Chest computed tomography features of heart failure: A prospective observational study in patients with acute dyspnea.

BACKGROUND: Pulmonary congestion is a key component of heart failure (HF) that chest computed tomography (CT) can detect. However, no guideline describes which of many anticipated CT signs are most associated with HF in patients with undifferentiated dyspnea. METHODS: In a prospective observational single-center study, we included consecutive patients ≥ 50 years admitted with acute dyspnea to the emergency department. Patients underwent immediate clinical examination, blood sampling, echocardiography, and CT. Two radiologists independently evaluated all images. Acute HF (AHF) was adjudicated by an expert panel blinded to radiology images. LASSO and logistic regression identified the independent CT signs of AHF. RESULTS: Among 232 patients, 102 (44%) had AHF. Of 18 examined CT signs, 5 were associated with AHF (multivariate odds ratio, 95% confidence interval): enlarged heart (20.38, 6.86-76.16), bilateral interlobular thickening (11.67, 1.78-230.99), bilateral pleural effusion (6.39, 1.98-22.85), and increased vascular diameter (4.49, 1.08-33.92). Bilateral ground-glass opacification (2.07, 0.95-4.52) was a consistent fifth essential sign, although it was only significant in univariate analysis. Eighty-eight (38%) patients had none of the five CT signs corresponding to a 68% specificity and 86% sensitivity for AHF, while two or more of the five CT signs occurred in 68 (29%) patients, corresponding to 97% specificity and 67% sensitivity. A weighted score based on these five CT signs had an 0.88 area under the curve to detect AHF. CONCLUSIONS: Five CT signs seem sufficient to assess the risk of AHF in the acute setting. The absence of these signs indicates a low probability, one sign makes AHF highly probable, and two or more CT signs mean almost certain AHF.

Potassium Disturbances and Risk of Ventricular Fibrillation Among Patients With ST-Segment-Elevation Myocardial Infarction.

Background Potassium disturbances per se increase the risk of ventricular fibrillation (VF). Whether potassium disturbances in the acute phase of ST-segment-elevation myocardial infarction (STEMI) are associated with VF before primary percutaneous coronary intervention (PPCI) is uncertain. Methods and Results All consecutive STEMI patients were identified in the Eastern Danish Heart Registry from 1999 to 2016. Comorbidities and medication use were assessed from Danish nationwide registries. Potassium levels were collected immediately before PPCI start. Multivariate logistic models were performed to determine the association between potassium and VF. The main analysis included 8624 STEMI patients of whom 822 (9.5%) had VF before PPCI. Compared with 6693 (77.6%) patients with normokalemia (3.5-5.0 mmol/L), 1797 (20.8%) patients with hypokalemia (<3.5 mmol/L) were often women with fewer comorbidities, whereas 134 (1.6%) patients with hyperkalemia (>5.0 mmol/L) were older with more comorbidities. After adjustment, patients with hypokalemia and hyperkalemia had a higher risk of VF before PPCI (odds ratio 1.90, 95% CI 1.57-2.30, P<0.001) and (odds ratio 3.36, 95% CI 1.95-5.77, P<0.001) compared with normokalemia, respectively. Since the association may reflect a post-resuscitation phenomenon, a sensitivity analysis was performed including 7929 STEMI patients without VF before PPCI of whom 127 (1.6%) had VF during PPCI. Compared with normokalemia, patients with hypokalemia had a significant association with VF during PPCI (odds ratio 1.68, 95% CI 1.01-2.77, P=0.045) after adjustment. Conclusions Hypokalemia and hyperkalemia are associated with increased risk of VF before PPCI during STEMI. For hypokalemia, the association may be independent of the measurement of potassium before or after VF.

Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome.

BACKGROUND: The optimal timing of invasive coronary angiography (ICA) and revascularization in patients with non-ST-segment elevation acute coronary syndrome is not well defined. We tested the hypothesis that a strategy of very early ICA and possible revascularization within 12 hours of diagnosis is superior to an invasive strategy performed within 48 to 72 hours in terms of clinical outcomes. METHODS: Patients admitted with clinical suspicion of non-ST-segment elevation acute coronary syndrome in the Capital Region of Copenhagen, Denmark, were screened for inclusion in the VERDICT trial (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) ( ClinicalTrials.gov NCT02061891). Patients with ECG changes indicating new ischemia or elevated troponin, in whom ICA was clinically indicated and deemed logistically feasible within 12 hours, were randomized 1:1 to ICA within 12 hours or standard invasive care within 48 to 72 hours. The primary end point was a combination of all-cause death, nonfatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia, or hospital admission for heart failure. RESULTS: A total of 2147 patients were randomized; 1075 patients allocated to very early invasive evaluation had ICA performed at a median of 4.7 hours after randomization, whereas 1072 patients assigned to standard invasive care had ICA performed 61.6 hours after randomization. Among patients with significant coronary artery disease identified by ICA, coronary revascularization was performed in 88.4% (very early ICA) and 83.1% (standard invasive care). Within a median follow-up time of 4.3 (interquartile range, 4.1-4.4) years, the primary end point occurred in 296 (27.5%) of participants in the very early ICA group and 316 (29.5%) in the standard care group (hazard ratio, 0.92; 95% CI, 0.78-1.08). Among patients with a GRACE risk score (Global Registry of Acute Coronary Events) >140, a very early invasive treatment strategy improved the primary outcome compared with the standard invasive treatment (hazard ratio, 0.81; 95% CI, 0.67-1.01; P value for interaction=0.023). CONCLUSIONS: A strategy of very early invasive coronary evaluation does not improve overall long-term clinical outcome compared with an invasive strategy conducted within 2 to 3 days in patients with non-ST-segment elevation acute coronary syndrome. However, in patients with the highest risk, very early invasive therapy improves long-term outcomes. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02061891.

Long-Term Exposure to Road Traffic Noise and Nitrogen Dioxide and Risk of Heart Failure: A Cohort Study.

BACKGROUND: Although air pollution and road traffic noise have been associated with higher risk of cardiovascular diseases, associations with heart failure have received only little attention. OBJECTIVES: We aimed to investigate whether long-term exposure to road traffic noise and nitrogen dioxide (NO2) were associated with incident heart failure. METHODS: In a cohort of 57,053 people 50-64 y of age at enrollment in the period 1993-1997, we identified 2,550 cases of first-ever hospital admission for heart failure during a mean follow-up time of 13.4 y. Present and historical residential addresses from 1987 to 2011 were found in national registers, and road traffic noise (Lden) and NO2 were modeled for all addresses. Analyses were done using Cox proportional hazard model. RESULTS: An interquartile range higher 10-y time-weighted mean exposure for Lden and NO2 was associated with incidence rate ratios (IRR) for heart failure of 1.14 (1.08-1.21) and 1.11 (1.07-1.16), respectively, in models adjusted for gender, lifestyle, and socioeconomic status. In models with mutual exposure adjustment, IRRs were 1.08 (1.00-1.16) for Lden and 1.07 (1.01-1.14) for NO2. We found statistically significant modification of the NO2-heart failure association by gender (strongest association among men), baseline hypertension (strongest association among hypertensive), and diabetes (strongest association among diabetics). The same tendencies were seen for noise, but interactions were not statistically significant. CONCLUSIONS: Long-term exposure to NO2 and road traffic noise was associated with higher risk of heart failure, mainly among men, in both single- and two-pollutant models. High exposure to both pollutants was associated with highest risk. https://doi.org/10.1289/EHP1272.

Value of N-terminal pro brain natriuretic peptide in the elderly: data from the prospective Copenhagen Hospital Heart Failure study (CHHF).

UNLABELLED: We describe the value of Nt-proBNP in relation to cardiac normality and risk of major adverse cardiac events (MACE) in consecutive hospitalised patients below and above 75 years of age. METHOD: During a 10 month period 2224 consecutive patients, admitted to all departments in a general city hospital, had a full cardiac examination and were prospectively followed for 1 year. We identified a normal group (without obvious heart disease) and a group with MACE (significant heart disease at admission or a cardiac event within the following 90 days). NT-proBNP measurements were done using an ELISA-a two-step sandwich assay with streptavidin coated microtitre plates. RESULTS: The age dependent 90th percentiles of Nt-proBNP in the normal group were approximately 3 times higher than values reported in previous community studies. Elderly patients had 3-fold higher absolute cut off values than did patients under the age of 75 years. One-hundred-and-sixteen patients had a MACE, and areas under the receiver operating curve (ROC) to predict a MACE were 0.83 (from 40 to 59 years), 0.82 (60 to 74) and 0.79 (from 75 years). In younger patients, the upper limit of Nt-proBNP in normal patients was similar to the value, which defined the top quintile of risk. In patients aged greater than 75 years the predictive cut point included more than 40% of the population. CONCLUSION: Nt-proBNP was useful at all ages but specificity was slightly lower in the elderly. Cut off values in hospitalised cardiac normal patients are approximately three times higher than community derived values.