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Emergencias ; 32(1): 9-18, 2020 Feb.
Artigo em Espanhol, Inglês | MEDLINE | ID: mdl-31909907


OBJECTIVES: To analyze clinical data and electrocardiographic (ECG) findings obtained during the initial evaluation of patients with nontraumatic chest pain (NTCP). To explore associations between these findings and the initial and final diagnoses of acute coronary syndrome (ACS). To assess which variables initially over- or underestimate risk ACS. MATERIAL AND METHODS: Consecutive patients with NTCP attended in a chest pain unit during the 10-year period of 2008-2017 were included if the suspected and discharge diagnoses of interest (ACS or non-ACS) had been recorded. Thirtythree independent variables (demographic, 2; cardiovascular, 5; chest pain, 22; ECG, 4). We included all variables in models to calculate crude and adjusted odds ratios (ORs) between each independent variable and the initial and final diagnoses. The adjusted ORs were compared to determine whether the initial and final diagnoses of ACS differed significantly in relation to the variables. RESULTS: A total of 34 552 patient visits were attended. The ORs for the 33 variables were significantly associated with initial and final NTCP classification as ACS or non-ACS, and in many cases the association was confirmed by the adjusted ORs. The adjusted ORs for 19 variables were significantly different in their relation to the initial and final diagnoses of ACS: 10 overpredicted the probability of the diagnosis and 9 underpredicted it. CONCLUSION: The variables traditionally used to warn of ACS in emergency patients with NTCP identify individuals likely to be initially and finally diagnosed with ACS. However, some of these variables overestimate or underestimate the risk of a final ACS diagnosis. Emergency medicine physicians should be aware of variables associated with underestimation of risk.

Emerg Med J ; 31(9): 706-13, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23793945


BACKGROUND: The mainstay of treatment for acutely decompensated heart failure (ADHF) is intravenous diuretic therapy either as a bolus or via continuous infusion. OBJECTIVES: We evaluated the clinical effects and safety of three strategies of intravenous furosemide administration used in emergency departments (EDs) for ADHF. METHODS: We performed a multicentre, randomised, parallel-group study. Patients with ADHF were randomised within 2 h of ED arrival to receive furosemide by continuous infusion (10 mg/h, group 1) or boluses (20 mg/6 h, group 2; or 20 mg/8 h, group 3). The primary end point was total diuresis, and secondary end points were dyspnoea, orthopnoea, extension of rales and peripheral oedema, blood pressure, respiratory and heart rates, and pulse oximetry, which were measured at arrival and 3, 6, 12 and 24 h after treatment onset. We also measured serum creatinine, sodium and potassium levels at arrival and after 24 h. RESULTS: Group 1 patients (n=36) showed greater 24 h diuresis (3705 mL) than those in groups 2 (n=37) and 3 (n=36) (3093 and 2670 mL, respectively; p<0.01), and this greater diuretic effect was observed earlier. However, no differences were observed among groups in the nine secondary clinical end points evaluated. Creatinine deterioration developed in 15.6% of patients, hyponatraemia in 9.2%, and hypokalaemia in 19.3%, with the only difference among groups observed in hypokalaemia (group 1, 36.3%; group 2, 13.5%; group 3, 8.3%; p<0.01). CONCLUSIONS: In patients with ADHF attending the ED, boluses of furosemide have a smaller diuretic effect but provide similar clinical relief, similar preservation of renal function, and a lower incidence of hypokalaemia than continuous infusion. TRIAL REGISTRATION NUMBER: This randomised trial was registered in the European Clinical Trial Database (EudraCT) with the reference number 2008-004488-20.

Diuréticos/administração & dosagem , Furosemida/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Renal/tratamento farmacológico , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Creatinina/sangue , Diuréticos/efeitos adversos , Feminino , Furosemida/efeitos adversos , Humanos , Hipopotassemia/etiologia , Hiponatremia/etiologia , Infusões Intravenosas , Masculino , Pesquisa Qualitativa , Insuficiência Renal/sangue , Inquéritos e Questionários
Emergencias (St. Vicenç dels Horts) ; 22(5): 331-337, oct. 2010. tab, ilus
Artigo em Espanhol | IBECS | ID: ibc-95910


Introducción y objetivos: Existe un escaso seguimiento de las recomendaciones de las guías de manejo diagnóstico y terapéutico de los pacientes con insuficiencia cardiaca aguda (ICA) en los servicios de urgencias hospitalarios (SUH). Se evalúa si un programa de intervención sobre urgenciólogos permite mejorar el cumplimiento de estas guías. Método: Se diseñó un estudio de intervención cuasi-experimental sin grupo control y con una comparación pre y post-intervención. En una primera fase, se incluyeron de forma consecutiva a 708 pacientes que acudieron al SUH de 6 hospitales españoles durante un mes con el diagnóstico principal de ICA. En una segunda fase, se realizaron diferentes programas de formación sobre el manejo de la ICA según las guías vigentes. Tras la intervención, se volvió a incluir, siguiendo la misma metodología, a 613 pacientes que acudieron de ICA. Las variables principales fueron aquéllas que estudios previos habían detectado una mayor desviación de las recomendaciones de las principales guías (determinación de troponinas plasmáticas y BNP o pro-BNP, uso de furosemida en perfusión continua o nitroglicerina endovenosa y utilización de ventilación no invasiva-VNI). Resultados: Hubo escasas diferencias entre los grupos pre y postintervención en sus características demográficas, clínicas o en el tratamiento (en el grupo postintervención, existía un mayor porcentaje de pacientes con enfermedad cerebrovascular, neumopatíacrónica, disfunción sistólica y tratamiento ambulatorio con bloqueadores beta-adrenérgicos; p < 0,05 para todos ellos). Se detectó un aumento significativo en (..) (AU)

Background and objective: Current guidelines on the diagnostic and therapeutic management of acute heart failure have not been strictly followed in hospital emergency departments. This study aimed to assess whether a training course for emergency physicians improved compliance with recommended practices. Methods: A quasi-experimental study, without a control group, was designed to compare compliance pre- and posttraining. In the first phase, we included data for 708 consecutive patients who received a principal diagnosis of acute heart failure at 6 Spanish hospitals within 1 month. In the second phase, we organized guidelines-based training on the management of acute heart failure. After the intervention, we included data for 613 consecutive patients following the same methodology. The main outcome variables were the ones that previous studies had identified as deviating most from current guidelines (determination of serum levels of troponin, brain natriuretic peptide [BNP], and N-terminal prohormone-BNP [NT-pro-BNP]; use of furosemide in continuous perfusion or intravenous nitroglycerin; and use of noninvasive ventilation). Results: Few statistically significant differences in patient, clinical, or outpatient treatment characteristics were detected between the pre- and post-training patient groups, although there was a slightly greater percentage of cerebrovascular disease, chronic respiratory disease, systolic dysfunction, and outpatient treatment with â-blockers in the postintervention group. BNP or NT-pro-BNP determinations were performed significantly more often after training (absolute increased in score, 44.7%; 95% confidence interval [CI], 39.9-49.5; (..) (AU)

Humanos , Insuficiência Cardíaca/terapia , Tratamento de Emergência , Serviço Hospitalar de Emergência , Avaliação de Eficácia-Efetividade de Intervenções , Antagonistas Adrenérgicos beta/uso terapêutico , Nitroglicerina/uso terapêutico
Eur J Emerg Med ; 17(4): 197-202, 2010 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-20215973


BACKGROUND: Patients with acute heart failure (AHF) are frequently evaluated in the Emergency Departments (ED) and discharged from their observation units (OU) without hospital admission. We examined direct discharge rates from the ED OU, risk factors for returning to the ED, and returning and mortality rates. PATIENTS AND METHODS: This prospective, longitudinal, noninterventional, population-based cohort study included all the patients with AHF consecutively attended in seven Spanish EDs who were directly discharged without hospital admission. Reattendance (dependent variable) was accepted if occurred during the next 30 days after discharge. Twenty-nine independent variables were recorded, covering epidemiological, clinical, and functional data. RESULTS: Two hundred and fifty-nine of 740 patients (35%) diagnosed with AHF were entirely managed in the ED OU and discharged home (mean stay: 18.8 h); 26.7% of them were reattended. Only three variables were independently associated with the chance of reattendance: functional impairment predicted adverse outcomes [odds ratio (OR): 4.0, 95% confidence interval (95% CI): 1.7-9.1], while past history of hypertension and a systolic blood pressure greater than 160 mmHg at ED arrival decreased the risk of ED return (OR: 0.4, 95% CI: 0.2-0.9; and OR: 0.3; 95% CI: 0.1-0.9; respectively). An overall mortality of 4.7% was recorded during the next 30 days. CONCLUSION: One-third of the patients consulting at the ED for an episode of AHF can be directly discharged from the OU of ED, with relatively low rates of reattendance (26.7%) and mortality (4.7%). Emergency physicians should be especially cautious discharging patients with functional dependence because they are at increased risk of returning.

Insuficiência Cardíaca , Readmissão do Paciente , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Serviço Hospitalar de Emergência/normas , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Humanos , Masculino , Estudos Prospectivos , Fatores de Risco