High-frequency QRS analysis superior to conventional ST-segment analysis of women with chest pain.

BACKGROUND: The novel analysis of high-frequency QRS components (HF/QRS) has been proposed in patients with chest pain (CP) referred for exercise tolerance test (ex-ECG). We sought to evaluate the prognostic role of exercise high-frequency QRS-analysis (ex-HF/QRS) in patients with recent-onset stable CP, in the emergency setting. METHODS: Patients with CP underwent ex-ECG. A decrease greater than or equal to 50% of the signal of HF/QRS intensity was considered as index of ischemia as ST-segment depression greater than or equal to 2 mm or greater than or equal to 1 mm associated with CP. Exclusion criteria were QRS duration greater than or equal to 120 milliseconds and inability to exercise. Baseline characteristics were adjusted with the propensity score matching specifying nearest-neighbor matching in cardiovascular risk factors and risk scores. The primary end point was the composite of coronary stenosis greater than or equal to 70% or acute coronary syndrome, revascularization, and cardiac death on the 6-month follow-up. RESULTS: Of 589 patients, 22 achieved the end point. On the univariate analysis, known cardiovascular disease, GRACE score, and ex-HF/QRS were predictors of the end point. On the multivariate analysis, only ex-HF/QRS was predictor of the end point (odd ratio, 28; 95% confidence interval [CI], 6-120; P < .001). Overall, the ex-HF/QRS when compared to ex-ECG showed higher sensitivity (91% vs 27%; P = .02), lower specificity (74% vs 86%; P = .09), and comparable negative predictive value (99% vs 97%; P = .78). Receiver operating characteristic curve analysis showed the larger area of ex-HF/QRS (0.83; 95% CI, 0.75-0.90) over ex-ECG (0.57; CI, 0.44-0.70) and GRACE score (0.65; CI, 0.54-0.76); P < .03 on C-statistic. Women showed the largest area (0.89; CI, 0.83-0.95; P < .03) vs the other clinical data. CONCLUSIONS: In patients with CP, the novel ex-HF/QRS analysis has a valuable incremental prognostic role over ex-ECG, especially in women.

Coronary atherosclerosis and adverse outcomes in patients with recent-onset atrial fibrillation and troponin rise.

BACKGROUND: The relationship between troponin and atrial fibrillation (AF) without acute coronary syndrome is still unclear. We sought to investigate the presence of coronary atherosclerosis and adverse outcomes in patients with AF. METHODS: Consecutive patients with recent-onset AF and without severe comorbidities were enrolled between 2004 and 2013. Patients with a troponin rise or with adverse outcomes were considered for coronary angiography and revascularization when "critical" stenosis (≥70%) was recognized. Propensity score matching was performed to adjust for baseline characteristics; after matching, no differences existed between the groups of patients with or without troponin rise. The primary end point was the composite of acute coronary syndrome, revascularization, and cardiac death at 1- and 12-month follow-ups. RESULTS: Of 3627 patients enrolled, 3541 completed the study; 202 (6%) showed troponin rise; and 91 (3%), an adverse outcome. In the entire cohort, on multivariate analysis, the odds ratio for the occurrence of the primary end point of troponin rise was 14 (95% confidence interval [CI], 10-23; P<.001), and that of known coronary artery disease was 3 (CI, 2-5; P=.001). In the matching cohort, the odds ratio of troponin rise was 10 (CI, 4-22; P<.001), and that of TIMI score greater than 2 was 4 (CI, 2-9; P≤.001). In the entire cohort, patients with or without troponin rise achieved the primary end point in 38 (19%) and 43 (1%) patients, respectively (P<.001). Stroke occurred in 4 (2%) and 20 (1%), respectively (P=.018). Critical stenosis and revascularization account for 23 (12%) and 15 (1%), respectively (P<.001). In the matching cohort, results were confirmed, but incidence of stroke was comparable. CONCLUSIONS: Patients with recent-onset AF and troponin rise showed higher prevalence of coronary atherosclerosis and adverse cardiac events. Stroke per se did not succeed in justifying the high morbidity. Thus, beyond stroke, coronary atherosclerosis might have a pivotal role in poor outcomes.

Hypertension and atrial fibrillation: prognostic aspects of troponin elevations in clinical practice.

BACKGROUND: Hypertension and atrial fibrillation (AFib) frequently coexist in clinical practice. However, it is unclear whether this association per se or in combination with coronary artery disease (CAD) is a predictor of adverse outcomes. AIM: The aim of this study is to recognize and treat CAD in patients with hypertension and AFib. METHODS: Patients with long-standing hypertension and recent-onset AFib (lasting ≤48 hours) were enrolled and managed with standard care regardless of the presence of troponin elevations (e-TnI) (group 1, n=636, 2010-2011 years) or managed with tailored-care including echocardiography and stress testing when presenting with e-TnI (group 2, n=663, 2012-2013 years). ENDPOINT: The composite of ischemic vascular events including stroke, acute coronary syndrome, revascularization, and death at the 6-month follow-up. RESULTS: Out of 1299 patients enrolled, those with e-TnI (56 and 57 in groups 2 and 1, respectively, P=0.768) were more likely to admit in group 2 vs. group 1 (21 vs. 32, respectively, P=0.060), and less likely to undergo stress testing in group 2 vs. group 1 (15 vs. 1, respectively, P<0.001). Twenty-one patients in group 2 were admitted with positive stress testing (n=9) or high e-TnI (n=12; 1.04±1.98 ng/mL); conversely 35 were discharged with negative stress testing (n=6) or very-low e-TnI (n=29; 0.27±0.22 ng/mL). Finally, 7 patients vs. 1, in groups 2 and 1, respectively, underwent revascularization (P=0.032), and 3 vs. 12 reached the endpoint (P=0.024). On multivariate analysis, e-TnI, known CAD and age were predictors of the endpoint. CONCLUSIONS: In patients with hypertension, AFib, and e-TnI, tailored-care inclusive of echocardiography and stress testing succeeded in recognizing and treating CAD avoiding adverse events without increase in admissions.

Stress echocardiography in the ED: diagnostic performance in high-risk subgroups.

PURPOSE: To assess stress-echo (SE) diagnostic performance in patients presenting to the emergency department (ED) with spontaneous chest pain, especially in subgroups in which exercise ECG diagnostic performance has been questioned (women, elderly, history of coronary artery disease). METHODS: Between June 2008 and May 2011, 474 patients with an episode of spontaneous chest pain, non-diagnostic electrocardiogram and negative cardiac necrosis markers underwent SE. Patients with inducible ischemia (Isch) were asked to undergo coronary angiography. Patients with negative SE were discharged and contacted by telephone at least 6 months after discharge, to ascertain the occurrence of new cardiac events. MAIN FINDINGS: Exercise stress-echo (ESE) was employed in 270 patients and dobutamine (DSE) in 218 (including 14 with inconclusive ESE); a diagnosis of coronary artery disease (CAD) was confirmed or excluded in 434 (92%) patients. SE was negative for Isch in 318 patients (206 ESE and 112 DSE) and positive in 132. During follow-up, patients with negative SE had 4 cardiac events. SE showed: sensitivity 90%, specificity 92%, positive predictive value 78% and negative predictive value 97%. Sensitivity was comparable between patients aged < or ≥70 years (84 vs 94%) and between gender (89 vs 96%), but lower in patients with known CAD (88 vs 94%, P < .05); specificity was comparable regardless of age (94 vs 99%) and presence of CAD (97 vs 91%), but was lower among women (87 vs 96%, P < .05). CONCLUSIONS: SE had a very good diagnostic performance in ED patients with suspected Isch, both overall and in selected high-risk groups.

A case of combined septic and obstructive shock: usefulness of bedside integrated cardiothoracic emergency ultrasonography.

A 59-year-old woman presented at the emergency department with cough and weakness that started a few days before. She had a history of breast cancer treated with mastectomy with negative followup. Physical examination revealed tachycardia and tachypnea, normal blood pressure, lower lobe crackles bilaterally, and jugular venous distention. Laboratory data underlined neutrophilic leukocytosis, mild renal failure, and high procalcitonin. Chest radiography revealed bilateral nodular lesions, presumably secondary. Patient was treated with fluid therapy and broad-spectrum antibiotic therapy because of suspected sepsis. In clinical revaluation patient showed systolic hypotension unresponsive to fluid resuscitation. Because of suspected pulmonary embolism an echocardiography was performed revealing normal dimensions of right ventricle with presence of a hypoechoic mass involving tricuspid annulus and obstructing the opening of anterior tricuspid flap; inferior vena cava appeared dilated and not collapsible. Subsequently, chest ultrasonography was performed, confirming multiple rounded lesions involving the pleura bilaterally, compatible with metastasis, and absence of interstitial syndrome. Finally a computed tomography scan of chest excluded pulmonary embolism and confirmed the presence of the obstructive mass responsible for hemodynamic instability together with pulmonary sepsis.