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).

Comparison of Specific Prediction Equations to Estimate Peak Oxygen Uptake in Obese Women.

The aim of the current study was to compare 2 equations to predict peak oxygen uptake (V̇O2peak) in obese women, according to their obesity class. 92 maximal cardiopulmonary exercise testing sets (CPET with initial and subsequent increments set to achieve an exercise duration between 8-12 min) were retrospectively analysed. These CPET were divided into 3 groups according to the women body mass indexes (BMI): class 1 (30 kg.m-2≤BMI<35 kg.m-2, n=22), class 2 (35 kg.m-2≤BMI<40 kg.m-2, n=36) or class 3 (BMI≥40 kg.m-2, n=34). Each participant's V̇O2peak was predicted from 2 prediction equations (from Wasserman et al.'s and Debeaumont et al.'s equations) and compared with the actual V̇O2peak. Moreover, the correlations between these values were studied, and the accuracy of the predictions was analysed. Only predicted V̇O2peak from the Debeaumont et al.'s equation was not significantly different from the actual V̇O2peak in the women in obesity class 3 (p=0.89). Moreover, significant correlation was found between these values (p<0.001, r=0.68). The bias and the 95% limits of agreement represented -3.2±34.0%. In women in obesity class 3, Debeaumont et al.'s equation may be the accurate one to predict V̇O2peak. However, the accuracy of predictions is low. Consequently, to improve this accuracy, new prediction equations for obese women are required according to the obesity class.

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.

Emergency reversal of anticoagulation: the real use of prothrombin complex concentrates: a prospective multicenter two year French study from 2006 to 2008.

INTRODUCTION: Prothrombin complex concentrate (PCC) for reversal of vitamin K antagonist (VKA) is the main therapeutic option in cases of life-threatening bleeding. Clinical use of PCC is poorly documented. METHODS: We prospectively assessed PCC use in four French emergency departments during a two year period 2006-2008 before publication of French Guidelines. An appropriate treatment was defined when PCC was recommended, with a dose of PCC above or equal to 20 UI/kg, with vitamin K and with an assessment of international normalized ratio (INR) after PCC. Time of diagnosis and PCC administration were collected, as INR values, thromboembolic events within seven days, hospital mortality. RESULTS: 256 patients received PCC for reversal of OAT. PCC was mainly prescribed for major intracerebral (ICH) or gastrointestinal hemorrhage. An appropriate treatment was observed in 26% of patients. Intra-hospital mortality for major bleeding was 33% for ICH and 26% for non-ICH major bleeding. A PCC dose>20 UI/kg was able to reach an INR<1.5 in 65% of patients. For major hemorrhages (70%), time between patient arrival and treatment delivery exceeded three hours in half of cases. Control of INR was omitted in 20% of patients. No patients presented a thromboembolic event. CONCLUSION: A suitable treatment was administered in 26% of patients. A PCC dose of 20-30 IU/kg seems adequate in most cases to reverse VKA activity, but both higher and lower doses achieve similar effects. Considerable progress is required to improve PCC administration and control of treatment efficacy, and to shorten time to diagnosis.

Prediction of peak oxygen uptake from age and power output at RPE 15 in obese women.

The purpose of this study was to develop a simple, convenient and indirect method for predicting peak oxygen uptake (VO2peak) from a sub-maximal graded exercise test (GXT), in obese women. Thirty obese women performed GXT to volitional exhaustion. During GXT, oxygen uptake and the power at RPE 15 (VO2peak) were measured, and VO2peak was determined. Following assessment of the relationships between VO2peak and PRPE 15, age, height and mass were made available in a stepwise multiple regression analysis with VO2peak as the dependent variable. The equation to predict VO2peak was: (1 min-1) = 1.355 - 9.920e-3 x age + 8.497e-3 x PRPE 15 (r = 0.83; SEE = 0.156 l min(-1)). This study suggests that age and PRPE 15 elicited during a sub-maximal GXT provides a reasonably accurate prediction of VO2peak in obese women.

A computerized handheld decision-support system to improve pulmonary embolism diagnosis: a randomized trial.

BACKGROUND: Testing for pulmonary embolism often differs from that recommended by evidence-based guidelines. OBJECTIVE: To assess the effectiveness of a handheld clinical decision-support system to improve the diagnostic work-up of suspected pulmonary embolism among patients in the emergency department. DESIGN: Cluster randomized trial. Assignment was by random-number table, providers were not blinded, and outcome assessment was automated. (ClinicalTrials.gov registration number: NCT00188032). SETTING: 20 emergency departments in France. PATIENTS: 1103 and 1768 consecutive outpatients with suspected pulmonary embolism. INTERVENTION: After a preintervention period involving 20 centers and 1103 patients, in which providers grew accustomed to inputting clinical data into handheld devices and investigators assessed baseline testing, emergency departments were randomly assigned to activation of a decision-support system on the devices (10 centers, 753 patients) or posters and pocket cards that showed validated diagnostic strategies (10 centers, 1015 patients). MEASUREMENTS: Appropriateness of diagnostic work-up, defined as any sequence of tests that yielded a posttest probability less than 5% or greater than 85% (primary outcome) or as strict adherence to guideline recommendations (secondary outcome); number of tests per patient (secondary outcome). RESULTS: The proportion of patients who received appropriate diagnostic work-ups was greater during the trial than in the preintervention period in both groups, but the increase was greater in the computer-based guidelines group (adjusted mean difference in increase, 19.3 percentage points favoring computer-based guidelines [95% CI, 2.9 to 35.6 percentage points]; P = 0.023). Among patients with appropriate work-ups, those in the computer-based guidelines group received slightly fewer tests than did patients in the paper guidelines group (mean tests per patient, 1.76 [SD, 0.98] vs. 2.25 [SD, 1.04]; P < 0.001). LIMITATION: The study was not designed to show a difference in the clinical outcomes of patients during follow-up. CONCLUSION: A handheld decision-support system improved diagnostic decision making for patients with suspected pulmonary embolism in the emergency department.

Prediction of peak oxygen uptake from sub-maximal ratings of perceived exertion elicited during a graded exercise test in obese women.

The purpose was to assess the validity of predicting peak oxygen uptake (.VO(2)peak) from Ratings of Perceived Exertion (RPE)< or =15, during a graded exercise test (GXT), in obese women. Forty-three obese women performed GXT to volitional exhaustion. During GXT, oxygen uptake (.VO(2)) and RPE were measured. Individual linear regressions between .VO(2) and RPE< or =15 were extrapolated to RPE 20 in order to predict .VO(2)peak. Actual and predicted .VO(2)peak were not significantly different (13.9+/-3.0 vs 14.2+/-3.3 ml kg(-1) min(-1), respectively; p=.26). The Pearson product moment correlation between actual and predicted .VO(2)peak was high (r=0.82). The 95% limits of agreement analysis on these values (bias+/-1.96SD) was -0.3+/-3.7 ml kg(-1) min(-1). Results suggested that RPE< or =15 elicited during a sub-maximal GXT provides accurate .VO(2)peak prediction. Therefore, it is not necessary to perform GXT to voluntary exhaustion to determine .VO(2)peak in obese women.

Intermittent versus continuous exercise: effects of perceptually lower exercise in obese women.

INTRODUCTION: Exercise has beneficial effects on obesity and diabetes treatments. However, obese subjects do not closely adhere to training programs probably because of the monotony of the continuous exercise that is frequently proposed. To increase adherence to training programs, intermittent exercise, which is less monotonous, may be more appropriate. PURPOSE: The purposes of this study were to determine the perceptually less hard exercise (continuous vs intermittent exercise) and to analyze the impact of a training program on the basis of this exercise in obese women with and without type 2 diabetes. METHODS: Twenty type 2 diabetic obese women and 20 obese women without diabetes were recruited. In each group, 10 patients integrated a training program (i.e., training groups), whereas the remaining patients were untrained (i.e., control groups). The training groups performed a continuous exercise and an intermittent exercise to determine the perceptually less hard exercise thanks to lower ratings of perceived exertion (RPE). Then, a training program that included 32 min (3 d x wk(-1) x 10 wk(-1)) of the perceptually less hard exercise was proposed to training groups. RESULTS: RPE were significantly lower during the intermittent exercise compared to the continuous exercise in the obese women with or without diabetes (RPE = 12.3 +/- 2.3 vs 13.7 +/- 2.3 and RPE = 11.9 +/- 1.1 vs 13.2 +/- 1.6, respectively). After the training program, significant beneficial effects on the glycosylated hemoglobin (6.8 +/- 1.4% vs 6.5 +/- 1.2%), body mass (97.1 +/- 16.9 vs 95.2 +/- 16.2 kg), body mass index (37.6 +/- 6.1 vs 36.8 +/- 6.0 kg x m(-2)), and on the HR and the walked distance limit were noticed in the training groups. CONCLUSION: The obese women with or without diabetes perceived the intermittent exercise as being less hard than the continuous exercise, and a training program based on intermittent exercises produced beneficial effects on obesity and type 2 diabetes.

Real-time myocardial perfusion imaging for pharmacologic stress testing: added value to single photon emission computed tomography.

BACKGROUND: Little is known about the incremental value of real-time myocardial contrast echocardiography (MCE) as an adjunct to pharmacologic stress testing. This study was performed to evaluate the diagnostic value of MCE to detect abnormal myocardial perfusion by technetium Tc 99m sestamibi-single photon emission computed tomography (SPECT) and anatomically significant coronary artery disease (CAD) by angiography. METHODS: Myocardial contrast echocardiography was performed at rest and during vasodilator stress in consecutive patients (N = 120) undergoing SPECT imaging for known or suspected CAD. Myocardial opacification, wall motion, and tracer uptake were visually analyzed in 12 myocardial segments by 2 pairs of blinded observers. Concordance between the 2 methods was assessed using the kappa statistic. RESULTS: Of 1356 segments, 1025 (76%) were interpretable by MCE, wall motion, and SPECT. Sensitivity of wall motion was 75%, specificity 83%, and accuracy 81% for detecting abnormal myocardial perfusion by SPECT (kappa = 0.53). Myocardial contrast echocardiography and wall motion together yielded significantly higher sensitivity (85% vs 74%, P < .05), specificity of 83%, and accuracy of 85% (kappa = 0.64) for the detection of abnormal myocardial perfusion. In 89 patients who underwent coronary angiography, MCE and wall motion together yielded higher sensitivity (83% vs 64%, P < .05) and accuracy (77% vs 68%, P < .05) but similar specificity (72%) compared with SPECT for the detection of high-grade, stenotic (> or = 75%) coronary lesions. CONCLUSION: Assessment of myocardial perfusion adds value to conventional stress echocardiography by increasing its sensitivity for the detection of functionally abnormal myocardial perfusion. Myocardial contrast echocardiography and wall motion together provide higher sensitivity and accuracy for detection of CAD compared with SPECT.

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.

Cyclic variation of myocardial signal intensity in real-time myocardial perfusion imaging.

BACKGROUND: The presence of cyclic intensity variation during real-time myocardial perfusion imaging (RTPI) has been controversially discussed. We investigated whether cyclic intensity variation is systematically found during RTPI and whether such variations are related to regional functional parameters. METHODS: Intraoperative RTPI were obtained in 12 pigs before, during, and after left descending coronary artery occlusion with 60 mL/h SonoVue infusion. Furthermore, RTPI was performed in 14 patients after slow bolus injection of 0.7 mL of Optison. Instantaneous regional systolic to diastolic (S/D) myocardial intensity ratios were calculated after high mechanical index bubble destruction. S/D ratios were correlated with A- and beta-values, and fractional area shortening. RESULTS: Systematic cyclic S/D changes were present in both experimental settings showing significantly higher systolic values (animals, S/D 1.28 +/- 0.44; patients, S/D 1.25 +/- 0.7). Cyclic S/D variation was not related to fractional area shortening, or A- or beta-values (all r < 0.3, not significant). CONCLUSION: Consistent cyclic changes in myocardial contrast intensity can be measured both in intraoperative animals and in patients, showing higher systolic values. S/D ratios are not related to regional functional parameters.