Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 582
Filtrar
2.
PLoS One ; 15(8): e0237036, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32756583

RESUMO

BACKGROUND: Despite the use of high-sensitive cardiac troponin there remains a group of high-sensitive cardiac troponin negative patients with unstable angina with a non-neglectable risk for future adverse cardiovascular events, emphasising the need for additional risk stratification. Plasma extracellular vesicles are small bilayer membrane vesicles known for their potential role as biomarker source. Their role in unstable angina remains unexplored. We investigate if extracellular vesicle proteins are associated with unstable angina in patients with chest pain and low high-sensitive cardiac troponin. METHODS: The MINERVA study included patients presenting with acute chest pain but no acute coronary syndrome. We performed an exploratory retrospective case-control analysis among 269 patients. Cases were defined as patients with low high-sensitive cardiac troponin and proven ischemia. Patients without ischemia were selected as controls. Blood samples were fractionated to analyse the EV proteins in three plasma-subfractions: TEX, HDL and LDL. Protein levels were quantified using electrochemiluminescence immunoassay. RESULTS: Lower levels of (adjusted) EV cystatin c in the TEX subfraction were associated with having unstable angina (OR 0.93 95% CI 0.88-0.99). CONCLUSION: In patients with acute chest pain but low high-sensitive cardiac troponin, lower levels of plasma extracellular vesicle cystatin c are associated with having unstable angina. This finding is hypothesis generating only considering the small sample size and needs to be confirmed in larger cohort studies, but still identifies extracellular vesicle proteins as source for additional risk stratification.


Assuntos
Angina Instável/metabolismo , Cistatina C/análise , Vesículas Extracelulares/metabolismo , Síndrome Coronariana Aguda/fisiopatologia , Adulto , Idoso , Angina Instável/sangue , Angina Instável/fisiopatologia , Biomarcadores/sangue , Estudos de Casos e Controles , Dor no Peito/sangue , Dor no Peito/metabolismo , Dor no Peito/fisiopatologia , Estudos de Coortes , Creatina Quinase/sangue , Cistatina C/sangue , Cistatina C/metabolismo , Eletrocardiografia , Vesículas Extracelulares/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/fisiopatologia , Estudos Retrospectivos , Troponina/sangue
3.
PLoS One ; 15(8): e0237024, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32764787

RESUMO

BACKGROUND: Thrombin, a key enzyme of the clotting system, is involved in thrombus formation, platelet activation, and atherosclerosis, thereby possessing a central role in the pathogenesis of ischemic heart disease. Studies have shown an association between thrombin generation (TG) and cardiovascular morbidity and mortality, but results have been equivocal. Our aim was to study the predictive ability of TG assay in evaluating coronary stenosis severity. METHODS: In this prospective study we recruited patients with acute coronary syndrome (ACS) or acute chest pain (without evidence of myocardial injury) planned for coronary angiography. Thrombin generation was evaluated by Calibrated Automated Thrombogram (CAT) prior to angiography. Primary end points were significant coronary stenosis and the Syntax I score evaluated by coronary angiography. RESULTS: From April 2018 through September 2019, we recruited 128 patients. In the primary analysis there was no significant association between TG and significant coronary stenosis nor between TG and syntax I score, however, there was a positive correlation between peak height and troponin peak (Spearman correlation coefficient 0.194, P-value = 0.035). In sub-group analysis, the chest pain group bare no association between TG and coronary stenosis. In unstable angina group there was an association between peak height and significant coronary stenosis (P-value = 0.029), and in non ST-elevation myocardial infarction group, TG values possessed a relatively good predictive ability of significant coronary stenosis (area under the receiver operating characteristic curve of ~65%) and a positive correlation between both lag time and ttpeak with the syntax I score was noticed (Spearman correlation coefficient 0.31, P-value = 0.099 and Spearman correlation coefficient 0.37, P-value = 0.045 respectively). CONCLUSION: In patients with acute chest pain, TG values, evaluated by CAT, do not predict severity of coronary stenosis, nor do they possess prognostic value. Yet, in ACS patients, TG may have the ability to predict coronary disease severity.


Assuntos
Doença da Artéria Coronariana/sangue , Trombina/biossíntese , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/diagnóstico por imagem , Adulto , Idoso , Angina Instável/sangue , Angina Instável/diagnóstico por imagem , Biomarcadores/sangue , Dor no Peito/sangue , Dor no Peito/diagnóstico por imagem , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Estenose Coronária/sangue , Estenose Coronária/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/sangue , Infarto do Miocárdio sem Supradesnível do Segmento ST/sangue , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico por imagem , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença
4.
Am J Cardiol ; 127: 36-40, 2020 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-32418720

RESUMO

Acute chest pain is one of the most common presenting symptoms to the emergency department. Currently available risk scores are suboptimal in identifying low-risk patients eligible for early and safe discharge. Various, initially obtained clinical data have valuable discriminating power but are not being fully utilized. We developed a new scoring system based on 5 sets of variables; characteristics of Symptoms, history of Vascular disease,  Electrocardiography,  Age, and Troponin (SVEAT score). A total of 321 subjects presenting to the emergency department or admitted to the clinical decision unit at our institution with chest pain from May 2017 to August 2018 were prospectively recruited. The subjects were followed for 30 days for any major cardiovascular events (MACE); acute myocardial infarction, confirmed coronary artery disease requiring revascularization or medical therapy or death. A 30-day MACE occurred in 19.6% of the subjects. Predictive ability of SVEAT score for a 30-day MACE was compared with HEART and TIMI risk score using receiving-operator characteristic curve. The area under the curve of SVEAT score (0.98, 95% confidence interval [CI] 0.97 to 0.99) is higher than HEART (0.92, 95% CI 0.88 to 0.96) and TIMI score (0.88, 95% CI 083 to 0.93). Using SVEAT score of 4 as a cut off, 0.8% of the subjects developed a 30-day MACE compared with 1.4% and 1.5% of those classified as low-risk based on the HEART and TIMI score respectively. SVEAT score additionally identified larger proportion of low-risk (73.8%) than the HEART (45.2%) and TIMI risk score (40.1%), (p <0.01, for both).


Assuntos
Dor no Peito/diagnóstico , Eletrocardiografia , Serviço Hospitalar de Emergência , Medição de Risco/métodos , Doença Aguda , Adulto , Idoso , Biomarcadores/sangue , Dor no Peito/sangue , Dor no Peito/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Nevada/epidemiologia , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Troponina/sangue
5.
Am J Med Sci ; 359(2): 73-78, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32039768

RESUMO

BACKGROUND: Prevailing hospital practice dictates a protracted phase of observation for patients with chest pain to establish or exclude the diagnosis of myocardial infarction. Early diagnosis of acute myocardial infarction may improve patient care and reduce both complications and hospital costs. A study was performed to investigate the feasibility of early diagnosis of myocardial infarction within the first 9 hours of the hospital stay. METHODS: The records of all patients admitted with chest pain within one calendar year were analyzed. The timing of creatine kinase-MB (CK-MB) quantification was determined with reference to the initial phlebotomy (time 0). An enzymatic diagnosis of myocardial infarction was assigned if any determination of CK-MB exceeded the upper limit of normal, and the diagnosis of each patient at or before 9 hours (early diagnosis) was compared to the ultimate diagnosis at 14 to 24 hours (final diagnosis) beyond initial assessment. RESULTS: Of the 528 included patients, 523 patients (99.1%) had identical early and final diagnostic outcomes; 5 patients (0.9%) had conflicting results. An early diagnosis of myocardial infarction was assigned to 195 of the 528 patients (36.9%). Of these, 190 achieved the diagnosis within 9 hours (sensitivity 97.4%). The negative predictive value was 98.5%. CONCLUSION: Standard CK-MB mass measurements within 9 hours of arrival provided an accurate clinical assessment in > 99% of the cases. The high sensitivity and negative predictive values suggest that early diagnosis of myocardial infarction is feasible and reliable.


Assuntos
Dor no Peito , Creatina Quinase Forma MB/sangue , Infarto do Miocárdio , Idoso , Idoso de 80 Anos ou mais , Dor no Peito/sangue , Dor no Peito/diagnóstico , Diagnóstico Precoce , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Tempo
6.
Acad Emerg Med ; 27(6): 487-491, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32056327

RESUMO

OBJECTIVES: The objective was to evaluate if there is an association between patient-physician language concordance and adverse patient outcomes or physician adherence to clinical recommendations for emergency department (ED) patients with chest pain. METHODS: We conducted a retrospective observational study of adult ED chest pain encounters with a troponin order from May 2016 to September 2017 across 15 community EDs. Outcomes were 30-day acute myocardial infarction or all-cause mortality, hospital admission/observation, or noninvasive cardiac testing. To assess patient outcomes, we used the overall cohort. To assess adherence to clinical recommendations, we used a subgroup of patients with a low-risk HEART score. A mixed-effects logistic regression model was used to compare the odds of the outcomes between language concordant and discordant patient-physician pairs, controlling for patient characteristics. RESULTS: Overall, 52,014 ED encounters were included (10,791 low-risk HEART encounters). Of those 6,452 (12.4%) encounters were language discordant and 1.7% in each group had an adverse outcome. Adjusted models demonstrated no increased risk for language discordant ED encounters when comparing adverse outcomes (odds ratio [OR] = 0.96, 95% confidence interval [CI] = 0.6 to 1.5) for all patients or recommended care (OR = 1.02, 95% CI = 0.87 to 1.2) for low-risk patients. CONCLUSIONS: No associations were found between patient-physician language concordance and outcomes or physician adherence to clinical recommendations for ED patients with chest pain. Accessible and effective interpretation services, combined with a decision support tool with standard clinical recommendations, may have contributed to equitable care.


Assuntos
Dor no Peito/terapia , Serviço Hospitalar de Emergência , Infarto do Miocárdio/diagnóstico , Relações Médico-Paciente , Adulto , Idoso , Biomarcadores/sangue , Dor no Peito/sangue , Estudos de Coortes , Diagnóstico Diferencial , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Troponina/sangue
7.
Emerg Med J ; 37(4): 223-228, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32047076

RESUMO

OBJECTIVE: Point-of-care (POC) cardiac troponin (cTn) assays have a rapid turnaround time but are generally less sensitive than laboratory-based assays. Previous research found that the Abbott i-Stat cardiac troponin I (cTnI) assay has good diagnostic accuracy when used with the Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid and serial sampling over 3 hours. Accuracy of other assays may differ. We therefore evaluated the diagnostic accuracy of a different POC cTnI assay with serial sampling over 3 hours, both with T-MACS and when used alone. METHODS: In a prospective diagnostic accuracy study at eight EDs in England (July 2015-October 2017), we collected clinical data from consenting adults with suspected ACS at the time of assessment in the ED. Blood samples were drawn on arrival and 3 hours later for POC cTnI (Cardio 3 Triage, Alere). The target condition was an adjudicated diagnosis of acute myocardial infarction (AMI), based on reference standard serial laboratory-based cTn testing. We calculated test characteristics for POC cTnI using the limit of detection (LoD, 0.01 µg/L) and the T-MACS decision aid. RESULTS: Of 347 participants, 59 (14.9%) had AMI. With serial POC cTnI testing over 3 hours, POC cTnI at the LoD cut-off ruled out AMI in 193 (55.6%) patients with 98.1% sensitivity (95% CI 89.9% to 100.0%) and 99.5% negative predictive value (NPV, 95% CI 96.5% to 99.9%). T-MACS ruled out AMI in 117 (33.7%) patients with 98.1% sensitivity (95% CI 89.9% to 100%) and 99.2% NPV (95% CI 94.3% to 99.9%). T-MACS ruled in AMI with 97.9% specificity (95% CI 95.8% to 99.5%) and 83.7% positive predictive value (95% CI 70.6% to 91.7%). CONCLUSIONS: With serial sampling over 3 hours, the Alere Cardio 3 Triage cTnI assay has relatively high NPV for AMI using either the LoD cut-off alone or the T-MACS decision aid. However, wide CIs around the measures of diagnostic accuracy mean that further prospective testing of this strategy is required before clinical implementation. TRIAL REGISTRATION NUMBER: UKCRN 18000.


Assuntos
Síndrome Coronariana Aguda/sangue , Técnicas de Apoio para a Decisão , Troponina/análise , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/epidemiologia , Idoso , Bioensaio/instrumentação , Bioensaio/métodos , Biomarcadores/análise , Biomarcadores/sangue , Dor no Peito/sangue , Dor no Peito/diagnóstico , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Inglaterra/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Testes Imediatos/normas , Testes Imediatos/estatística & dados numéricos , Estudos Prospectivos , Reprodutibilidade dos Testes , Troponina/sangue , Troponina I/sangue , Troponina T/sangue
8.
Am J Emerg Med ; 38(6): 1226-1232, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32029342

RESUMO

BACKGROUND: Coagulation panels are ordered for a variety of conditions in the emergency department (ED). OBJECTIVE: This narrative review evaluates specific conditions for which a coagulation panel is commonly ordered but has limited utility in medical decision-making. DISCUSSION: Coagulation panels consist of partial thromboplastin time (PTT) or activated partial thromboplastin time (aPTT), prothrombin time (PT), and international normalized ratio (INR). These tests evaluate the coagulation pathway which leads to formation of a fibrin clot. The coagulation panel can monitor warfarin and heparin therapy, evaluate for vitamin K deficiency, evaluate for malnutrition or severe systemic disease, and assess hemostatic function in the setting of bleeding. The utility of coagulation testing in chest pain evaluation, routine perioperative assessment, prior to initiation of anticoagulation, and as screening for admitted patients is low, with little to no change in patient management based on results of these panels. Coagulation testing should be considered in systemically ill patients, those with a prior history of bleeding or family history of bleeding, patients on anticoagulation, or patients with active hemorrhage and signs of bleeding. Thromboelastography and rotational thromboelastometry offer more reliable measures of coagulation function. CONCLUSIONS: Little utility for coagulation assessment is present for the evaluation of chest pain, routine perioperative assessment, initiation of anticoagulation, and screening for admitted patients. However, coagulation panel assessment should be considered in patients with hemorrhage, patients on anticoagulation, and personal history or family history of bleeding.


Assuntos
Anticoagulantes/análise , Testes de Coagulação Sanguínea/normas , Medicina de Emergência/métodos , Anticoagulantes/uso terapêutico , Testes de Coagulação Sanguínea/métodos , Testes de Coagulação Sanguínea/estatística & dados numéricos , Dor no Peito/sangue , Dor no Peito/diagnóstico , Serviço Hospitalar de Emergência/organização & administração , Heparina/análise , Heparina/uso terapêutico , Humanos , Coeficiente Internacional Normatizado/métodos , Coeficiente Internacional Normatizado/normas , Complicações Intraoperatórias/sangue , Complicações Intraoperatórias/diagnóstico , Tempo de Tromboplastina Parcial/métodos , Tempo de Tromboplastina Parcial/normas , Tempo de Protrombina/métodos , Tempo de Protrombina/normas , Varfarina/análise , Varfarina/uso terapêutico
9.
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
10.
Am J Med ; 133(8): 976-985, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-31987803

RESUMO

BACKGROUND: Compared with troponin T/I test, the introduction of a high-sensitive (hs) troponin test may result in a higher proportion of positive test results in patients with chest pain and over-testing in patients without acute coronary syndrome. We assessed the impact of the introduction of the hs-troponin assay on the discharge diagnoses and the number of diagnostic tests in patients presenting with chest pain in a real-life setting in an emergency department. METHODS: Retrospective chart review of patients presenting with chest pain to one of the largest hospitals in Switzerland. We compared the standard troponin period (December 2009 to November 2010) with the hs-troponin period (December 2010 to December 2011). RESULTS: Data from 1274 patients (standard 597 [46.9%], hs-troponin 677 [53.1%]) were analyzed. The proportion of patients with non-ST-segment elevation myocardial infarction increased (hs-troponin 14.9%, compared with 9.7%); the proportion in unstable angina (1.5% to 4.0%) and other cardiac illnesses (8.1% to 11.7%) decreased. Although the proportion of noncardiac chest pain illnesses (67%) remained unchanged, the proportion of positive hs-troponin was higher (6.1% vs 2.0%). The average number of additional tests/person decreased in troponin-positive patients (2.0 to 1.7 test per patient; P = .02) and troponin-negative patients (3.1 to 2.8 tests; P < .0001). CONCLUSION: Although the introduction of the hs-troponin test resulted in a higher proportion of positive hs-troponin tests in patients with noncardiac chest pain, the average number of diagnostic tests decreased in patients with chest pain presenting to an emergency department, indicating an increased confidence of clinicians in their diagnosis.


Assuntos
Síndrome Coronariana Aguda/sangue , Angina Instável/sangue , Análise Química do Sangue/métodos , Dor no Peito/sangue , Infarto do Miocárdio sem Supradesnível do Segmento ST/sangue , Troponina T/sangue , Síndrome Coronariana Aguda/diagnóstico , Adulto , Idoso , Angina Instável/diagnóstico , Dor no Peito/etiologia , Angiografia Coronária/estatística & dados numéricos , Ecocardiografia/estatística & dados numéricos , Serviço Hospitalar de Emergência , Teste de Esforço/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Imagem de Perfusão do Miocárdio/estatística & dados numéricos , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Estudos Retrospectivos , Suíça , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Ultrassonografia/estatística & dados numéricos
11.
Emerg Med J ; 37(1): 8-13, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31767674

RESUMO

OBJECTIVES: To directly compare the diagnostic accuracy of four decision aids (Troponin-only Manchester Acute Coronary Syndromes (T-MACS), History, ECG, Age, Risk factors and Troponin (HEART), Thrombolysis in Myocardial Infarction (TIMI) and Emergency Department Assessment of Chest Pain (EDACS)) used to expedite the early diagnosis of acute coronary syndromes (ACS) in the ED. METHODS: We prospectively included patients who presented to 14 EDs in England (February 2015 to June 2017) with suspected ACS within 12 hours of symptom onset. Data to enable evaluation of the T-MACS, HEART, TIMI and EDACS decision aids (without recalibration) were prospectively collected, blinded to patient outcome. We tested admission blood samples for high-sensitivity cardiac troponin I (hs-cTnI; Siemens ADVIA Centaur). Patients also underwent serial cardiac troponin testing over 3-12 hours. The target condition was an adjudicated diagnosis of acute myocardial infarction (AMI). We also evaluated the incidence of major adverse cardiac events (including death, AMI or coronary revascularisation) at 30 days. Diagnostic accuracy of each decision aid and hs-cTnI alone (using the limit of quantification cut-off, 3 ng/L) was evaluated by calculating sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS: Of 999 included patients, 132 (13.2%) had AMI. C-statistics were 0.96 for T-MACS, 0.78 for HEART and 0.69 for TIMI. The sensitivities of T-MACS, HEART, TIMI, EDACS and hs-cTnI <3 ng/L for AMI were 99.2% (95% CI 95.7% to 100.0%), 91.8% (85.0% to 96.2%), 97.5% (92.9% to 99.5%), 96.2% (92.2% to 99.4%) and 99.2% (95.9% to 100.0%), respectively. The respective strategies would have ruled out 46.5%, 34.9%, 19.4%, 48.3% and 28.8% patients. PPVs for the decision aids that identify 'high-risk' patients were 80.4% (T-MACS), 51.9% (TIMI) and 37.2% (HEART). CONCLUSIONS: In this study, T-MACS could rule out AMI in 46.5% patients with 99.2% sensitivity. EDACS could rule out AMI in 48.3% patients with lower sensitivity, although the difference was not statistically significant. The HEART and TIMI scores had lower diagnostic accuracy.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Dor no Peito/diagnóstico , Serviço Hospitalar de Emergência , Troponina I/sangue , Troponina T/sangue , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/mortalidade , Idoso , Biomarcadores/sangue , Dor no Peito/sangue , Dor no Peito/mortalidade , Técnicas de Apoio para a Decisão , Diagnóstico Precoce , Eletrocardiografia , Inglaterra/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Estudos Prospectivos , Medição de Risco , Sensibilidade e Especificidade
12.
Nephrology (Carlton) ; 25(2): 135-143, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31568610

RESUMO

AIM: Acute kidney injury (AKI) is often underdiagnosed due to several limitations of the renal marker creatinine. Tubular urinary biomarkers may substantially contribute to diagnose AKI early. For early detection of AKI, we evaluated for the first time N-acetyl-ß-d-glucosaminidase (NAG), Kidney-injury-molecule-1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL) in acute chest pain. METHODS: We included 402 chest pain patients aged 18 to 95 years seen in the emergency department. From 311 subjects, blood and urine samples were collected. RESULTS: Thirty-three patients developed an AKI and showed a significant increase in all three tubular markers compared to patients without AKI (each P < .001). According to receiver operating characteristic (ROC) analysis, combining NAG and creatinine showed a significantly increased area under the curve (AUC) compared to creatinine alone (AUC: 0.75 vs 0.87; P < .001). KIM-1, NGAL and cystatin C showed no significant differences in AUC compared to creatinine. In 120 individuals with blood and urine sampling before contrast media exposure, ROC analysis showed a significantly improved diagnostic performance for the combination of both (AUC: 0.83 vs creatinine AUC: 0.66; P = .004). AKI occurrence showed no dependency from CM volume. NAG presented as an independent AKI predictor beside creatinine, age, the diagnosis of myocardial infarction and mean arterial pressure. Regarding the prognostic value for renal replacement therapy, the combination of NAG and creatinine showed a significantly lager AUC than creatinine (AUC: 0.95 vs AUC: 0.85; P < .001). CONCLUSION: NAG presented as a promising marker of impending AKI and the necessity of renal replacement therapy.


Assuntos
Acetilglucosaminidase/sangue , Injúria Renal Aguda , Dor no Peito , Receptor Celular 1 do Vírus da Hepatite A/sangue , Lipocalina-2/sangue , Injúria Renal Aguda/sangue , Injúria Renal Aguda/diagnóstico , Biomarcadores/sangue , Dor no Peito/sangue , Dor no Peito/diagnóstico , Dor no Peito/etiologia , Diagnóstico Precoce , Serviços Médicos de Emergência/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Terapia de Substituição Renal/métodos , Tempo para o Tratamento
13.
Dtsch Med Wochenschr ; 145(5): e24-e31, 2020 03.
Artigo em Alemão | MEDLINE | ID: mdl-31561254

RESUMO

INTRODUCTION: Cardiac troponins are the prefered cardial biomarker in the diagnosis of acute myocardial infarction. Because they are detectable by myocardial cell damage, no matter what pathophysiology, the interpretation of a positive test is difficult. The aim of this study is to assess the quality criteria of the troponin test in the diagnosis of acute myocardial infarction in everyday life and whether clinical leading symptoms have an influence on it. METHODS: This is a retrospective cross-sectional study, in which all patients who presented themselves in the emergency department of the Klinikum Lippe-Detmold between 01.01.2014 and 31.05.2014, and had a Troponin-I test were included. The diagnosis "acute myocardial infarction" referred to myocardial infarction type I and was made by the cardiologist on-duty. The patients were divided into four subgroups according to the leading symptoms. The quality criteria of the Troponin-test were calculated. RESULTS: 1046 patients were included. In 15 %, acute myocardial infarction was present, of which 97 % had thoracic pain. The sensitivities and the negative predictive values were over 90 %. The specificities ranged between 56 % and 81 %. The positive predictive values were modest and best in case of thoracic pain 58 %. CONCLUSION: The Troponin test had a good negative predictive value for all clinical symptoms. Thus, an acute myocardial infarction could be excluded with high precision. However, the positive predictive value was low. The only direct symptom that achieved acceptable levels was thoracic pain.


Assuntos
Infarto do Miocárdio/diagnóstico , Troponina/sangue , Dor no Peito/sangue , Dor no Peito/diagnóstico , Dor no Peito/fisiopatologia , Estudos Transversais , Humanos , Infarto do Miocárdio/sangue , Infarto do Miocárdio/fisiopatologia , Valor Preditivo dos Testes , Estudos Retrospectivos
14.
Am J Emerg Med ; 38(8): 1560-1567, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-31493982

RESUMO

BACKGROUND: This study compared the performance of a single blood draw of high-sensitivity troponin T (hsTnT), high-sensitivity troponin I (hsTnI) and conventional troponin I (cTnI) within a modified HEART score for predicting 30-day MACE at Emergency Department (ED) presentation, and established local reference norms for all three assays by determining the cut-off point which yielded the highest sensitivity and negative predictive value for acute myocardial infarction and 30-day MACE. METHODS: This single-center prospective cohort study recruited chest pain patients at the ED, whose hsTnT, hsTnI and cTnI were taken on admission. Subjects were classified into low and non-low risk group according to their modified HEART score, with MACE as the primary endpoint. Receiver-operating characteristic (ROC) curves were generated, area under the curves (AUCs) were calculated; the performance characteristics were determined. RESULTS: The performance of modified HEART scores was comparable among the three assays for 30-day MACE (84.9-87.0% sensitivity, 95.6-96.0% NPV, 95%CI) and none of these had very high AUC and specificity (AUC 0.70-0.71, 53.7-56.7% specificity, 95% CI). The modified HEART score using a single blood draw of either hsTnT (3.9ng/L), hsTnI (0.9ng/L) or cTnI (0.0ng/L) at presentation yielded a sensitivity of 100% for 30-day MACE. CONCLUSION: The modified HEART score using a single blood draw of either hsTnT, hsTnI or cTnI was equally effective in risk-stratifying chest pain patients for safe discharge. The theoretical cut-off points yielding 100% sensitivity are potentially useful (when achieved) for safely discharging low risk patients with undifferentiated chest pain in the ED.


Assuntos
Serviço Hospitalar de Emergência , Infarto do Miocárdio/sangue , Troponina I/sangue , Troponina T/sangue , Adulto , Idoso , Biomarcadores/sangue , Dor no Peito/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Medição de Risco , Sensibilidade e Especificidade
15.
J Med Case Rep ; 13(1): 387, 2019 Dec 30.
Artigo em Inglês | MEDLINE | ID: mdl-31884973

RESUMO

BACKGROUND: Chest pain associated with transient electrocardiogram changes mimicking an acute myocardial infarction have been described in acute pancreatitis. These ischemic electrocardiogram changes can present a diagnostic dilemma, especially when patients present with concurrent angina pectoris and epigastric pain warranting noninvasive or invasive imaging studies. CASE PRESENTATION: A 45-year-old African-American man with a history of alcohol use disorder presented to the emergency department of our institution with 36 hours of concurrent epigastric pain and left-sided chest pain radiating to his left arm and associated with nausea and dyspnea. On physical examination, he was afebrile; his blood pressure was elevated; and he had epigastric tenderness. His laboratory test results were significant for hypokalemia, normal troponin, and elevated serum lipase and amylase levels. Serial electrocardiograms for persistent chest pain showed ST-segment elevations with dynamic T-wave changes in the right precordial electrocardiogram leads, consistent with Wellens syndrome. He was immediately taken to the cardiac catheterization laboratory, where selective coronary angiography showed normal coronary arteries with an anomalous origin of the right coronary artery from the opposite sinus. Given his elevated lipase and amylase levels, the patient was treated for acute alcohol-induced pancreatitis with intravenous fluids and pain control. His chest pain and ischemic electrocardiogram changes resolved within 24 hours of admission, and coronary computed tomography angiography showed an interarterial course of the right coronary artery without high-risk features. CONCLUSIONS: Clinicians may consider deferring immediate cardiac catheterization and attribute electrocardiogram changes to acute pancreatitis in patients presenting with angina pectoris and acute pancreatitis if confirmed by normal cardiac enzymes and elevated levels of lipase and amylase. However, when clinical signs and electrocardiogram findings are highly suggestive of myocardial ischemia/injury, immediate noninvasive coronary computed tomography angiography may be the best approach to make an early diagnosis.


Assuntos
Dor Abdominal/induzido quimicamente , Transtornos Induzidos por Álcool/diagnóstico por imagem , Dor no Peito/induzido quimicamente , Vasos Coronários/diagnóstico por imagem , Etanol/envenenamento , Pancreatite/diagnóstico por imagem , Dor Abdominal/sangue , Dor Abdominal/diagnóstico por imagem , Transtornos Induzidos por Álcool/sangue , Transtornos Induzidos por Álcool/terapia , Dor no Peito/sangue , Dor no Peito/diagnóstico por imagem , Angiografia Coronária , Vasos Coronários/fisiopatologia , Diagnóstico Diferencial , Eletrocardiografia , Serviço Hospitalar de Emergência , Hidratação , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor , Pancreatite/fisiopatologia , Pancreatite/terapia , Resultado do Tratamento
16.
Coron Artery Dis ; 30(6): 455-460, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31094894

RESUMO

BACKGROUND: Currently, there are no clinical scores for risk stratification of low-risk patients with chest pain. We aimed to examine the association between mean platelet volume (MPV) and risk for adverse clinical outcomes in patients with chest pain discharged from internal medicine wards following acute coronary syndrome (ACS) rule-out. PATIENTS AND METHODS: Included were patients who were admitted to internal medicine wards and were discharged following an ACS-rule-out during 2010-2016. The primary endpoint was the composite of all-cause mortality and hospital admission due to ACS at 30-days following hospital discharge. RESULTS: Included in the study were12 440 patients who were divided into three groups according to MPV. The composite endpoint of 30-day all-cause mortality and hospital admission for ACS occurred more frequently among patients with high MPV. Each one-point increase in MPV was associated with an 18% increase in the risk for the composite endpoint (P = 0.02). Considering patients with MPV less than 7.8 fl as the reference group yielded adjusted hazard ratios for the composite endpoint that was significantly higher in patients in the high MPV tertile ( > 8.8 fl) (hazard ratio 1.6; 95% confidence interval = 1.1-2.5; P = 0.04). Each one-point increase in MPV was associated with an 11% increase in the risk for 1-year all-cause mortality (P = 0.01) and a 10% increase in the risk for 1-year ACS (P = 0.04). CONCLUSION: We found an independent association between high MPV and the risk of death and ACS among patients with chest pain who were discharged from internal medicine wards following an ACS-rule-out. MPV may be combined in the risk stratification of patients with chest pain.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Angina Pectoris/diagnóstico , Dor no Peito/diagnóstico , Unidades Hospitalares , Medicina Interna , Volume Plaquetário Médio , Alta do Paciente , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/mortalidade , Adulto , Idoso , Angina Pectoris/sangue , Angina Pectoris/mortalidade , Causas de Morte , Dor no Peito/sangue , Dor no Peito/mortalidade , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Readmissão do Paciente , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Fatores de Tempo
17.
Int J Cardiol ; 291: 168-172, 2019 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-30987836

RESUMO

BACKGROUND: Endothelin-1 (ET-1) is a vasoconstrictor associated with cardiovascular disease, whereas adrenomedullin (ADM) is a vasorelaxant with cardioprotective properties. We sought to determine the relationship between plasma ET-1 and ADM with coronary circulatory function and long-term major adverse cardiovascular events (MACE). METHODS: Thirty-two patients undergoing coronary angiography for chest pain were recruited. Baseline plasma ET-1 and ADM levels were measured. The index of microcirculatory resistance (IMR), coronary flow mediated dilatation (cFMD) and coronary flow reserve (CFR) were measured in a non-obstructed coronary artery. Patients were assessed for MACE over a median period of 8.8 years. RESULTS: Plasma ET-1 levels correlated with IMR (r = 0.57; p < 0.01) and ADM levels correlated with CFR (r = 0.50; p = 0.04) and cFMD (r = 0.62; p = 0.01). After adjustment for age, gender and cardiovascular risk factors, the association between ADM and cFMD (ß = 0.79; p < 0.01) and between ET-1 and IMR (ß = 5.7; p = 0.01) remained significant. IMR was higher, although not statistically significant, in patients with long-term MACE (17.9 ±â€¯5.3 vs. 13.1 ±â€¯6.0 units; p = 0.14). In patients free of MACE, cFMD (9.3 ±â€¯7.6 vs. 2.8 ±â€¯5.0%; p = 0.01) and plasma ADM levels (7.6 ±â€¯5.3 vs. 4.0 ±â€¯1.9 pmol/L; p = 0.07) were higher. CONCLUSIONS: Plasma ET-1 and ADM were associated with measures of coronary microvascular and coronary conduit vessel function, respectively. Increased cFMD and elevated plasma ADM were associated with a cardioprotective effect.


Assuntos
Adrenomedulina/sangue , Angiografia Coronária/tendências , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/diagnóstico por imagem , Circulação Coronária/fisiologia , Endotelina-1/sangue , Idoso , Biomarcadores/sangue , Dor no Peito/sangue , Dor no Peito/diagnóstico por imagem , Estudos de Coortes , Feminino , Seguimentos , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade
19.
Hellenic J Cardiol ; 60(3): 171-177, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30851457

RESUMO

Cardiac troponins are pivotal in the evaluation of patients who suffer from acute chest pain, and the introduction of the high-sensitivity cardiac troponins (hs-cTn) has shown that there are differences between male and female patients. Recent recommendations from experts point out that an appropriate evaluation must take into account the patients' sex, but there is no clear evidence of the implementation of this recommendation in the clinical practice, and the matter has sparked controversy. If the same cutoff value is used for both sexes, myocardial infarction in men might be overdiagnosed, especially in the elderly, who have relatively higher values, and might be underdiagnosed in most women. The International Federation of Clinical Chemistry and Laboratory Medicine Task Force on Clinical Applications of Cardiac Bio-Markers (IFCCLM, TF-CB) 2018 and the Fourth Universal Definition of Acute Myocardial Infarction support the overall and sex-specific 99th percentile Upper Reference Limit (URL) cutoff value, but based on the definition of hs-cTn assays, the Limit of Detection (LoD) may be considered a starting point for an assessment method that does not differentiate between the levels of hs-cTn in male and female patients suspected of suffering from acute coronary syndrome (ACS). In this paper, we discuss the evidence and a novel strategy based on hs-cTn for rapidly ruling out myocardial infarction in low-risk patients who suffer from acute chest pain.


Assuntos
Dor no Peito/sangue , Infarto do Miocárdio/diagnóstico , Troponina/sangue , Biomarcadores/sangue , Dor no Peito/diagnóstico , Dor no Peito/etiologia , Diagnóstico Diferencial , Humanos , Infarto do Miocárdio/sangue , Infarto do Miocárdio/complicações , Reprodutibilidade dos Testes , Fatores Sexuais
20.
Sci Rep ; 9(1): 2125, 2019 02 14.
Artigo em Inglês | MEDLINE | ID: mdl-30765820

RESUMO

A rapid differential diagnosis of the clinical conditions underlying chest pain is a relevant clinical issue. Specifically, a fast rule-in or -out of acute myocardial infarction (AMI) is mandatory to improve diagnostic outcome and cost-effectiveness of patient management. We demonstrated that Protein Kinase C (PKC) epsilon is selectively expressed by platelets from AMI patients, accounting for increased platelet activation. Thus, we hypothesized that PKCepsilon-expressing platelets may represent a pathophysiological marker of AMI that could be utilized in combination with troponin-I, the conventional marker of cardiac injury, to add diagnostic information in chest pain workup. In 94 chest pain patients consecutively admitted to Parma University Hospital, we tested the diagnostic performance of flow-cytometric detection of PKCepsilon expressing platelets in discriminating AMI vs. non-AMI conditions. We demonstrated that PKCepsilon-expressing platelets were significantly higher in patients with AMI. Flow cytometry detection of PKCepsilon-expressing platelets showed high sensitivity and specificity (87.5% and 84.4%, respectively) and good diagnostic accuracy (AUC: 0.875). The combination of PKCepsilon expressing platelets and cardiac troponin clearly discriminates patients with 100% and 0% of probability to be affected by AMI. Overall, we highlighted a dual marker strategy potentially useful for a rapid rule-in or -out of myocardial infarction in chest pain patients.


Assuntos
Biomarcadores/sangue , Plaquetas/metabolismo , Dor no Peito/diagnóstico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Infarto do Miocárdio/diagnóstico , Proteína Quinase C-épsilon/sangue , Troponina I/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor no Peito/sangue , Diagnóstico Diferencial , Diagnóstico Precoce , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Prognóstico , Curva ROC , Adulto Jovem
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...