183 showed cTnI elevations, 92 in group 1 and 91 in group 2. cTnI elevations, known ischemic heart disease and age were predictors of the endpoint on multivariate analysis. Overall, two versus seven patients (P=0.033) in groups 1 and 2, respectively, underwent revascularization. Eventually, 16 patients in group 1 versus five patients in group 2 reached the endpoint (P=0.019). Patients of group 2 were managed as follow: 35 were admitted, 15 with positive stress testing and 20 with high cTnI values (mean values: 0.64±1.01 ng/ml). Fifty-six patients were discharged with negative stress testing results (n=13) or very low cTnI values (n=43, mean values 0.29±0.30 ng/ml). CONCLUSION: In patients with AF and cTnI elevations, tailored care inclusive of echocardiography and stress testing succeeded in recognizing and treating masked 'critical' coronary heart disease, avoiding adverse events.

Long-term prognostic value of dysglycemia and ischemic vascular disease beyond abnormal troponin levels in patients presenting acute atrial fibrillation.

BACKGROUND: Prognostication beyond troponin levels in patients with acute atrial fibrillation (AF) is still unclear. METHODS: One-month and 1-year outcomes in 1091 patients with acute AF were analyzed. Primary endpoints were stroke or the composite of acute coronary syndrome, revascularization, and death. RESULTS: In the short term, troponin (odds ratio (OR) 15, 95% confidence interval (CI), 3.4-67.9, P < 0.001) and known ischemic heart disease (OR 5.83, 95% CI, 1.3-26.2, P = 0.021) were predictors of the composite endpoint, with multivariate analysis. No variables linked with stroke. In the long term, metabolic syndrome (OR 4.7, 95% CI, 1.2-18.3, P = 0.024) and age (OR 1.1, 95% CI, 1.0-1.1, P = 0.009) were predictors of stroke; metabolic syndrome (OR 4.3, 95% CI, 1.6-11.0, P = 0.003), known ischemic heart disease (OR 3.3, 95% CI, 1.7-6.4, P = 0.001), persistence of AF after the first-line approach (OR 2.2, 95% CI, 1.2-4.3, P = 0.018), and age (OR 1.0, 95% CI, 1.0-1.1, P = 0.025), but not troponin so were of the composite endpoint. In the short term, increased discriminative values in prognostication of the composite endpoint were observed with C-statistic when troponin was compared with dysglycemia (P = 0.032). No variables did better than others in the prognostication of stroke. In the long term, increased discriminative values in the prognostication of stroke were observed with C-statistic when age was compared with troponin (P = 0.020), ischemic heart disease (P = 0.025), and persistence of AF after the first-line approach (P = 0.049); so was for CHADS2 score ≥1 versus vascular disease (P = 0.038). CONCLUSIONS: In patients with acute AF, abnormal troponin levels add prognostic value to clinical parameters in the short term; dysglycemia and known vascular disease in the long term.

Prognostic value of emergency physician performed echocardiography in patients with acute pulmonary thromboembolism.

INTRODUCTION: Pulmonary embolism (PE) is a life-threatening illness with high morbidity and mortality. Echocardiography (ECG) plays an important role in the early identification of right ventricular (RV) dysfunction, making it a helpful tool in identifying hemodynamically stable patients affected by PE with a higher mortality risk. The purpose of this study was to evaluate if one or more ECG indexes could predict a short-term evolution towards RV dysfunction. METHODS: We selected all patients consecutively admitted to the Careggi Hospital Emergency Department with the clinical suspicion of PE, confirmed by computed tomography angiography prior to enrollment. Subsequently, properly trained emergency physicians acquired a complete ECG to measure RV morphological and functional indices. For each patient, we recorded if he or she received a fibrinolytic treatment, a surgical embolectomy or heparin therapy during the emergency department (ED) stay. Then, every patient was re-evaluated with ECG, by the same physician, after 1 week in our intensive observation unit and 1 month as outpatient in our ED regional referral center for PE. RESULTS: From 2002 to 2007, 120 consecutive patients affected by PE were evaluated by echocardiography at the Careggi Hospital ED. Nine patients (8%) were treated with thrombolytic therapy. Six died within 1 week and 4 abandoned the study, while the remaining 110 survived and were re-evaluated by ECG after 1 week and 1 month. The majority of the echocardiographic RV indexes improve mostly in the first 7 days: Acceleration Time (AT) from 78±14 ms to 117±14 ms (p<0.001), Diameter of Inferior Vena Cava (DIVC) from 25±6 mm to 19±5 mm (p<0.001), Tricuspid Annular Plane Systolic Excursion (TAPSE) from 16±6 mm to 20±6 mm (p<0.001). Pulmonary Artery Systolic Pressure (PASP) showed a remarkable decrease from 59±26 mmHg to 37±9 mmHg, (p<0.001). The measurements of the transverse diameters of both ventricles and the respective ratio showed a progressive normalization with a reduction of RV diameter, an increase of Left Ventricular (LV) diameter and a decrease of RV/LV ratio over time. To evaluate the RV function, the study population was divided into 3 groups based on the TAPSE and PASP mean values at the admission: Group 1 (68 patients) (TAPSE+/ PASP-), Group 2 (12 patients) (TAPSE-/PASP-), and Group 3 (30 patients) (TAPSE-/PASP+). Greater values of AT, minor RV diameter, greater LV diameter and a lesser RV/LV ratio were associated with a short-term improvement of TAPSE in the Group 2. Instead, in Group 3 the only parameter associated with short-term improvement of TAPSE and PASP was the treatment with thrombolytic therapy (p<0.0001). CONCLUSION: Greater values of AT, minor RV diameter, greater LV diameter and a lesser RV/LV ratio were associated with a short-term improvement of TAPSE-/PASP- values. Patients with evidence of RV dysfunction (TAPSE-/PASP+), may benefit from thrombolytic therapy to improve a short- term RV function. After 1 month, also a decreased DIVC predicted improved RV function.

High plasma lactate levels are associated with increased risk of in-hospital mortality in patients with pulmonary embolism.

OBJECTIVES: The objective was to investigate the prognostic value of plasma lactate in patients with acute pulmonary embolism (PE). METHODS: This was a retrospective study at the emergency department (ED) of a third-level teaching hospital. The authors considered consecutive patients with a diagnosis of PE established by lung scan or spiral computed tomography (CT) and confirmed by pulmonary angiography if necessary. Only patients for whom plasma lactate levels had been tested within 6 hours from presentation to the ED were included. Primary outcome was in-hospital death due to any cause; secondary outcome was mortality related to PE. RESULTS: From September 1997 to June 2006, a total of 384 patients were diagnosed with PE in the ED. Of these patients, 287 had registered plasma lactate levels and were included in this analysis. Included patients had a mean age of 70 (SD ± 15 years, range = 18 to 100 years), 163 (57%) were female, 26 (9%) showed systolic blood pressure lower than 100 mm Hg at presentation, and 160 (56%) had echocardiographic evidence of right ventricular dysfunction (RVD). Twenty patients died during their hospital stay (7%). Plasma lactate levels ≥ 2 mmol/L were associated with in-hospital mortality from all causes (odds ratio [OR] = 4.60, 95% confidence interval [CI] = 1.57 to 13.53) and with PE-related mortality (OR = 4.94, 95% CI = 1.38 to 17.63), independent of hypotension or RVD at presentation. CONCLUSIONS: High plasma lactate was associated with increased in-hospital mortality in this sample of patients with acute PE.