Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 21
Filtrar
Mais filtros










Intervalo de ano de publicação
1.
ESC Heart Fail ; 7(5): 3219-3224, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32578962

RESUMO

AIMS: Acute kidney injury (AKI) during acute heart failure (AHF) is common and associated with increased morbidity and mortality. The underlying pathophysiological mechanism appears to have prognostic relevance; however, the differentiation of true, structural AKI from hemodynamic pseudo-AKI remains a clinical challenge. METHODS AND RESULTS: The Basics in Acute Shortness of Breath Evaluation Study (NCT01831115) prospectively enrolled adult patients presenting with AHF to the emergency department. Mortality of patients was prospectively assessed. Haemoconcentration, transglomerular pressure gradient (n = 231) and tubular injury patterns (n = 253) were evaluated to investigate pathophysiological mechanisms underlying AKI timing (existing at presentation vs. developing during in-hospital period). Of 1643 AHF patients, 755 patients (46%) experienced an episode of AKI; 310 patients (19%; 41% of AKI patients) presented with community-acquired AKI (CA-AKI), 445 patients (27%; 59% of AKI patients) developed in-hospital AKI. CA-AKI but not in-hospital AKI was associated with higher mortality compared with no-AKI (adjusted hazard ratio 1.32 [95%-CI 1.01-1.74]; P = 0.04). Independent of AKI timing, haemoconcentration was associated with a lower two-year mortality. Transglomerular pressure gradient at presentation was significantly lower in CA-AKI compared to in-hospital AKI and no-AKI (P < 0.01). Urinary NGAL ratio concentrations were significantly higher in CA-AKI compared to in-hospital AKI (P < 0.01) or no-AKI (P < 0.01). CONCLUSIONS: CA-AKI but not in-hospital AKI is associated with increased long-term mortality and marked by decreased transglomerular pressure gradient and tubular injury, probably reflecting prolonged tubular ischemia due to reno-venous congestion. Adequate decongestion, as assessed by haemoconcentration, is associated with lower long-term mortality independent of AKI timing.

2.
ESC Heart Fail ; 7(4): 1817-1829, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32452635

RESUMO

AIMS: The aim of this study was to investigate the diagnostic and prognostic utility of the QRS-T angle, an electrocardiogram (ECG) marker quantifying depolarization-repolarization heterogeneity, in patients with suspected acute decompensated heart failure (ADHF). METHODS AND RESULTS: We prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of ADHF. The QRS-T angle was automatically derived from a standard 12-lead ECG recorded at presentation. The primary diagnostic endpoint was a final adjudicated diagnosis of ADHF. The primary prognostic endpoint was all-cause mortality during 2 years of follow-up. Among the 1915 patients enrolled, those with higher QRS-T angles were older, were more commonly male, and had a higher rate of co-morbidities such as arterial hypertension, coronary artery disease, or chronic kidney disease. ADHF was the final adjudicated diagnosis in 1140 (60%) patients. The QRS-T angle in patients with ADHF was significantly larger than in patients with non-cardiac causes of dyspnoea {median 110° [inter-quartile range (IQR) 46-156°] vs. median 33° [IQR 15-57°], P < 0.001}. The diagnostic accuracy of the QRS-T angle as quantified by the area under the receiver operating characteristic curve (AUC) was 0.75 [95% confidence interval (CI) 0.73-0.77, P < 0.001], which was inferior to N-terminal pro-B-type natriuretic peptide (AUC 0.93, 95% CI 0.92-0.94, P < 0.001), but similar to that of high-sensitivity troponin T (AUC 0.78, 95% CI 0.76-0.80, P = 0.09). The AUC of the QRS-T angle for discrimination between ADHF and non-cardiac dyspnoea remained similarly high in subgroups of patients known to be diagnostically challenging, including patients older than 75 years [0.71 (95% CI 0.67-0.74)], renal failure [0.79 (95% CI 0.71-0.87)], and atrial fibrillation at presentation [0.68 (95% CI 0.60-0.76)]. Mortality rates according to QRS-T angle tertiles were 4%, 6%, and 10% after 30 days (P < 0.001) and 24%, 31%, and 43% after 2 years (P < 0.001). After adjustment for clinical, laboratory, and ECG parameters, the QRS-T angle remained an independent predictor for 2 year mortality with a 4% increase in mortality for every 20° increase in QRS-T angle (P = 0.02). CONCLUSIONS: The QRS-T angle is a readily available and inexpensive marker that can assist in the discrimination between ADHF and non-cardiac causes of acute dyspnoea and may aid in the risk stratification of these patients.

3.
Emergencias (Sant Vicenç dels Horts) ; 32(2): 97-104, abr. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-188157

RESUMO

Objetivo: Analizar los episodios de pericarditis aguda (PA) diagnosticados en urgencias en función de la edad y de la afectación miocárdica (miopericarditis, MioP), y determinar los factores asociados a hospitalización. Método: Estudio observacional, descriptivo, unicéntrico de casos consecutivos, con análisis retrospectivo de todos los casos diagnosticados de PA en urgencias durante 10 años (2008-2017), y revisión de las características clínicas, ECG, analíticas y ecográficas (en MioP). Se compararon características clínicas según la edad (< 50 y $ 50 años) y existencia de MioP. Los factores asociados a hospitalización (PA y MioP) se identificaron de forma cruda y ajustada por las diferencias clínicas entre grupos. Resultados: Se diagnosticaron 983 PA (34% mujeres, mediana de edad: 42 años). Los pacientes más jóvenes referían con mayor frecuencia dolor torácico (DT) punzante y modificable con la respiración o cambios posturales, y los más mayores tenían más comorbilidades cardiovasculares, refirieron más frecuentemente DT opresivo y generaron mayor sospecha de síndrome coronario agudo. Las alteraciones en el ECG (OR = 4,26; IC95% = 1,89-9,59) se asociaron a MioP (72 casos, 7%). Ingresaron 62 PA (6%), hecho asociado a antecedente de insuficiencia renal (OR = 4,83; IC95% = 1,66-14,05), DT que se modifica con movimientos respiratorios/posturales (OR = 0,54, IC95% = 0,29-0,99), taquicardia (OR = 2,29, IC95% = 1,15-4,55) y MioP (OR = 8,73, IC95% = 4,65-16,38). Ingresaron 24 MioP (33%), hecho asociado a alteraciones en la ecoscopia dirigida (protocolo FOCUS; OR = 13,72, IC95% = 1,80-104). Conclusiones: La edad puede condicionar la presentación clínica en los pacientes con PA. Las alteraciones en el segmento ST en el ECG son sugestivos de implicación miocárdica. La insuficiencia renal, la taquicardia y la MioP son factores que incrementan la decisión de hospitalización en las PA; mientras que en las MioP, las alteraciones ecográficas


Objectives: To analyze the clinical features of acute pericarditis diagnosed in the emergency department according to patient age and myocardial involvement (myopericarditis) and to determine factors associated with hospitalization. Methods: Retrospective, descriptive, observational, single-center study of consecutive patients. We analyzed all cases of pericarditis diagnosed in the emergency department over a period of 10 years (2008-2017), reviewing clinical, electrocardiographic, and laboratory findings as well as ultrasound imaging for myocardial involvement. Characteristics were analyzed by age (under 50 years or 50 or older) and presence or not of myocardial involvement. Factors associated with hospitalization for both pericarditis and myopericarditis were identified by crude and adjusted odds ratios (ORs). Results: A total of 983 patients were diagnosed with pericarditis (34% women, mean age, 42 years). The younger patients more often reported sharp chest pain modified by breathing or posture changes. Older patients had more concurrent cardiovascular disease and described chest pain as pressure (oppressive); acute coronary syndrome was suspected more often in the older patients. The only independent predictor of myopericarditis was a finding of electrocardiographic abnormalities, recorded in 72 cases (7%) (OR, 4.26; 95% CI, 1.89-9.59). Sixty-two patients (6%) were admitted for pericarditis. Associated factors were renal insufficiency (OR, 4.83; 95% CI, 1.66-14.05), pain modified by breathing or posture changes (OR, 0.54; 95% CI, 0.29-0.99), tachycardia (OR, 2.29; 95% CI, 1.15-4.55), and myopericarditis (OR, 8.73; 95% CI, 4.65-16.38). Admission of 24 patients (33%) for myocarditis was related to focused cardiac ultrasound findings (OR, 13.72; 95% CI, 1.80-104). Conclusions: Age may affect the presentation of pericarditis. ST segment abnormalities on an electrocardiogram suggest myocardial involvement. Renal insufficiency, tachycardia, and myocardial involvement are the factors associated with a decision to admit patients with pericarditis. Ultrasound findings are associated with admission for myopericarditis


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Pericardite/diagnóstico , Hospitalização , Fatores de Risco , Serviços Médicos de Emergência/métodos , Estudos Retrospectivos , Intervalos de Confiança , Comorbidade , Dor no Peito/classificação , Dor no Peito/etiologia , Razão de Chances , Diagnóstico Diferencial
4.
Emergencias ; 32(2): 97-104, 2020.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-32125108

RESUMO

OBJECTIVES: To analyze the clinical features of acute pericarditis diagnosed in the emergency department according to patient age and myocardial involvement (myopericarditis) and to determine factors associated with hospitalization. MATERIAL AND METHODS: Retrospective, descriptive, observational, single-center study of consecutive patients. We analyzed all cases of pericarditis diagnosed in the emergency department over a period of 10 years (2008-2017), reviewing clinical, electrocardiographic, and laboratory findings as well as ultrasound imaging for myocardial involvement. Characteristics were analyzed by age (under 50 years or 50 or older) and presence or not of myocardial involvement. Factors associated with hospitalization for both pericarditis and myopericarditis were identified by crude and adjusted odds ratios (ORs). RESULTS: A total of 983 patients were diagnosed with pericarditis (34% women, mean age, 42 years). The younger patients more often reported sharp chest pain modified by breathing or posture changes. Older patients had more concurrent cardiovascular disease and described chest pain as pressure (oppressive); acute coronary syndrome was suspected more often in the older patients. The only independent predictor of myopericarditis was a finding of electrocardiographic abnormalities, recorded in 72 cases (7%) (OR, 4.26; 95% CI, 1.89-9.59). Sixty-two patients (6%) were admitted for pericarditis. Associated factors were renal insufficiency (OR, 4.83; 95% CI, 1.66-14.05), pain modified by breathing or posture changes (OR, 0.54; 95% CI, 0.29-0.99), tachycardia (OR, 2.29; 95% CI, 1.15- 4.55), and myopericarditis (OR, 8.73; 95% CI, 4.65-16.38). Admission of 24 patients (33%) for myocarditis was related to focused cardiac ultrasound findings (OR, 13.72; 95% CI, 1.80-104). CONCLUSION: Age may affect the presentation of pericarditis. ST segment abnormalities on an electrocardiogram suggest myocardial involvement. Renal insufficiency, tachycardia, and myocardial involvement are the factors associated with a decision to admit patients with pericarditis. Ultrasound findings are associated with admission for myopericarditis.

5.
JAMA ; 322(23): 2292-2302, 2019 12 17.
Artigo em Inglês | MEDLINE | ID: mdl-31846016

RESUMO

Importance: Short-term infusions of single vasodilators, usually given in a fixed dose, have not improved outcomes in patients with acute heart failure (AHF). Objective: To evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation using individualized up-titrated doses of established vasodilators in patients with AHF. Design, Setting, and Participants: Randomized, open-label blinded-end-point trial enrolling 788 patients hospitalized for AHF with dyspnea, increased plasma concentrations of natriuretic peptides, systolic blood pressure of at least 100 mm Hg, and plan for treatment in a general ward in 10 tertiary and secondary hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Enrollment began in December 2007 and follow-up was completed in February 2019. Interventions: Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization (n = 386) or usual care (n = 402). Early intensive and sustained vasodilation was a comprehensive pragmatic approach of maximal and sustained vasodilation combining individualized doses of sublingual and transdermal nitrates, low-dose oral hydralazine for 48 hours, and rapid up-titration of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or sacubitril-valsartan. Main Outcomes and Measures: The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days. Results: Among 788 patients randomized, 781 (99.1%; median age, 78 years; 36.9% women) completed the trial and were eligible for primary end point analysis. Follow-up at 180 days was completed for 779 patients (99.7%). The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 117 patients (30.6%) in the intervention group (including 55 deaths [14.4%]) and in 111 patients (27.8%) in the usual care group (including 61 deaths [15.3%]) (absolute difference for the primary end point, 2.8% [95% CI, -3.7% to 9.3%]; adjusted hazard ratio, 1.07 [95% CI, 0.83-1.39]; P = .59). The most common clinically significant adverse events with early intensive and sustained vasodilation vs usual care were hypokalemia (23% vs 25%), worsening renal function (21% vs 20%), headache (26% vs 10%), dizziness (15% vs 10%), and hypotension (8% vs 2%). Conclusions and Relevance: Among patients with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, did not significantly improve a composite outcome of all-cause mortality and AHF rehospitalization at 180 days. Trial Registration: ClinicalTrials.gov Identifier: NCT00512759.


Assuntos
Insuficiência Cardíaca/tratamento farmacológico , Vasodilatadores/administração & dosagem , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Comorbidade , Esquema de Medicação , Feminino , Insuficiência Cardíaca/mortalidade , Hospitalização , Humanos , Masculino , Readmissão do Paciente/estatística & dados numéricos , Vasodilatadores/efeitos adversos
6.
Clin Chem ; 65(12): 1532-1542, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31615771

RESUMO

BACKGROUND: The clinical utility of procalcitonin in the diagnosis and management of pneumonia remains controversial. METHODS: We assessed the clinical utility of procalcitonin in 2 prospective studies: first, a multicenter diagnostic study in patients presenting to the emergency department with acute dyspnea to directly compare the diagnostic accuracy of procalcitonin with that of interleukin 6 and C-reactive protein (CRP) in the diagnosis of pneumonia; second, a randomized management study of procalcitonin guidance in patients with acute heart failure and suspected pneumonia. Diagnostic accuracy for pneumonia as centrally adjudicated by 2 independent experts was quantified with the area under the ROC curve (AUC). RESULTS: Among 690 patients in the diagnostic study, 178 (25.8%) had an adjudicated final diagnosis of pneumonia. Procalcitonin, interleukin 6, and CRP were significantly higher in patients with pneumonia than in those without. When compared to procalcitonin (AUC = 0.75; 95% CI, 0.71-0.78), interleukin 6 (AUC = 0.80; 95% CI, 0.77-0.83) and CRP (AUC = 0.82; 95% CI, 0.79-0.85) had significantly higher diagnostic accuracy (P = 0.010 and P < 0.001, respectively). The management study was stopped early owing to the unexpectedly low AUC of procalcitonin in the diagnostic study. Among 45 randomized patients, the number of days on antibiotic therapy and the length of hospital stay were similar (both P = 0.39) in patients randomized to the procalcitonin-guided group (n = 25) and usual-care group (n = 20). CONCLUSIONS: In patients presenting with dyspnea, diagnostic accuracy of procalcitonin for pneumonia is only moderate and lower than that of interleukin 6 and CRP. The clinical utility of procalcitonin was lower than expected. SUMMARY: Pneumonia has diverse and often unspecific symptoms. As the role of biomarkers in the diagnosis of pneumonia remains controversial, it is often difficult to distinguish pneumonia from other illnesses causing shortness of breath. The current study prospectively enrolled unselected patients presenting with acute dyspnea and directly compared the diagnostic accuracy of procalcitonin, interleukin 6, and CRP for the diagnosis of pneumonia. In this setting, diagnostic accuracy of procalcitonin for pneumonia was lower as compared to interleukin 6 and CRP. The clinical utility of procalcitonin was lower than expected. CLINICALTRIALSGOV IDENTIFIER: NCT01831115.


Assuntos
Pneumonia/diagnóstico , Pró-Calcitonina/análise , Idoso , Área Sob a Curva , Biomarcadores/sangue , Biomarcadores/metabolismo , Proteína C-Reativa/análise , Calcitonina , Testes Diagnósticos de Rotina , Dispneia/diagnóstico , Feminino , Insuficiência Cardíaca/diagnóstico , Humanos , Interleucina-6/análise , Interleucina-6/sangue , Masculino , Pessoa de Meia-Idade , Pró-Calcitonina/metabolismo , Estudos Prospectivos , Precursores de Proteínas/metabolismo , Curva ROC
7.
Heart ; 105(18): 1423-1431, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31018955

RESUMO

OBJECTIVE: Assess the relative incidence and compare characteristics and outcome of unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI). DESIGN: Two independent prospective multicentre diagnostic studies (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] and High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome [High-STEACS]) enrolling patients with acute chest discomfort presenting to the emergency department. Central adjudication of the final diagnosis was done by two independent cardiologists using all clinical information including serial measurements of high-sensitivity cardiac troponin (hs-cTn). All-cause death and future non-fatal MI were assessed at 30 days and 1 year. RESULTS: 8992 patients were enrolled at 11 centres. UA was adjudicated in 8.9%(95% CI 8.0 to 9.7) and 2.8% (95% CI 2.3 to 3.3) patients in APACE and High-STEACS, respectively, and NSTEMI in 15.1% (95% CI 14.0 to 16.2) and 13.4% (95% CI 12.4 to 14.3). Coronary artery disease was pre-existing in 73% and 76% of patients with UA. At 30 days, all-cause mortality in UA was substantially lower as compared with NSTEMI (0.5% vs 3.7%, p=0.002 in APACE, 0.7% vs 7.4%, p=0.004 in High-STEACS). Similarly, at 1 year in UA all-cause mortality was 3.3% (95% CI 1.2 to 5.3) vs 10.4% (95% CI 7.9 to 12.9) in APACE, and 5.1% (95% CI 0.7 to 9.5) vs 22.9% (95% CI 19.3 to 26.4) in High-STEACS, and similar to non-cardiac chest pain (NCCP). In contrast, future non-fatal MI in APACE was comparable in UA and NSTEMI (11.2%, 95% CI 7.8 to 14.6 and 7.9%, 95% CI 5.7 to 10.2), and higher than in NCCP (0.6%, 95% CI 0.2 to 1.0). CONCLUSIONS: The relative incidence and mortality of UA is substantially lower than that of NSTEMI, while the rate of future non-fatal MI is similar.

9.
Int J Cardiol ; 286: 104-110, 2019 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-30853296

RESUMO

BACKGROUND: Relative hypochromia of erythrocytes defined as a reduced mean corpuscular hemoglobin concentration (MCHC) is a surrogate of iron deficiency. We aimed to evaluate the prevalence and prognostic impact of relative hypochromia in acute heart failure (AHF). METHODS: We prospectively characterized 1574 patients presenting with an adjudicated diagnosis of AHF to the emergency department. Relative hypochromia was defined as a MCHC ≤330 g/l and determined at presentation. The presence of AHF was adjudicated by two independent cardiologists. All-cause mortality and AHF-rehospitalization were the primary prognostic end-points. RESULTS: Overall, 455 (29%) AHF patients had relative hypochromia. Patients with relative hypochromia had higher hemodynamic cardiac stress as quantified by NT-proBNP concentrations (p < 0.001), more extensive cardiomyocyte injury as quantified by high-sensitive cardiac troponin T (hs-cTnT) concentrations (p < 0.001), and lower estimated glomerular filtration rate (eGFR; p < 0.001) as compared to AHF patients without hypochromia. Cumulative incidences for all-cause mortality and AHF-rehospitalization at 720-days were 50% and 55% in patients with relative hypochromia as compared to 33% and 39% in patients without hypochromia, respectively (both p < 0.0001). The association between relative hypochromia and increased mortality (HR 1.7, 95% CI 1.4-2-0) persisted after adjusting for anemia (HR 1.5, 95% CI 1.3-1.8), and after adjusting for hemodynamic cardiac stress (HR 1.46, 95% CI 1.21-1.76) and eGFR (HR 1.5, 95% CI 1.3-1.8, p < 0.001). CONCLUSIONS: Relative hypochromia is common and a strong and independent predictor of increased mortality in AHF. Given the direct link to diagnostic (endoscopy) and therapeutic interventions to treat functional iron deficiency, relative hypochromia deserves increased attention as an inexpensive and universally available biomarker.


Assuntos
Anemia Hipocrômica/etiologia , Insuficiência Cardíaca/diagnóstico , Ferro/sangue , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Anemia Hipocrômica/sangue , Anemia Hipocrômica/epidemiologia , Biomarcadores/sangue , Feminino , Seguimentos , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/epidemiologia , Humanos , Incidência , Masculino , Prognóstico , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Suíça/epidemiologia
10.
Ann Intern Med ; 170(4): 248-256, 2019 02 19.
Artigo em Inglês | MEDLINE | ID: mdl-30690646

RESUMO

Background: The MEESSI-AHF (Multiple Estimation of risk based on the Emergency department Spanish Score In patients with AHF) score was developed to predict 30-day mortality in patients presenting with acute heart failure (AHF) to emergency departments (EDs) in Spain. Whether it performs well in other countries is unknown. Objective: To externally validate the MEESSI-AHF score in another country. Design: Prospective cohort study. (ClinicalTrials.gov: NCT01831115). Setting: Multicenter recruitment of dyspneic patients presenting to the ED. Participants: The external validation cohort included 1572 patients with AHF. Measurements: Calculation of the MEESSI-AHF score using an established model containing 12 independent risk factors. Results: Among 1572 patients with adjudicated AHF, 1247 had complete data that allowed calculation of the MEESSI-AHF score. Of these, 102 (8.2%) died within 30 days. The score predicted 30-day mortality with excellent discrimination (c-statistic, 0.80). Assessment of cumulative mortality showed a steep gradient in 30-day mortality over 6 predefined risk groups (0 patients in the lowest-risk group vs. 35 [28.5%] in the highest-risk group). Risk was overestimated in the high-risk groups, resulting in a Hosmer-Lemeshow P value of 0.022. However, after adjustment of the intercept, the model showed good concordance between predicted risks and observed outcomes (P = 0.23). Findings were confirmed in sensitivity analyses that used multiple imputation for missing values in the overall cohort of 1572 patients. Limitations: External validation was done using a reduced model. Findings are specific to patients with AHF who present to the ED and are clinically stable enough to provide informed consent. Performance in patients with terminal kidney failure who are receiving long-term dialysis cannot be commented on. Conclusion: External validation of the MEESSI-AHF risk score showed excellent discrimination. Recalibration may be needed when the score is introduced to new populations. Primary Funding Source: The European Union, the Swiss National Science Foundation, the Swiss Heart Foundation, the Cardiovascular Research Foundation Basel, the University of Basel, and University Hospital Basel.


Assuntos
Insuficiência Cardíaca/mortalidade , Medição de Risco/métodos , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência , Feminino , Insuficiência Cardíaca/diagnóstico , Humanos , Modelos Logísticos , Masculino , Estudos Prospectivos , Reprodutibilidade dos Testes , Espanha/epidemiologia , Suíça/epidemiologia
11.
Europace ; 21(3): 511-521, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-30137300

RESUMO

AIMS: It is unknown whether cardiac syncope, and possibly also other syncope aetiologies exhibit circadian, weekly, seasonal, and temperature-dependent patterns. METHODS AND RESULTS: We prospectively recorded the exact time, date, and outside temperature of syncope of patients >40 years old presenting with syncope to the emergency department in a diagnostic multicentre study. Two independent cardiologists/emergency physicians adjudicated the final diagnosis based on all information becoming available during clinical work-up including 1-year follow-up. Among 1230 patients, the adjudicated aetiology was cardiac in 14.6%, reflex in 39.2%, orthostatic in 25.7%, other non-cardiac in 9.7%, and unknown in 10.8% of patients. All syncope aetiologies occurred much more frequently during the day when compared with the night (P < 0.01). While reflex and orthostatic syncope showed a broad peak of prevalence with 80.9% of these events occurring between 4 am and 4 pm, cardiac syncope showed a narrow peak of prevalence with 70.1% of all events occurring between 8 am and 2 pm. A weekly pattern was present for most syncope aetiologies, with events occurring mainly from Monday to Friday (P < 0.01). Reflex syncope displayed a seasonal rhythm and was more common in winter (P < 0.01), while cardiac syncope stayed constant over the year. Syncope occurred most often when the outside temperature was coldest. Overall the patterns observed for cardiac syncope were similar to the patterns observed for its differential diagnosis. CONCLUSION: Syncope aetiologies in patients >40 years old display circadian, weekly, seasonal, and temperature-dependent patterns. Unfortunately, these patterns do not allow to reliably differentiate cardiac syncope from other aetiologies.

12.
J Am Coll Cardiol ; 72(6): 620-632, 2018 08 07.
Artigo em Inglês | MEDLINE | ID: mdl-30071991

RESUMO

BACKGROUND: The safety of the European Society of Cardiology (ESC) 0/1-h algorithm for rapid rule-out and rule-in of non-ST-segment elevation myocardial infarction (NSTEMI) using high-sensitivity cardiac troponin (hs-cTn) has been questioned. OBJECTIVES: This study aimed to validate the diagnostic performance of the 0/1-h algorithm in a large multicenter study. METHODS: The authors prospectively enrolled unselected patients in 6 countries presenting to the emergency department with symptoms suggestive of NSTEMI. Final diagnosis was centrally adjudicated by 2 independent cardiologists. Hs-cTnT and hs-cTnI blood concentrations were measured at presentation and after 1 h. Safety of rule-out was quantified by the negative predictive value (NPV) for NSTEMI, accuracy of rule-in by the positive predictive value (PPV), and overall efficacy by the proportion of patients triaged towards rule-out or rule-in within 1 h. RESULTS: Prevalence of NSTEMI was 17%. Among 4,368 patients with serial hs-cTnT measurements available, safety of rule-out (NPV 99.8%, 2,488 of 2,493), accuracy of rule-in (PPV 74.5%, 572 of 768), and overall efficacy were high by assigning three-fourths of patients either to rule-out (57%, 2,493 to 4,368) or rule-in (18%, 768 to 4,368). Similarly, among 3,500 patients with serial hs-cTnI measurements, safety of rule-out (NPV 99.7%, 1,528 of 1,533), accuracy of rule-in (PPV 62.3%, 498 of 800), and overall efficacy were high by assigning more than two-thirds of patients either to rule-out (44%, 1,533 of 3,500) or rule-in (23%, 800 of 3,500). Excellent safety was confirmed in multiple subgroup analyses including patients presenting early (≤3 h) after chest pain onset. CONCLUSIONS: The ESC 0/1-h algorithm using hs-cTnT and hs-cTnI is very safe and effective in triaging patients with suspected NSTEMI. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE]; NCT00470587; and Biomarkers in Acute Cardiac Care [BACC]; NCT02355457).


Assuntos
Algoritmos , Dor no Peito/diagnóstico , Internacionalidade , Infarto do Miocárdio/diagnóstico , Idoso , Dor no Peito/epidemiologia , Dor no Peito/fisiopatologia , Diagnóstico Precoce , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/fisiopatologia , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes
13.
Circulation ; 138(10): 989-999, 2018 09 04.
Artigo em Inglês | MEDLINE | ID: mdl-29691270

RESUMO

BACKGROUND: Combining 2 signals of cardiomyocyte injury, cardiac troponin I (cTnI) and T (cTnT), might overcome some individual pathophysiological and analytical limitations and thereby increase diagnostic accuracy for acute myocardial infarction with a single blood draw. We aimed to evaluate the diagnostic performance of combinations of high-sensitivity (hs) cTnI and hs-cTnT for the early diagnosis of acute myocardial infarction. METHODS: The diagnostic performance of combining hs-cTnI (Architect, Abbott) and hs-cTnT (Elecsys, Roche) concentrations (sum, product, ratio, and a combination algorithm) obtained at the time of presentation was evaluated in a large multicenter diagnostic study of patients with suspected acute myocardial infarction. The optimal rule-out and rule-in thresholds were externally validated in a second large multicenter diagnostic study. The proportion of patients eligible for early rule-out was compared with the European Society of Cardiology 0/1 and 0/3 hour algorithms. RESULTS: Combining hs-cTnI and hs-cTnT concentrations did not consistently increase overall diagnostic accuracy as compared with the individual isoforms. However, the combination improved the proportion of patients meeting criteria for very early rule-out. With the European Society of Cardiology 2015 guideline recommended algorithms and cut-offs, the proportion meeting rule-out criteria after the baseline blood sampling was limited (6% to 24%) and assay dependent. Application of optimized cut-off values using the sum (9 ng/L) and product (18 ng2/L2) of hs-cTnI and hs-cTnT concentrations led to an increase in the proportion ruled-out after a single blood draw to 34% to 41% in the original (sum: negative predictive value [NPV] 100% [95% confidence interval (CI), 99.5% to 100%]; product: NPV 100% [95% CI, 99.5% to 100%]) and in the validation cohort (sum: NPV 99.6% [95% CI, 99.0-99.9%]; product: NPV 99.4% [95% CI, 98.8-99.8%]). The use of a combination algorithm (hs-cTnI <4 ng/L and hs-cTnT <9 ng/L) showed comparable results for rule-out (40% to 43% ruled out; NPV original cohort 99.9% [95% CI, 99.2-100%]; NPV validation cohort 99.5% [95% CI, 98.9-99.8%]) and rule-in (positive predictive value [PPV] original cohort 74.4% [95% Cl, 69.6-78.8%]; PPV validation cohort 84.0% [95% Cl, 79.7-87.6%]). CONCLUSIONS: New strategies combining hs-cTnI and hs-cTnT concentrations may significantly increase the number of patients eligible for very early and safe rule-out, but do not seem helpful for the rule-in of acute myocardial infarction. CLINICAL TRIAL REGISTRATION: URL (APACE): https://www.clinicaltrial.gov . Unique identifier: NCT00470587. URL (ADAPT): www.anzctr.org.au . Unique identifier: ACTRN12611001069943.


Assuntos
Infarto do Miocárdio/diagnóstico , Troponina I/sangue , Troponina T/sangue , Austrália , Biomarcadores/sangue , Diagnóstico Precoce , Europa (Continente) , Humanos , Infarto do Miocárdio/sangue , Nova Zelândia , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de Tempo , Regulação para Cima
14.
Clin Res Cardiol ; 107(9): 824-835, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29667014

RESUMO

BACKGROUND: Myocardial scar is associated with adverse cardiac outcomes. The Selvester QRS-score was developed to estimate myocardial scar from the 12-lead ECG, but its manual calculation is difficult. An automatically computed QRS-score would allow identification of patients with myocardial scar and an increased risk of mortality. OBJECTIVES: To assess the diagnostic and prognostic value of the automatically computed QRS-score. METHODS: The diagnostic value of the QRS-score computed automatically from a standard digital 12-lead was prospectively assessed in 2742 patients with suspected myocardial ischemia referred for myocardial perfusion imaging (MPI). The prognostic value of the QRS-score was then prospectively tested in 1151 consecutive patients presenting to the emergency department (ED) with suspected acute heart failure (AHF). RESULTS: Overall, the QRS-score was significantly higher in patients with more extensive myocardial scar: the median QRS-score was 3 (IQR 2-5), 4 (IQR 2-6), and 7 (IQR 4-10) for patients with 0, 5-20 and > 20% myocardial scar as quantified by MPI (p < 0.001 for all pairwise comparisons). A QRS-score ≥ 9 (n = 284, 10%) predicted a large scar defined as > 20% of the LV with a specificity of 91% (95% CI 90-92%). Regarding clinical outcomes in patients presenting to the ED with symptoms suggestive of AHF, mortality after 1 year was 28% in patients with a QRS-score ≥ 3 as opposed to 20% in patients with a QRS-score < 3 (p = 0.001). CONCLUSIONS: The QRS-score can be computed automatically from the 12-lead ECG for simple, non-invasive and inexpensive detection and quantification of myocardial scar and for the prediction of mortality. TRIAL-REGISTRATION: http://www.clinicaltrials.gov . Identifier, NCT01838148 and NCT01831115.


Assuntos
Algoritmos , Cicatriz/patologia , Eletrocardiografia/métodos , Processamento Eletrônico de Dados/métodos , Isquemia Miocárdica/mortalidade , Miocárdio/patologia , Idoso , Cicatriz/etiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/complicações , Isquemia Miocárdica/diagnóstico , Tomografia por Emissão de Pósitrons , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de Risco , Taxa de Sobrevida/tendências , Suíça/epidemiologia
16.
Clin Chem ; 64(3): 515-525, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29343534

RESUMO

BACKGROUND: There is concern that high-sensitivity cardiac troponin (hs-cTn) may have low diagnostic accuracy in patients with low acute coronary syndrome (ACS) probability. METHODS: We prospectively stratified patients presenting with acute chest discomfort to the emergency department (ED) into 3 groups according to their probability for ACS as assessed by the treating ED physician using a visual analog scale: ≤10%, 11% to 79%, and ≥80%, reviewing all information available at 90 min. hs-cTnT and hs-cTnI concentrations were determined in a blinded fashion. Two independent cardiologists adjudicated the final diagnosis. RESULTS: Among 3828 patients eligible for analysis, 1189 patients had low (≤10%) probability for ACS. The incidence of non-ST-segment elevation myocardial infarction (NSTEMI) increased from 1.3% to 12.2% and 54.8% in patients with low, intermediate, and high ACS probability, respectively. The positive predictive value of hs-cTnT and hs-cTnI was low in patients with low ACS probability and increased with the incidence of NSTEMI, whereas the diagnostic accuracy of hs-cTnT and hs-cTnI for NSTEMI as quantified by the area under the curve (AUC) was very high and comparable among all 3 strata, e.g., AUC hs-cTnI, 0.96 (95% CI, 0.94-0.97); 0.87 (95% CI, 0.85-0.89); and 0.89 (95% CI, 0.87-0.92), respectively. Findings were validated using bootstrap analysis as an alternative methodology to define ACS probability. Similarly, higher hs-cTnT/I concentrations independently predicted all-cause mortality within 2 years (e.g., hs-cTnT hazard ratio, 1.39; 95% CI, 1.27-1.52), irrespective of ACS probability. CONCLUSIONS: Diagnostic and prognostic accuracy and utility of hs-cTnT and hs-cTnI remain high in patients with acute chest discomfort and low ACS probability.ClinicalTrials.gov Identifier: NCT00470587.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Troponina I/sangue , Troponina T/sangue , Síndrome Coronariana Aguda/sangue , Adulto , Idoso , Biomarcadores/sangue , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Probabilidade , Sensibilidade e Especificidade
19.
J Am Heart Assoc ; 6(12)2017 12 14.
Artigo em Inglês | MEDLINE | ID: mdl-29426039

RESUMO

BACKGROUND: The early detection of cardiac syncope is challenging. We aimed to evaluate the diagnostic value of 4 novel prohormones, quantifying different neurohumoral pathways, possibly involved in the pathophysiological features of cardiac syncope: midregional-pro-A-type natriuretic peptide (MRproANP), C-terminal proendothelin 1, copeptin, and midregional-proadrenomedullin. METHODS AND RESULTS: We prospectively enrolled unselected patients presenting with syncope to the emergency department (ED) in a diagnostic multicenter study. ED probability of cardiac syncope was quantified by the treating ED physician using a visual analogue scale. Prohormones were measured in a blinded manner. Two independent cardiologists adjudicated the final diagnosis on the basis of all clinical information, including 1-year follow-up. Among 689 patients, cardiac syncope was the adjudicated final diagnosis in 125 (18%). Plasma concentrations of MRproANP, C-terminal proendothelin 1, copeptin, and midregional-proadrenomedullin were all significantly higher in patients with cardiac syncope compared with patients with other causes (P<0.001). The diagnostic accuracies for cardiac syncope, as quantified by the area under the curve, were 0.80 (95% confidence interval [CI], 0.76-0.84), 0.69 (95% CI, 0.64-0.74), 0.58 (95% CI, 0.52-0.63), and 0.68 (95% CI, 0.63-0.73), respectively. In conjunction with the ED probability (0.86; 95% CI, 0.82-0.90), MRproANP, but not the other prohormone, improved the area under the curve to 0.90 (95% CI, 0.87-0.93), which was significantly higher than for the ED probability alone (P=0.003). An algorithm to rule out cardiac syncope combining an MRproANP level of <77 pmol/L and an ED probability of <20% had a sensitivity and a negative predictive value of 99%. CONCLUSIONS: The use of MRproANP significantly improves the early detection of cardiac syncope among unselected patients presenting to the ED with syncope. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01548352.


Assuntos
Adrenomedulina/sangue , Fator Natriurético Atrial/sangue , Diagnóstico Precoce , Endotelina-1/sangue , Glicopeptídeos/sangue , Fragmentos de Peptídeos/sangue , Precursores de Proteínas/sangue , Síncope/diagnóstico , Idoso , Biomarcadores/sangue , Serviço Hospitalar de Emergência , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Síncope/sangue , Síncope/fisiopatologia
20.
Appl Microbiol Biotechnol ; 100(2): 837-46, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26519051

RESUMO

Soil-transmitted helminths, which affect the poorest communities, worldwide cause a range of symptoms and morbidity, yet few treatment options are available and drug resistance is a concern. To improve and accelerate anthelminthic drug discovery, novel drug screening tools such as isothermal microcalorimetry (IMC) have been tested with great potential. In this study, we used a novel microcalorimeter, the calScreener™, to study the viability on the hookworms Necator americanus and Ancylostoma ceylanicum as well as the whipworm Trichuris muris. Significant heat flow signals could be obtained with already one adult worm per channel for all three species. High-amplitude oscillations were observed for the hookworms; however, adult T. muris showed a twofold heat flow decrease during the first 24 h. Antinematodal effects of ivermectin and levamisole at 1, 10, and 100 µg/ml were evaluated on adult N. americanus and A. ceylanicum. Levamisole-treated hookworms showed a decline in heat flow and oscillation amplitude in a dose-response manner. Heat flow for ivermectin-treated hookworms increased proportionally with increased concentrations of ivermectin, though the wavelet analysis showed an opposite trend as observed by flatter wavelets. In conclusion, the calScreener™ is an excellent tool to study drug effects on intestinal hookworms at the adult worm stage as it offers a lower detection limit than other IMC devices and the possibility to monitor worm viability online.


Assuntos
Ancylostoma/efeitos dos fármacos , Antinematódeos/farmacologia , Calorimetria/instrumentação , Descoberta de Drogas/instrumentação , Necator americanus/efeitos dos fármacos , Ancylostoma/fisiologia , Animais , Antiparasitários/farmacologia , Cricetinae , Avaliação Pré-Clínica de Medicamentos/métodos , Temperatura Alta , Intestinos/parasitologia , Ivermectina/farmacologia , Levamisol/farmacologia , Camundongos , Necator americanus/fisiologia , Trichuris/efeitos dos fármacos , Trichuris/fisiologia
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA