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1.
Adv Clin Exp Med ; 29(1): 147-155, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-32011830

RESUMO

BACKGROUND: Chest pain is one of the most frequent symptoms in patients seeking treatment at emergency departments (ED). These patients differ according to the cause of their reported symptoms and resultant mortality. OBJECTIVES: Evaluation of the influence of hospitalization and biochemical parameters on mortality rates in patients admitted to the ED with chest pain, in whom no cardiovascular emergencies were established. MATERIAL AND METHODS: The study group consisted of 243 patients with chest pain admitted to the ED in the Wroclaw Medical University Clinical Hospital, Poland, between January 1 and March 31, 2015, in whom no specific diagnosis was made at discharge. A retrospective analysis was carried out based on medical documentation, and 60-day and 1-year survival was assessed. RESULTS: In the study group, the 60-day mortality rate was 0.8% (2 persons) while the 1-year mortality rate was 6.6% (16 persons). The stepwise multivariable logistic regression analysis revealed that 1-year mortality was related to increased level of D-dimer (odds ratio (OR) = 8.5, 95% confidence interval (95% CI) = 21.9-37.5, p < 0.005), age (OR (per year) = 1.10, 95% CI = 1.03-1.18, p < 0.03) and lower than 12 g/dL hemoglobin concentration (OR = 18.5, 95% CI = 4.2-80.4, p < 0.001). Troponin I (TNI) levels and hospitalization were not related independently to mortality when other clinical factors were considered. CONCLUSIONS: Hospitalization of patients with chest pain who were not diagnosed with cardiac emergencies is not related with better survival than of those discharged home from the ED. The 60-day mortality is very low and occurs in older patients with numerous comorbidities. In multivariate analysis, survival of the 1-year period depends on the patient's age, hemoglobin levels and D-dimer levels. Risk of death in patients admitted to the ED due to chest pain in whom the cause of the chest pain was not due to cardiovascular emergencies depends on the presence of old age and comorbidities.


Assuntos
Dor no Peito/diagnóstico , Dor no Peito/terapia , Emergências , Serviço Hospitalar de Emergência/estatística & dados numéricos , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Mortalidade Hospitalar , Troponina I/sangue , Idoso , Biomarcadores/sangue , Dor no Peito/sangue , Dor no Peito/mortalidade , Hospitalização/estatística & dados numéricos , Humanos , Pessoa de Meia-Idade , Polônia/epidemiologia , Estudos Retrospectivos
2.
Medicine (Baltimore) ; 98(32): e16370, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31393346

RESUMO

Validated risk scoring systems in African American (AA) population are under studied. We utilized history, electrocardiogram, age, risk factors, and initial troponin (HEART) and thrombolysis in myocardial infarction (TIMI) scores to predict major adverse cardiovascular events (MACE) in non-high cardiovascular (CV) risk predominantly AA patient population.A retrospective emergency department (ED) charts review of 1266 chest pain patients where HEART and TIMI scores were calculated for each patient. Logistic regression model was computed to predict 6-week and 1-year MACE and 90-day cardiac readmission. Decision curve analysis (DCA) was constructed to differentiate between clinical strategies in non-high CV risk patients.Of the 817 patients included, 500 patients had low HEART score vs. 317 patients who had moderate HEART score. Six hundred sixty-three patients had low TIMI score vs. 154 patients had high TIMI score. The univariate logistic regression model shows odds ratio of predicting 6-week MACE using HEART score was 3.11 (95% confidence interval [CI] 1.43-6.76, P = .004) with increase in risk category from low to moderate vs. 2.07 (95% CI 1.18-3.63, P = .011) using TIMI score with increase in risk category from low to high and c-statistic of 0.86 vs. 0.79, respectively. DCA showed net benefit of using HEART score is equally predictive of 6-week MACE when compared to TIMI.In non-high CV risk AA patients, HEART score is better predictive tool for 6-week MACE when compared to TIMI score. Furthermore, patients presenting to ED with chest pain, the optimal strategy for a 2% to 4% miss rate threshold probability should be to discharge these patients from the ED.


Assuntos
Afro-Americanos , Doenças Cardiovasculares/etnologia , Dor no Peito/etnologia , Indicadores Básicos de Saúde , Hospitais Comunitários/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Doenças Cardiovasculares/mortalidade , Dor no Peito/etiologia , Dor no Peito/mortalidade , Eletrocardiografia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/tratamento farmacológico , Readmissão do Paciente , Estudos Prospectivos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Terapia Trombolítica/estatística & dados numéricos , Troponina/sangue
3.
BMC Cardiovasc Disord ; 19(1): 158, 2019 06 28.
Artigo em Inglês | MEDLINE | ID: mdl-31253098

RESUMO

BACKGROUND: Non-traumatic chest pain (NTCP) is a common reason for emergency department (ED) attendance in high-income countries, with the primary concern focused on life threatening cardiovascular diseases. There is general lack of data on aetiologies, diagnosis and management of NTPC in Sub Sahara African (SSA) countries. We aimed to describe evaluation, diagnosis and outcomes of adult patients presenting with NTCP to an urban ED in Tanzania. METHOD: This was a prospective observational cohort study of consecutive adult (≥18 years) patients presenting with non-traumatic chest pain to the Emergency Medicine Department (EMD) of Muhimbili National Hospital (MNH) in Dar es salaam from September 2017 to April 2018. Structured case report form was used to collected demographics, clinical presentation, investigations, diagnosis, and EMD disposition and in hospital mortality. We determined frequency of NTCP among our patients, aetiologies, 24-h and 7-day in-hospital mortality, and predictors for mortality. RESULTS: We screened 29,495 adults attending EMD-MNH during the study and 389 (1.3%) presented with NTCP of these, 349 (90%) were enrolled. The median age was 45 (IQR 29-60) years and 177 (50.7%) were female. Overall, 69.1% patients received electrocardiography (ECG) in the EMD and 34.1% had a troponin test. Heart failure and pulmonary tuberculosis (PTB) were the leading hospital diagnoses (12.6% each), followed by chronic kidney disease (10%) and acute coronary syndrome (ACS) (9.6%). Total of 167 (48%) patients were admitted, and the 24-h and 7-day in-hospital mortality were 5 (3%) and 16 (9.6%) respectively. Univariate risk factors for mortality were a Glasgow Coma Scale of < 15 [RR = 3.4 (95%CI 3.2-23)], Acute Coronary Syndrome [RR = 5.7 (95% CI 1.7-11.8) and Troponin > 0.04 ng/ml [RR 2.9 (95%CI 1.2-7.3)]. Features distinguishing cardiovascular from other causes were: bradycardia [RR = 2.6 (95%CI 2.1-3.2)], heart beat awareness [RR = 2.3 (95%CI 1.7-3.2)] and history of diabetic mellitus [RR = 2.2 (95% CI 1.6-3.0)]. CONCLUSION: In this ED of SSA country, heart failure and pulmonary tuberculosis were the leading causes of NCTP, and ACS was present in 9.6%. NTCP in this setting carries high mortality, and ACS was the leading risk factor for death. ED providers in SSA must increasingly consider cardiovascular causes of NTCP.


Assuntos
Síndrome Coronariana Aguda/epidemiologia , Angina Pectoris/epidemiologia , Dor no Peito/epidemiologia , Serviço Hospitalar de Emergência , Insuficiência Cardíaca/epidemiologia , Tuberculose Pulmonar/epidemiologia , Saúde da População Urbana , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/terapia , Adulto , Angina Pectoris/diagnóstico , Angina Pectoris/mortalidade , Angina Pectoris/terapia , Dor no Peito/diagnóstico , Dor no Peito/mortalidade , Dor no Peito/terapia , Comorbidade , Feminino , Nível de Saúde , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Tanzânia/epidemiologia , Fatores de Tempo , Tuberculose Pulmonar/diagnóstico , Tuberculose Pulmonar/mortalidade , Tuberculose Pulmonar/terapia
4.
Ann Emerg Med ; 74(3): 345-356, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31229391

RESUMO

STUDY OBJECTIVE: We describe the association between emergency department (ED) crowding and 10-day mortality for patients triaged to lower acuity levels at ED arrival and without need of acute hospital care on ED departure. METHODS: This was a registry study based on ED visits with all patients aged 18 years or older, with triage acuity levels 3 to 5, and without need of acute hospital care on ED departure during 2009 to 2016 (n=705,699). The sample was divided into patients surviving (n=705,076) or dying (n=623) within 10 days. Variables concerning patient characteristics and measures of ED crowding (mean length of stay and ED occupancy ratio) were extracted from the hospital's electronic health records. ED length of stay per ED visit was estimated by the average length of stay for all patients who presented to the ED during the same day and shift and with the same acuity level. The 10-day mortality after ED discharge was used as the outcome measure. Multivariable logistic regression analyses were conducted. RESULTS: The 10-day mortality rate was 0.09% (n=623). The event group had larger proportions of patients aged 80 years or older (51.4% versus 7.7%) and triaged with acuity level 3 (63.3% versus 35.6%), and greater comorbidity (age-combined Charlson comorbidity index median interquartile range 6 versus 0). We observed an increased 10-day mortality for patients with a mean ED length of stay greater than or equal to 8 hours versus less than 2 hours (adjusted odds ratio 5.86; 95% confidence interval [CI] 2.15 to 15.94) and for elevated ED occupancy ratio. Adjusted odds ratios for ED occupancy ratio quartiles 2, 3, and 4 versus quartile 1 were 1.48 (95% CI 1.14 to 1.92), 1.63 (95% CI 1.24 to 2.14), and 1.53 (95% CI 1.15 to 2.03), respectively. CONCLUSION: Patients assigned to lower triage acuity levels when arriving to the ED and without need of acute hospital care on departure from the ED had higher 10-day mortality when the mean ED length of stay exceeded 8 hours and when ED occupancy ratio increased.


Assuntos
Aglomeração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Triagem/estatística & dados numéricos , Dor Abdominal/mortalidade , Doença Aguda/mortalidade , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Dor no Peito/mortalidade , Comorbidade , Dispneia/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Sistema de Registros , Estudos Retrospectivos , Índice de Gravidade de Doença , Suécia , Adulto Jovem
5.
Acta Cardiol ; 74(5): 413-418, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30650021

RESUMO

Background: Red blood cell distribution width (RDW) is a measure of the degree of heterogeneity of erythrocyte volume. Higher RDW levels are associated with increased mortality among patients with acute coronary syndrome (ACS), heart failure and other cardiovascular diseases. The association between RDW levels and clinical outcomes in patients admitted for further evaluation of chest pain is not known. Methods: A retrospective analysis of patients hospitalised with chest pain 2010-2016 was conducted. Patients diagnosed with ACS in the emergency department (ED) were excluded. Patients were divided into tertiles according to baseline ED RDW levels (≤13.1%, 13.1%13.9%). Study endpoints were diagnosis of ACS during the index hospitalisation and ACS and all-cause mortality during a median follow-up of 3.3 ± 1.9 years. Results: Included were 13,018 patients (mean age 58 ± 13 years, 61% male). Increased RDW levels were associated with higher rates of ACS in the index hospitalisation (6.1%, 6.6% and 8.1% for 1st, 2nd and 3rd tertiles, respectively, p < .01), ACS during follow-up (8.6%, 10.1% and 13.4%, respectively, p < .01), and with all-cause mortality during follow-up (2.5%, 4.6% and 15.4%, respectively, p < .01). In multivariate analysis, RDW levels >13.9% (vs. ≤13.1%) were associated with ACS in the index hospitalisation (adjusted OR 1.25, 95% CI 1.04-1.51, p = .02), ACS during follow-up (adjusted OR 1.35, 95% CI 1.05-1.73, p = .02) and with all-cause mortality (adjusted HR 2.41, 95% CI 1.94-2.99, p < .01). Conclusion: In this retrospective study of patients hospitalised with chest pain, higher RDW levels were associated with future ACS and long-term mortality.


Assuntos
Dor no Peito/sangue , Hospitalização , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Causas de Morte/tendências , Dor no Peito/mortalidade , Dor no Peito/terapia , Índices de Eritrócitos , Feminino , Humanos , Israel/epidemiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Curva ROC , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Adulto Jovem
6.
Eur J Emerg Med ; 26(4): 242-248, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29878922

RESUMO

OBJECTIVE: To describe patients presenting with chest pain to the emergency department (ED) according to acute kidney injury (AKI) status at arrival, with a focus on the most common discharge diagnoses and on long-term mortality. METHODS: All adult patients visiting the Karolinska University Hospital ED between December 2010 and October 2014 with a principal complaint of chest pain were included. AKI at arrival was defined as an increase in presentation serum creatinine concentration of at least 26 µmol/l ( ≥ 0.3 mg/dl) or at least 50% above baseline. Risk ratios (RR) with 95% confidence intervals (CIs) between the AKI and no-AKI groups were calculated for the most common discharge diagnoses in the AKI group. Hazard ratios for long-term mortality were calculated using Cox regression models with adjustment for covariates. RESULTS: In total, 8480 patients were included, of whom 476 (5.6%) had AKI. AKI patients were older and had more comorbidities. It was more common in AKI patients compared to no AKI patients to be diagnosed with heart failure, RR 3.03 (CI: 2.15-4.26) and myocardial infarction RR 1.44 (CI: 1.01-2.04). During a median follow-up of 3.2 years (interquartile range: 2.1-4.3), 37% of the patients with AKI died compared with 16% of patients without AKI. The multivariable adjusted hazard ratio of death for AKI compared with no AKI was 1.30 (95% CI: 1.10-1.53). CONCLUSION: When attending the ED, patients with chest pain and AKI were more likely to be diagnosed with heart failure and myocardial infarction and had an increased long-term mortality compared with patients with no AKI.


Assuntos
Lesão Renal Aguda/diagnóstico , Causas de Morte , Dor no Peito/diagnóstico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Insuficiência Cardíaca/diagnóstico , Infarto do Miocárdio/diagnóstico , Centros Médicos Acadêmicos , Lesão Renal Aguda/mortalidade , Adulto , Idoso , Dor no Peito/mortalidade , Estudos de Coortes , Comorbidade , Intervalos de Confiança , Diagnóstico Diferencial , Feminino , Insuficiência Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Alta do Paciente , Modelos de Riscos Proporcionais , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Análise de Sobrevida , Suécia
7.
Dis Markers ; 2018: 9136971, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30538785

RESUMO

Background: Clinical short-term risk stratification is a recommended approach in patients with chest pain and possible acute myocardial infarction (AMI) to further improve high safety of biomarker-based rule-out algorithms. The study aim was to assess clinical performance of baseline concentrations of high-sensitivity cardiac troponin T (hs-TnT) and copeptin and the modified HEART score (mHS) in early presenters to the emergency department with chest pain. Methods: This cohort study included patients with chest pain with onset maximum of 6 h before admission and no persistent ST-segment elevation on electrocardiogram. hs-TnT, copeptin, and the mHS were assessed from admission data. The diagnostic and prognostic value for three baseline rule-out algorithms: (1) single hs-TnT < 14 ng/l, (2) hs-TnT < 14 ng/l/mHS ≤ 3, and (3) hs-TnT < 14 ng/l/mHS ≤ 3/copeptin < 17.4 pmol/l, was assessed with sensitivity and negative predictive value. Primary diagnostic endpoint was the diagnosis of AMI. Prognostic endpoint was death and/or AMI within 30 days. Results: Among 154 enrolled patients, 44 (29%) were classified as low-risk according to the mHS; AMI was diagnosed in 105 patients (68%). For ruling out AMI, the highest sensitivity and NPV from all studied algorithms were observed for hs-TnT/mHS/copeptin (100%, 95% CI 96.6-100, and 100%, 95% CI 75.3-100). At 30 days, the highest event-free survival was achieved in patients stratified with hs-TnT/mHS/copeptin algorithm (100%) with 100% (95% CI 75.3-100) NPV and 100% (95% CI 96.6-100) sensitivity. Conclusions: The combination of baseline hs-TnT, copeptin, and the mHS has an excellent sensitivity and NPV for short-term risk stratification. Such approach might improve the triage system in emergency departments and be a bridge for inclusion to serial blood sampling algorithms.


Assuntos
Dor no Peito/fisiopatologia , Glicopeptídeos/sangue , Infarto do Miocárdio/diagnóstico , Troponina T/sangue , Idoso , Algoritmos , Biomarcadores/sangue , Dor no Peito/sangue , Dor no Peito/etiologia , Dor no Peito/mortalidade , Estudos de Coortes , Estudos Transversais , Eletrocardiografia , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/mortalidade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos
8.
Int J Clin Pharm ; 40(6): 1482-1489, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30367373

RESUMO

Background A significant number of ischemic events occur even when adhering to dual antiplatelet therapy including aspirin and clopidogrel. Objectives The aim of our study was to determine predictors of long-term patient clinical outcome, among variables such as prodrug clopidogrel and intermediary metabolite 2-oxoclopidogrel concentrations, as well as patients' clinical characteristics. Setting Department for the Treatment of Acute Coronary Syndrome in tertiary teaching hospital, Serbia. Methods This study enrolled 88 consecutive patients with first STEMI, treated with primary PCI, within 6 h of the chest pain onset and followed them 40 months. On the third day of hospitalization, blood samples were collected from each patient to measure clopidogrel and its metabolite 2-oxo-clopidogrel concentration by UHPLC-DAD-MS method. Main outcome measure Mortality from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke or hospitalization for urgent myocardial revascularization or heart failure. Results The composite clinical outcome of cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for urgent myocardial revascularization or heart failure, was registered in 31 patients (35.2%) during the 40-month follow-up. Lower clopidogrel (p < 0.05) and dose-adjusted clopidogrel concentrations (p < 0.05) were associated with the higher incidence of composite outcome events. Their low plasma concentrations may be predicted by fentanyl administration (p < 0.001) and creatinine clearance (p < 0.01). The decrease in dose-adjusted clopidogrel unit for each ng/ml/mg increases the risk 21.7 times (p < 0.05). Conclusion Clopidogrel dose-adjusted plasma concentration in STEMI patients, as well as multivessel coronary artery disease, showed significance in predicting an unfavorable composite clinical outcome after 40-month follow-up.


Assuntos
Clopidogrel/sangue , Clopidogrel/uso terapêutico , Doença da Artéria Coronariana/tratamento farmacológico , Doença da Artéria Coronariana/cirurgia , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/sangue , Inibidores da Agregação de Plaquetas/uso terapêutico , Ticlopidina/análogos & derivados , Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor no Peito/tratamento farmacológico , Dor no Peito/mortalidade , Doença da Artéria Coronariana/mortalidade , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Ticlopidina/sangue , Resultado do Tratamento
9.
Clin Cardiol ; 41(4): 539-543, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29687656

RESUMO

BACKGROUND: Chest-pain patients deemed safe for discharge from internal medicine wards might still be at risk for adverse outcomes. HYPOTHESIS: CHA2 DS2 -VASc score improves risk stratification of low-risk chest-pain patients discharged after acute coronary syndrome (ACS) rule-out. METHODS: We accessed medical records of patients who were admitted to internal medicine wards at a single medical center during 2010-2016 and discharged following an ACS rule-out. Patients were classified according to CHA2 DS2 -VASc score: 0-1 (low), 2-3 (intermediate), >3 (high). Primary endpoint was occurrence of ACS at 1 year; 30-day and 1-year all-cause mortality (ACM) were secondary outcomes. RESULTS: Of 12 449 patients, 7057 (57%) had low, 3781 (30%) intermediate, and 1611 (13%) high CHA2 DS2 -VASc scores. Compared with a low score, intermediate and high scores were associated with significantly increased risk for 1-year ACS during the first year (OR: 2.89, 95% CI: 1.91-4.37, P < 0.01 and OR: 4.84, 95% CI: 3.02-7.74, P < 0.01, respectively). Each 1-point increase in CHA2 DS2 -VASc was associated with a 37% increased risk for 1-year ACS. A higher CHA2 DS2 -VASc score was associated with significantly higher 30-day ACM. Hazard ratios for 30-day ACM were 1.9 (95% CI: 1.1-3.4, P = 0.03) and 4.4 (95% CI: 2.4-7.9, P < 0.01) for intermediate and high CHA2 DS2 -VASc scores, respectively, compared with a low score. Each 1-point increase in CHA2 DS2 -VASc score was associated with 43% increased risk for 30-day mortality. CONCLUSIONS: High CHA2 DS2 -VASc score (>3) was associated with adverse outcomes among chest-pain patients discharged from internal medicine wards following ACS rule-out.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Angina Pectoris/diagnóstico , Dor no Peito/diagnóstico , Técnicas de Apoio para a Decisão , Departamentos Hospitalares , Medicina Interna , Alta do Paciente , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/mortalidade , Adulto , Idoso , Angina Pectoris/etiologia , Angina Pectoris/mortalidade , Causas de Morte , Dor no Peito/etiologia , Dor no Peito/mortalidade , Diagnóstico Diferencial , Registros Eletrônicos de Saúde , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Medição de Risco , Fatores de Risco , Fatores de Tempo
10.
Dis Markers ; 2018: 6597387, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29619130

RESUMO

Background: In patients admitted with chest pain and suspected acute coronary syndrome (ACS), it is crucial to early identify those who are at higher risk of adverse events. The study aim was to assess the predictive value of copeptin in patients admitted to the emergency department with chest pain and nonconclusive ECG. Methods: Consecutive patients suspected for an ACS were enrolled prospectively. Copeptin and high-sensitive troponin T (hs-TnT) were measured at admission. Patients were followed up at six and 12 months for the occurrence of death and major adverse cardiac and cerebrovascular events (MACCE). Results: Among 154 patients, 11 patients died and 26 experienced MACCE. Mortality was higher in copeptin-positive than copeptin-negative patients with no difference in the rate of MACCE. Copeptin reached the AUC 0.86 (0.75-0.97) for prognosis of mortality at six and 0.77 (0.65-0.88) at 12 months. It was higher than for hs-TnT and their combination at both time points. Copeptin was a strong predictor of mortality in the Cox analysis (HR14.1 at six and HR4.3 at 12 months). Conclusions: Copeptin appears to be an independent predictor of long-term mortality in a selected population of patients suspected for an ACS. The study registration number is ISRCTN14112941.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Biomarcadores/metabolismo , Dor no Peito/metabolismo , Glicopeptídeos/metabolismo , Regulação para Cima , Síndrome Coronariana Aguda/metabolismo , Síndrome Coronariana Aguda/mortalidade , Idoso , Área Sob a Curva , Dor no Peito/etiologia , Dor no Peito/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos
11.
Int J Cardiol ; 255: 15-19, 2018 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-29425553

RESUMO

BACKGROUND: Patients with non ST-segment elevation myocardial infarction (NSTEMI) represent the largest fraction of patients with acute coronary syndrome in German Chest Pain units. Recent evidence on early vs. selective percutaneous coronary intervention (PCI) is ambiguous with respect to effects on mortality, myocardial infarction (MI) and recurrent angina. With the present study we sought to investigate the prognostic impact of PCI and its timing in German Chest Pain Unit (CPU) NSTEMI patients. METHODS AND RESULTS: Data from 1549 patients whose leading diagnosis was NSTEMI were retrieved from the German CPU registry for the interval between 3/2010 and 3/2014. Follow-up was available at median of 167days after discharge. The patients were grouped into a higher (Group A) and lower risk group (Group B) according to GRACE score and additional criteria on admission. Group A had higher Killip classes, higher BNP levels, reduced EF and significant more triple vessel disease (p<0.001). Surprisingly, patients in group A less frequently received early diagnostic catheterization and PCI. While conservative management did not affect prognosis in Group B, higher-risk CPU-NSTEMI patients without PCI had a significantly worse survival. CONCLUSIONS: The present results reveal a substantial treatment gap in higher-risk NSTEMI patients in German Chest Pain Units. This treatment paradox may worsen prognosis in patients who could derive the largest benefit from early revascularization.


Assuntos
Dor no Peito/mortalidade , Dor no Peito/cirurgia , Medicina Baseada em Evidências/tendências , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio sem Supradesnível do Segmento ST/cirurgia , Intervenção Coronária Percutânea/tendências , Idoso , Idoso de 80 Anos ou mais , Dor no Peito/diagnóstico por imagem , Estudos de Coortes , Feminino , Seguimentos , Alemanha/epidemiologia , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico por imagem , Estudos Prospectivos , Sistema de Registros , Resultado do Tratamento
12.
JAMA Cardiol ; 3(2): 144-152, 2018 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-29322167

RESUMO

Importance: Coronary computed tomographic angiography (coronary CTA) can characterize coronary artery disease, including high-risk plaque. A noninvasive method of identifying high-risk plaque before major adverse cardiovascular events (MACE) could provide practice-changing optimizations in coronary artery disease care. Objective: To determine whether high-risk plaque detected by coronary CTA was associated with incident MACE independently of significant stenosis (SS) and cardiovascular risk factors. Design, Setting, and Participants: This prespecified nested observational cohort study was part of the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial. All stable, symptomatic outpatients in this trial who required noninvasive cardiovascular testing and received coronary CTA were included and followed up for a median of 25 months. Exposures: Core laboratory assessment of coronary CTA for SS and high-risk plaque (eg, positive remodeling, low computed tomographic attenuation, or napkin-ring sign). Main Outcomes and Measures: The primary end point was an adjudicated composite of MACE (defined as death, myocardial infarction, or unstable angina). Results: The study included 4415 patients, of whom 2296 (52%) were women, with a mean age of 60.5 years, a median atherosclerotic cardiovascular disease (ASCVD) risk score of 11, and a MACE rate of 3% (131 events). A total of 676 patients (15.3%) had high-risk plaques, and 276 (6.3%) had SS. The presence of high-risk plaque was associated with a higher MACE rate (6.4% vs 2.4%; hazard ratio, 2.73; 95% CI, 1.89-3.93). This association persisted after adjustment for ASCVD risk score and SS (adjusted hazard ratio [aHR], 1.72; 95% CI, 1.13-2.62). Adding high-risk plaque to the ASCVD risk score and SS assessment led to a significant continuous net reclassification improvement (0.34; 95% CI, 0.02-0.51). Presence of high-risk plaque increased MACE risk among patients with nonobstructive coronary artery disease relative to patients without high-risk plaque (aHR, 4.31 vs 2.64; 95% CI, 2.25-8.26 vs 1.49-4.69). There were no significant differences in MACE in patients with SS and high-risk plaque as opposed to those with SS but not high-risk plaque (aHR, 8.68 vs. 9.31; 95% CI, 4.25-17.73 vs 4.21-20.61). High-risk plaque was a stronger predictor of MACE in women (aHR, 2.41; 95% CI, 1.25-4.64) vs men (aHR, 1.40; 95% CI, 0.81-2.39) and younger patients (aHR, 2.33; 95% CI, 1.20-4.51) vs older ones (aHR, 1.36; 95% CI, 0.77-2.39). Conclusions and Relevance: High-risk plaque found by coronary CTA was associated with a future MACE in a large US population of outpatients with stable chest pain. High-risk plaque may be an additional risk stratification tool, especially in patients with nonobstructive coronary artery disease, younger patients, and women. The importance of findings is limited by low absolute MACE rates and low positive predictive value of high-risk plaque. Trial Registration: clinicaltrials.gov Indentifier: NCT01174550.


Assuntos
Dor no Peito/diagnóstico por imagem , Estenose Coronária/diagnóstico por imagem , Placa Aterosclerótica/diagnóstico por imagem , Dor no Peito/mortalidade , Angiografia por Tomografia Computadorizada , Angiografia Coronária , Estenose Coronária/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/diagnóstico por imagem , Isquemia Miocárdica/mortalidade , Placa Aterosclerótica/mortalidade , Prognóstico , Medição de Risco , Remodelação Ventricular/fisiologia
13.
BMJ Open ; 7(12): e018636, 2017 12 22.
Artigo em Inglês | MEDLINE | ID: mdl-29275346

RESUMO

OBJECTIVES: To determine the incidence of clinical, cardiac-related endpoints and mortality among patients presenting to an emergency or cardiology department with non-specific chest pain (NSCP), and who receive testing with a high-sensitivity troponin. A second objective was to identify risk factors for the above-noted endpoints during 12 months of follow-up. DESIGN: A prospective multicentre study. SETTING: Emergency and cardiology departments in Southern Denmark. SUBJECTS: The study enrolled 1027 patients who were assessed for acute chest pain in an emergency or cardiology department, and in whom a myocardial infarction or another obvious reason for chest pain had been ruled out. Patients were enrolled from September 2014 to June 2015 and followed for 1 year. MAIN OUTCOME MEASURES: Clinical, cardiac-related endpoints (cardiac-related death, acute myocardial infarction, unstable angina and coronary revascularisation) and all-cause mortality. RESULTS: Over a period of 1 year, cardiac-related endpoints were found in 19 patients (1.9%): 0 patients experienced cardiac-related death, 2 (0.2%) had myocardial infarction, 4 (0.4%) had unstable angina pectoris and 17 (1.7%) underwent coronary revascularisation. All-cause mortality was observed in seven patients (0.7%). When compared with the general population, the standardised mortality ratio did not differ. The risk factors associated with the study endpoints included male gender, body mass index >25 kg/m2, previous known coronary artery disease, hypertension, hypercholesterolaemia, diabetes mellitus and the use of statins. A total of 73% of the endpoints occurred in males. CONCLUSION: The prognosis for patients with NSCP is favourable, with a 1-year mortality after discharge that is comparable with the background population. Few clinical endpoints took place during follow-up, and those that did were predominantly in males.


Assuntos
Angina Instável/epidemiologia , Dor no Peito/etiologia , Dor no Peito/mortalidade , Infarto do Miocárdio/epidemiologia , Adulto , Idoso , Serviço Hospitalar de Cardiologia , Dinamarca , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Troponina/sangue
14.
J Am Coll Cardiol ; 70(18): 2226-2236, 2017 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-29073949

RESUMO

BACKGROUND: There is a paucity of data on the association between high-sensitivity cardiac troponin (hs-cTn) levels and outcomes in patients with chest pain but no myocardial infarction (MI), or any other condition that may lead to acutely elevated troponin levels. OBJECTIVES: The authors hypothesized that any detectable high-sensitivity cardiac troponin T (hs-cTnT) level is associated with adverse outcomes. METHODS: All patients (N = 22,589) >25 years of age with chest pain and hs-cTnT analyzed concurrently in the emergency department of Karolinska University Hospital, Stockholm, Sweden from 2011 to 2014 were eligible for inclusion. After excluding all patients with acute conditions that may have affected hs-cTnT, or MI associated with the visit, or insufficient information to determine whether troponin levels were stable, Cox regression was used to estimate risks for all-cause, cardiovascular, and noncardiovascular mortality, MI, and heart failure at different levels of troponins. RESULTS: A total of 19,460 patients with a mean age of 54 ± 17 years were included. During a mean follow-up of 3.3 ± 1.2 years, 1,349 (6.9%) patients died. Adjusted hazard ratios (with 95% confidence intervals) for all-cause mortality were 2.00 (1.66 to 2.42), 2.92 (2.38 to 3.59), 4.07 (3.28 to 5.05), 6.77 (5.22 to 8.78), and 9.68 (7.18 to 13.00) in patients with hs-cTnT levels of 5 to 9, 10 to 14, 15 to 29, 30 to 49, and ≥50 ng/l, respectively, compared with patients with hs-cTnT levels <5 ng/l. There was a strong and graded association between all detectable levels of hs-cTnT and risk for MI, heart failure, and cardiovascular and noncardiovascular mortality. CONCLUSIONS: Among patients with chest pain and stable troponin levels, any detectable level of hs-cTnT is associated with an increased risk of death and cardiovascular outcomes and should merit further attention.


Assuntos
Dor no Peito/sangue , Dor no Peito/diagnóstico , Troponina T/sangue , Adolescente , Adulto , Idoso , Biomarcadores/sangue , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/mortalidade , Dor no Peito/mortalidade , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Suécia/epidemiologia , Resultado do Tratamento , Adulto Jovem
15.
Int J Cardiol ; 245: 43-48, 2017 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-28874298

RESUMO

BACKGROUND: It is uncertain how the implementation of high-sensitivity cardiac troponin T (hs-cTnT) has affected the survival of patients with chest pain in the emergency department (ED). We studied prognosis and resource utilization in terms of coronary angiographies and revascularizations (percutaneous coronary intervention or coronary artery bypass grafting) in patients evaluated with hs-cTnT compared with conventional troponin T (cTnT). METHODS: All patients >25years presenting with chest pain and at least one troponin level analyzed in the ED at the Karolinska University Hospital, Sweden, were included. Hazard ratios (HR) for all-cause mortality, coronary angiographies and revascularizations were adjusted for age, sex and comorbidities during 1year of follow-up comparing patients tested with hs-cTnT (December 10, 2010 to December 31, 2013) with patients tested with cTnT (January 1, 2009 to December 9, 2010). RESULTS: In total, 31,904 patients were included (n=12,485 tested with cTnT and n=24,729 using hs-cTnT). Patient characteristics, comorbidities, and medications were similar during the study period. The absolute risk of all-cause mortality was 3.7% for those tested with cTnT compared with 3.4% for hs-cTnT. After adjustment for confounders, an increased all-cause mortality was observed for patients tested with hs-cTnT (HR 1.15; 95% confidence interval (CI) 1.02-1.29). Coronary angiographies increased by 13% (HR 1.13; 95% CI 1.00-1.28) and revascularizations by 18% (HR 1.18; 95% CI 1.01-1.37) when using hs-cTnT. CONCLUSIONS: In an observational cohort study including patients with chest pain in the ED we found a small increase in mortality, coronary angiographies and revascularizations after the introduction of hs-cTnT.


Assuntos
Dor no Peito/sangue , Dor no Peito/mortalidade , Recursos em Saúde/estatística & dados numéricos , Troponina T/sangue , Adulto , Idoso , Biomarcadores/sangue , Dor no Peito/diagnóstico por imagem , Estudos de Coortes , Angiografia Coronária/mortalidade , Angiografia Coronária/tendências , Feminino , Recursos em Saúde/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Taxa de Sobrevida/tendências
16.
Int J Cardiol ; 248: 77-81, 2017 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-28864133

RESUMO

BACKGROUND: In the assessment of patients with chest pain, there is support for the use of pre-hospital ECG in the literature and in the care guidelines. Using propensity score methods, we aim to examine whether the mere acquisition of a pre-hospital ECG among patients with chest pain affects the outcome (30-day mortality). METHODS: The association between pre-hospital ECG and 30-day mortality was studied in the overall cohort (n=13151), as well as in the one-to-one matched cohort with 2524 patients not examined with pre-hospital ECG and 2524 patients examined with pre-hospital ECG. RESULTS: In the overall cohort, 21% (n=2809) did not undergo an ECG tracing in the pre-hospital setting. Among those who had pain during transport, 14% (n=1159) did not undergo a pre-hospital ECG while 32% (n=1135) of those who did not have pain underwent an ECG tracing. In the overall cohort, the OR for 30-day mortality in patients who had a pre-hospital ECG, as compared with those who did not, was 0.63 (95% CI 0.05-0.79; p<0.001). In the matched cohort, the OR was 0.65 (95% CI 0.49-0.85; p<0.001). Using the propensity score, in the overall cohort, the corresponding HR was 0.65 (95% CI 0.58-0.74). CONCLUSION: Using propensity score methods, we provide real-world data demonstrating that the adjusted risk of death was considerably lower among the cases in whoma pre-hospital ECG was used. The PH-ECG is underused among patients with chest discomfort and the mere acquisition of a pre-hospital ECG may reduce mortality.


Assuntos
Dor no Peito/mortalidade , Dor no Peito/terapia , Eletrocardiografia/mortalidade , Eletrocardiografia/tendências , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/tendências , Idoso , Idoso de 80 Anos ou mais , Dor no Peito/diagnóstico , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências
18.
Am J Hypertens ; 30(7): 700-706, 2017 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-28430850

RESUMO

BACKGROUND: There are no comprehensive guidelines on management of hypertensive emergency (HTNE) and complications. Despite advances in antihypertensive medications HTNE is accompanied with significant morbidity and mortality. METHODS: We queried the 2002-2012 nationwide inpatient sample database to identify patients with HTNE. Trends in incidence of HTNE and in-hospital mortality were analyzed. Logistic regression analysis was used to assess the relationship between end-organ complications and in-hospital mortality. RESULTS: Between 2002 and 2012, 129,914 admissions were included. Six hundred and thirty (0.48%) patients died during their hospital stay. There was an increase in the number of HTNE admissions (9,511-15,479; Ptrend < 0.001) with concurrent reduction of in-hospital mortality (0.8-0.3%; Ptrend < 0.001) by the year 2012 compared to 2002. Patients who died during hospitalization were older, had longer length of stay, higher cost of stay, more comorbidities, and higher risk scores. Presence of acute cardiorespiratory failure [adjusted odds ratio (OR), 15.8; 95% confidence interval (CI), 13.2-18.9], stroke or transient ischemia attack (TIA) (adjusted OR, 7.9; 95% CI, 6.3-9.9), chest pain (adjusted OR, 5.9; 95% CI, 4.4-7.7), stroke/TIA (adjusted OR, 5.9; 95% CI, 4.5-7.7), and aortic dissection (adjusted OR, 5.9; 95% CI, 2.8-12.4) were most predictive of higher in-hospital mortality in addition to factors such as age, aortic dissection, acute myocardial infarction, acute renal failure, and presence of neurological symptoms. CONCLUSION: A rising trend in hospitalization for HTNE, with an overall decrease in in-hospital mortality was observed from 2002 to 2012, possibly related to changes in coding practices and improved management. Presence of acute cardiorespiratory failure, stroke/TIA, chest pain, and aortic dissection were most predictive of higher hospital mortality.


Assuntos
Mortalidade Hospitalar/tendências , Hipertensão/mortalidade , Admissão do Paciente/tendências , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Aneurisma Dissecante/mortalidade , Aneurisma Aórtico/mortalidade , Dor no Peito/mortalidade , Distribuição de Qui-Quadrado , Comorbidade , Bases de Dados Factuais , Emergências , Feminino , Insuficiência Cardíaca/mortalidade , Humanos , Hipertensão/diagnóstico , Hipertensão/fisiopatologia , Hipertensão/terapia , Incidência , Ataque Isquêmico Transitório/mortalidade , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Insuficiência Respiratória/mortalidade , Fatores de Risco , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Estados Unidos/epidemiologia
19.
Int J Cardiol ; 232: 289-293, 2017 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-28087181

RESUMO

BACKGROUND: Rule-out of non-ST-elevation myocardial infarction is based on consecutive measurements of cardiac troponins using the 99th percentile of the respective assay as cutoff. The new ESC guidelines alternatively offer rapid 1h algorithms with lower cutoffs than the 99th percentile for rule-out of non-ST-elevation myocardial infarction. We aimed to compare a recently introduced 1h algorithm based on a high-sensitivity cardiac troponin I (hs-TnI) cutoff of 6ng/L at 0h and 1h to the current standard of care using the 99th percentile (27ng/L) as cutoff with reference to follow-up events in a large chest pain cohort. METHODS: Hs-TnI was measured at three time points (0h, 1h and 3h) in 1625 patients presenting with suspected myocardial infarction to the emergency department of the University-Medical Center Hamburg-Eppendorf. Seventy-five patients with ST-elevation myocardial infarction were excluded from the analysis. All-cause mortality, cardiac death, acute myocardial infarction, revascularization and cardiac rehospitalization after 12months were assessed. RESULTS: Patients ruled out by the 1h algorithm showed significantly less cardiac rehospitalizations (12.84% vs. 17.66%; p<0.001), and overall mortality (1.30% vs 3.46%, p<0.001) compared to using the 99th percentile as cutoff. The majority of deaths were caused by non-cardiac reasons. Cardiac deaths were rare using the 1h algorithm (0.21%). CONCLUSION: The commonly used 99th percentile as cutoff neglects patients with a high risk in the setting of acute chest pain. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02355457).


Assuntos
Algoritmos , Dor no Peito/mortalidade , Troponina I/sangue , Doença Aguda , Idoso , Biomarcadores/sangue , Causas de Morte/tendências , Dor no Peito/sangue , Feminino , Seguimentos , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo
20.
CJEM ; 19(1): 18-25, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27461090

RESUMO

OBJECTIVES: The new Vancouver Chest Pain (VCP) Rule recommends early discharge for chest pain patients who are at low risk of developing acute coronary syndrome (ACS), and thus can be discharged within 2 hours of arrival at the emergency department (ED). This study aimed to assess the performance of the new VCP Rule for Asian patients presenting with chest pain at the ED. METHODS: This prospective cohort study involved patients attended to at the ED of a large urban centre. Patients of at least 25 years old, presenting with stable chest pain and a non-diagnostic ECG, and with no history of active coronary artery disease were included in the study. The main outcome measures were cardiac events, angioplasty, or coronary artery bypass within 30 days of enrolment. RESULTS: The study included 1690 patients from 27 August 2000 to 1 May 2002, with 661 patients fulfilling the VCP criteria. Of those for early discharge, 24 had cardiac events and 13 had angioplasty or bypass at 30 days, compared to 91 and 41, respectively, for those unsuitable for discharge. This gave the rule a sensitivity of 78.1% for cardiac events, including angioplasty and bypass. Specificity was 41.0%, and negative predictive value (NPV) was 94.4%. CONCLUSION: We found the new VCP Rule to have moderate sensitivity and poor specificity for adverse cardiac events in our population. With an NPV of less than 100%, this means that a small proportion of patients sent home with early discharge would still have adverse cardiac events.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Grupo com Ancestrais do Continente Asiático/estatística & dados numéricos , Dor no Peito/diagnóstico , Serviço Hospitalar de Emergência/normas , Infarto do Miocárdio/diagnóstico , Alta do Paciente/normas , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/terapia , Adulto , Fatores Etários , Idoso , Análise Química do Sangue , Colúmbia Britânica , Dor no Peito/mortalidade , Dor no Peito/terapia , Distribuição de Qui-Quadrado , Estudos de Coortes , Eletrocardiografia/métodos , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Estudos Prospectivos , Medição de Risco , Fatores Sexuais , Estatísticas não Paramétricas , População Urbana
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