Perfil clínico e avaliação de risco prognóstico dos pacientes com insuficiência cardíaca aguda com função sistólica preservada versus disfunção sistólica / Clinical profile and prognostic risk assessment of patients with acute heart failure with preserved systolic function versus systolic dysfunction

Objetivo: Comparar o perfil clínico e escala ADHERE na insuficiência cardíaca aguda (ICA) com (ICAD) e sem função sistólica (ICAS) preservada. Métodos: Avaliação retrospectiva da ICA na emergência, entre 04/2004 e 05/2005. 86 portadores de ICA submeteram-se a exames clínicos laboratoriais(BNP, sódio, hemoglobina, uréia e creatinina), classificação de ADHERE, e ecocardiograma com fração de ejeção (FE) maior que 40 por cento na ICAD e menor que 40 por cento na ICAS. Foram empregados os testes de Mann-Whitney e qui-quadrado. Resultados: 51 tinham ICAD e 35 ICAS, sem diferença quanto: sexo (p igual a 0,14), causa da IC (p igual a 0,48), diabetes (p igual a 0,36), DPOC (0,97), insuficiência renal (0,21) e infarto do miocárdio prévio (p igual a 0,92). Os pacientes com ICAD eram mais idosos (80 x 72 anos, p igual a 0,01), sem história (52 por cento x 20,5 por cento, p igual a 0,03) ou internações prévias por IC (37 por cento x 63 por cento, p igual a 0,018), tinham mais HAS (92 por cento vs 72 por cento, p igual a 0,01) e PAS admissional maior (150mmHg x 130mmHg, p igual a 0,0007)...

Probability stratification and systematic diagnostic approach for chest pain patients in the emergency department.

Management of chest pain patients in the emergency department has been a dilemma because of difficulty in identifying those who can be immediately discharged and those who need to be hospitalized. We assessed the efficacy of a probability stratification model and a systematic diagnostic strategy in 1003 consecutive chest pain patients prospectively evaluated and stratified for acute coronary syndromes according to chest pain characteristics and admission electrocardiogram. Patients with no suspicion of acute coronary syndromes (n = 224) were immediately discharged, whereas those with very-high probability (n =119) were admitted to the coronary care unit. Remaining patients were evaluated in a Chest Pain Unit and investigated during a 9-hour period (intermediate-probability, n = 433) (route 2) and a 6-hour period (low-probability, n = 277) (route 3). Sensitivity and negative predictive value of chest pain type for the diagnosis of acute myocardial infarction (94% and 97%, respectively) was much better than the admission electrocardiogram (49% and 86%, respectively) and admission creatine kinase-MB (46% and 86%, respectively). Serial creatine kinase-MB determinations ruled out acute myocardial infarction by the third-hour postadmission in all route 3 patients but only at the ninth-hour in route 2 patients. For patients with no ST-segment elevation, chest pain type was the strongest independent predictor of acute coronary syndromes. It is concluded that chest pain type is the best single diagnostic tool to rule in/out acute coronary syndromes on admission to the emergency department. Patients with suspicious chest pain must have serum creatine kinase-MB measurements up to 9 hours postadmission to rule out acute myocardial infarction.

Accuracy of a neural diagnostic tree for the identification of acute coronary syndrome in patients with chest pain and no ST-segment elevation.

Identifying acute coronary syndrome is a difficult task in the emergency department because symptoms may be atypical and the electrocardiogram has low sensitivity. In this prospective cohort study done in a tertiary community emergency hospital, we developed and tested a neural diagnostic tree in 566 consecutive patients with chest pain and no ST-segment elevation for the diagnosis of acute coronary syndrome. Multivariate regression and recursive partitioning analysis allowed the construction of decision rules and of a neural tree for the diagnosis of acute myocardial infarction and acute coronary syndrome. Predictive variables of acute coronary syndrome were: age > or =60 years (odds ratio [OR] = 2.3; P = 0.0016), previous history of coronary artery disease (OR = 2.9; P = 0.0008), diabetes (OR = 2.8; P = 0.0240), definite/probable angina-type chest pain (OR = 17.3; P = 0.0000) and ischemic electrocardiogram (ECG) changes on admission (OR = 3.5; P = 0.0002). The receiver operating characteristic curve of possible diagnostic decision rules of the regression model disclosed a C-index of 0.904 (95% confidence interval = 0.878 to 0.930) for acute coronary syndrome and 0.803 (95% confidence interval 0.757 to 0.849) for acute myocardial infarction. For both disorders, sensitivities of the neural tree were 99% and 93%, respectively, and negative predictive values were both 98%. Negative likelihood ratios were 0.02 and 0.1, respectively. It is concluded that this simple and easy-to-use neural diagnostic tree was very accurate in the identification of non-ST segment elevation chest pain patients without acute coronary syndrome. Patients identified as low probability of disease could receive immediate stress testing and be discharged if the test is negative.

Eficácia de uma estratégia diagnóstica para pacientes com dor torácica e sem supradesnível do segmento ST na sala de emergência / Efficacy of a diagnostic strategy for patients with chest pain and no ST-segment elevation in the emergency room

PURPOSE: To evaluate the efficacy of a systematic model of care for patients with chest pain and no ST segment elevation in the emergency room. METHODS: From 1003 patients submitted to an algorithm diagnostic investigation by probability of acute ischemic syndrome. We analyzed 600 ones with no elevation of ST segment, then enrolled to diagnostic routes of median (route 2) and low probability (route 3) to ischemic syndrome. RESULTS: In route 2 we found 17 per cent acute myocardial infarction and 43 per cent unstable angina, whereas in route 3 the rates were 2 per cent and 7 per cent, respectively. Patients with normal/non--specific ECG had 6 per cent probability of AMI whereas in those with negative first CKMB it was 7 per cent; the association of the 2 data only reduced it to 4 per cent. In patients in route 2 the diagnosis of AMI could only be ruled out with serial CKMB measurement up to 9 hours, while in route 3 it could be done in up to 3 hours. Thus, sensitivity and negative predictive value of admission CKMB for AMI were 52 per cent and 93 per cent, respectively. About one-half of patients with unstable angina did not disclose objective ischemic changes on admission. CONCLUSION: The use of a systematic model of care in patients with chest pain offers the opportunity of hindering inappropriate release of patients with ACI and reduces unnecessary admissions. However some patients even with normal ECG should not be released based on a negative first CKMB. Serial measurement of CKMB up to 9 hours is necessary in patients with medium probability of AMI.

Dor torácica na sala de emergência: a importância de uma abordagem sistematizada / Chest pain in the emergency room: importance of a systematic approach

OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a pre-established process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74 per cent of these had a final diagnosis of acute myocardial infarction [AMI]). Of the 660 patients that remained in the emergency room under observation, 77 (12 per cent) had AMI without ST segment elevation and 202 (31 per cent) had unstable angina (UA). In route 2 (high probability of ACS) 17 per cent of patients had AMI and 43 per cent had UA, whereas in route 3 (low probability) 2 per cent had AMI and 7 per cent had UA. The admission ECG has been confirmed as a poor sensitivity test for the diagnosis of AMI ( 49 per cent), with a positive predictive value considered only satisfactory (79 per cent). CONCLUSION : A systematic diagnostic strategy, as used in this study, is essential in managing patients with chest pain in the emergency room in order to obtain high diagnostic accuracy, lower cost, and optimization of the use of coronary care unit beds.