Risk assessment in patients with acute alcohol intoxication.

AIM: Patients with acute alcohol intoxication present a serious and still growing problem for pre- and intra-hospital emergency services. Data on the clinical risk assessment of alcohol-intoxicated patients are sparse. The aim of the present work was, therefore, to collect and assess relevant risk parameters. MATERIALS AND METHODS: At the Mannheim University Hospital, the medical records of 844 alcohol-intoxicated Emergency Department patients were retrospectively studied and evaluated. RESULTS: The patients with alcohol intoxications were predominantly males with an average age of 45 years. Mean blood alcohol concentration was 0.28%. The rate of haemodynamic, respiratory or metabolic complications in these patients was low. In 43% of cases, there was moderately to severely impaired consciousness. About half of the patients were treated on an outpatient basis. CONCLUSION: Our data demonstrate a low clinical risk for alcohol-intoxicated patients. Nevertheless, it is necessary to provide a defined monitoring standard in order to also be prepared for the few potential complications of alcohol intoxication and the possible differential diagnoses of impaired consciousness.

Importance of Wells score and Geneva score for the evaluation of patients suspected of pulmonary embolism.

AIM: The European Society of Cardiology guidelines for pulmonary embolism (PE) published in 2008 and updated in 2014 recommend a risk stratification including risk scores like Wells and the Geneva score. The utility and practicability of these scores are controversially discussed. Recently, in a trauma cohort and in spinal surgery patients, no correlation between Wells Score and PE diagnosis was found. The aim of the study was the evaluation of Wells and Geneva scores in patients presenting with chest pain, dyspnoea or syncope in an emergency department. PATIENTS AND METHODS: We retrospectively examined 326 patients suspected of PE, including assessment, according to Wells and Geneva scores. RESULTS: PE was detected in 13.5 %. The average Wells score was 1.0, the average Geneva score 3.9. The receiver operating characteristic (ROC) curve analyses showed for both scores a high significant area under the curve (Wells score 0.68; Geneva score 0.64). The association between the scores and the diagnosis of PE was calculated with logistic regression analysis and showed high significant odds ratios (OR) for both scores (Wells score 1.38; Geneva score 1.24). There was no significant difference between the area under the curve (AUC) of Wells score and Geneva score. CONCLUSION: The utility of Wells and Geneva scores for the evaluation of patients suspected of PE in an emergency patient cohort.

Importance of risk factors for the evaluation of patients with a suspected pulmonary embolism.

The reliable exclusion of a pulmonary embolism (PE) in hemodynamically stable patients remains a challenge. The European Society of Cardiology guidelines for PE diagnosis published in 2008 and updated in 2014 recommend a low-threshold computed tomography (CT) indication for patients with a high probability of pulmonary embolism or those with elevated levels of D-dimers. Certain elements of the recommendations are controversial, while others, including the evaluation of the risk factors for PE, are considered only in individual cases. In the present study, various risk factors, including obesity, smoking, contraceptive use, immobility level, history of malignant disease and thrombophilia and the factors of familial predisposition, deep vein thrombosis (DVT)/PE-history, long-distance flying <1 week and surgery <4 weeks previously, were retrospectively examined in 492 patients with a suspected PE. The data demonstrated a significant risk of PE with contraceptive use, a history of DVT/PE and thrombophilia. The immobility level, surgery <4 weeks and long-distance flying <1 week previously, as well as family history, malignant disease, obesity and smoking, were not observed to be associated with a significantly higher risk of PE. Contraceptive use and thrombophilia, in addition to a history of DVT/PE, each appear to have a significant predictive value in the context of PE risk stratification. Therefore, patients with a suspected PE, who additionally present with at least one of the aforementioned risk factors, should undergo further diagnostic steps for PE risk stratification, including a low-threshold CT examination, even in the absence of elevated D-dimers.

Effect of GPIIb/IIIa inhibition with eptifibatide or tirofiban on the expression of cellular adhesion molecules on monocytes.

AIM: The aim of the present study was to investigate the effect of GPIIb/IIIa inhibition with eptifibatide and tirofiban on the expression of cellular adhesion molecules on monocytes at different temperatures. MATERIALS AND METHODS: Circulation of blood from six volunteers was performed in an extracorporal circulation model at 36°C and 18°C for 30 min. The blood of each donor was prepared either with addition of eptifibatide or tirofiban, or was left untreated as control. CD54 and CD162 on monocytes was measured using flow cytometry. RESULTS: Expression of CD11b was lower at 18°C compared to 36°C by 51% in the eptifibatide group (p=0.0043), by 29% in the tirofiban group (p=0.095) and by 34% in the control group (p=0.038). Expression of CD54 was not significantly different at 18°C compared to 36°C, neither with eptifibatide (p=0.29) nor tirofiban (p=0.48) nor in the control group (p=0.26). Expression of CD162 was lower at 18°C compared to 36°C by 40% using eptifibatide (p=0.0010), by 94% using tirofiban (p=0.0095) and by 34% in the control group (p=0.019). At 36°C and 18°C, no significant differences were found regarding the expression of CD11b, CD54 and CD162 between the eptifibatide-treated group, the tirofiban-treated group and the control group. CONCLUSION: GPIIb/IIIa inhibition with eptifibatide or tirofiban seems to have no effect on the expression of CD11b, CD54 and CD162 on monocytes during normothermia or hypothermia. Our results show that the beneficial effect induced by hypothermia on the extracorporal circulation-associated alteration of leukocyte function, with decreased expression of CD11b and CD162, seems not to be affected by additional treatment with eptifibatide or tirofiban.

Expression of CD11b (MAC-1) and CD162 (PSGL-1) on monocytes is decreased under conditions of deep hypothermic circulatory arrest.

Deep hypothermic circulatory arrest (DHCA) is a common technique used to protect vital organs during surgical interventions on the thoracic aorta or during surgery for complex congenital heart disease. Activated leukocytes are key mediators of inflammatory responses during ischemia. Intercellular crosstalk between leukocytes, platelets and endothelial cells is mediated by cell adhesion molecules. These molecules trigger complex cell-cell interaction mechanisms and initiate the release of proinflammatory molecules. One parameter that is known to have a significant impact on inflammatory cell activation and the production of proinflammatory markers is temperature. However, to the best of our knowledge, no data have yet been published on the effect of hypothermia on leukocyte surface markers during DHCA. Thus, the aim of the present study was to investigate the effect of hypothermia on the expression of cell adhesion molecules on monocytes under DHCA conditions in vitro. Blood samples collected from 11 healthy volunteers were incubated in a well-established model simulating circulatory arrest at 36°C and 18°C for 30 min. The expression of cluster of differentiation (CD) molecule 11B (CD11b), CD54 and CD162 on monocytes was measured as the mean fluorescence intensity (MFI) using flow cytometry. The expression level of CD11b on monocytes was significantly decreased following the incubation of the blood samples at 18°C compared with the level in blood samples incubated at 36°C (P<0.001). After 30 min of blood stasis in the circulatory arrest model, the expression level of CD162 on monocytes was significantly lower in the blood samples incubated at 18°C than in those incubated at 36°C (P<0.001). No association was identified between temperature and the surface expression of CD54 on monocytes following 30 min of stasis. These findings demonstrate that deep hypothermia decreases the expression of CD11b and CD162 on monocytes in an experimental setup simulating the conditions of DHCA. This may be the result of the inhibition of leukocyte-endothelial and leukocyte-platelet interactions, which may be a beneficial aspect of deep hypothermia that affects the inflammatory response and tissue damage during DHCA.

Predictive value of high-sensitivity troponin I and D-dimer assays for adverse outcome in patients with acute pulmonary embolism.

High-sensitivity troponin (hs-cTn) assays enable the troponin cutoff value to be lowered, resulting in an increase of sensitivity at the cost of specificity. In the present study, the risk of a short-term adverse outcome was assessed in patients with acute pulmonary embolism (PE) using high-sensitivity troponin I (hs-cTnI). We used a cutoff value of 0.1 ng/ml in accordance with current guidelines for unstable angina (UA)/non-ST-segment elevation myocardial infarction (NSTEMI), although the detection limit of the troponin assay is lower. In addition, the risk of an adverse outcome in patients with acute PE was investigated with respect to initial D-dimer serum concentrations. In 65 patients with confirmed acute PE, hs-cTnI and D-dimer values were measured. Adverse clinical outcome was defined as cardiogenic shock, cardiopulmonary resuscitation, mechanical ventilation, vasopressor therapy, thrombolysis, catheter intervention or mortality within 60 days of PE. Patients with acute PE and serum hs-cTnI values >0.1 ng/ml showed significantly higher D-dimer concentrations (P= 0.0467) and a 5-fold increased risk of an adverse clinical outcome [odds ratio (OR), 4.9; 95% confidence interval (CI), 1.28-18.66; P=0.0235] compared with patients with acute PE and hs-cTnI values <0.1 ng/ml. In patients with acute PE suffering from adverse clinical outcome, D-dimer concentrations were significantly elevated compared with those in patients with acute PE without adverse clinical outcome (P=0.02). In patients with acute PE, a hs-cTnI cutoff value of 0.1 ng/ml, which is identical to the recommended cutoff value of NSTEMI, may identify patients with a 5-fold increased risk of a short-term adverse outcome. D-dimer values are significantly higher in PE patients with elevated hs-cTnI values as well as in patients with an adverse outcome.

Incidence of pulmonary embolism in an emergency department cohort evaluated with a simple symptom-based diagnostic algorithm.

BACKGROUND: Although complex scores were recommended for diagnosis of pulmonary embolism (PE), acceptance in clinical practice is limited. In our Emergency Department a symptom-based algorithm for patients with suspected PE including computed tomographic pulmonary angiography (CTPA) and D-dimer testing was implemented. PATIENTS AND METHODS: The cases of 492 patients presenting with either chest pain, dyspnea or syncope for whom this algorithm was applied, were retrospectively analyzed with respect to the incidence of PE, D-dimer and high-sensitive troponin levels. RESULTS: Our algorithm detected PE in 59 out of 492 patients. D-Dimer levels were significantly higher in the PE group than in the patients without PE (p<0.0001). High-sensitive troponin was significantly increased in patients with central PE compared to other patients (p<0.01). CONCLUSION: Our data demonstrate the utility and practicability of our symptom-based algorithm in combination with D-dimer testing and the use of CTPA in patients with suspected PE.

Coronary computed tomography and triple rule out CT in patients with acute chest pain and an intermediate cardiac risk for acute coronary syndrome: part 2: economic aspects.

OBJECTIVE: To evaluate the economic impact of integrating coronary CT angiography (cCTA) or whole chest "triple-rule-out" CTA (TRO-CTA) in the work-up of patients with acute chest pain. MATERIALS AND METHODS: 100 consecutive emergency department patients with acute chest pain and an intermediate cardiac risk for ACS underwent cCTA or TRO-CTA (cCTA group). Diagnostic performance, rate and length of hospitalization, hospital costs, hospital reimbursement and hospital profit were analyzed. All findings were compared to those of 100 different patients with acute chest pain that were evaluated with a standard of care (SOC) diagnostic algorithm (SOC group) that did not include cCTA. Diagnostic performance ("safety") of both algorithms was defined as the absence of major adverse cardiac events (MACE) over a 90-day follow-up period. RESULTS: In the cCTA group 60/100 patients were safely discharged at the same day. 19/100 patients were hospitalized due to significant coronary stenosis on cCTA, which was confirmed by invasive coronary catheterization (ICC) in 17/19 patients. Relevant non-coronary disease that led to hospitalization were found in 21 patients of the cCTA group. In the SOC group all patients were hospitalized. 87 of these hospitalized patients underwent ICC for exclusion of coronary artery stenosis. A significant coronary artery stenosis was found in only 25 of these patients. Within the cCTA group no patient suffered from MACE over the 90-day follow-up period. In the SOC group 2 patients were rehospitalized during the 90-day follow-up period due to recurrent chest pain and 1 patient because of a pseudoaneurym of the left femoral artery after ICC. The median hospital costs per patient were significantly lower in the cCTA group than in the SOC group (428.9€ vs. 1575.0€, p<0.001). The median reimbursement of the cCTA group was less compared to the SOC group (589.8€ vs. 2412.1€, p<0.001) and patients in the cCTA group gained less profit than patients in the SOC group (57.0€ vs. 448.4€, p<0.001). CONCLUSION: Integrating cCTA or TRO-CTA in a SOC algorithm can safely reduce the number of hospitalized patients and reduce total health care costs.

Prediction of adverse clinical outcome in patients with acute pulmonary embolism: evaluation of high-sensitivity troponin I and quantitative CT parameters.

PURPOSE: To evaluate the accuracy of high-sensitivity-cardiac-troponin-I (hs-cTnI) and quantitative CT-parameters, alone and in combination, for predicting right-ventricular-dysfunction (RVD) and adverse clinical outcome in patients with acute pulmonary embolism (PE). MATERIALS AND METHODS: 65 patients with PE and hs-cTnI measurements within 24 h of CT were retrospectively included. RVD was assessed on CT by calculating right ventricular/left ventricular (RV/LV) diameter ratios on transverse sections (RV/LVtrans), four-chamber-views (RV/LV4ch), and RV/LV volume ratio (RV/LVvol). Pulmonary CTA-obstruction-scores (OS) (Qanadli, Mastora) were calculated. Receiver operator characteristic (ROC) analysis was performed to compare Hs-cTnI, RV/LV ratios, and OS for predicting adverse clinical outcome (i.e. intensive care treatment, death). RESULTS: 12 patients with PE had adverse clinical outcome and showed significantly higher RV/LV ratios and OS compared to those without. ROC analysis revealed a cutoff value of 0.042 ng/mL for hs-cTnI resulting in a sensitivity and specificity of 84% and 92% for predicting adverse clinical outcome, respectively. Elevated hs-cTnI was significantly associated with adverse clinical outcome. In a ROC analysis the AUC for the prediction of adverse clinical outcome of RV/LV4Ch, RV/LVvol, and hs-cTnI were 0.77, 0.76, and 0.71. The combination of hs-cTnI and RV/LV ratios increased the AUC for the prediction of adverse clinical outcome. CONCLUSIONS: Hs-cTnI is associated with adverse clinical outcome in patients with acute PE. A combination of hs-cTnI with quantitative CT-parameters improves the prediction of adverse clinical outcome.

Hypothermia inhibits expression of CD11b (MAC-1) and CD162 (PSGL-1) on monocytes during extracorporeal circulation.

AIM: The aim of the present study was to investigate the effect of different hypothermic temperatures on the expression of cellular adhesion molecules on leukocytes. MATERIALS AND METHODS: Circulation of blood from six volunteers was performed in an extracorporeal circulation model at 36°C, 28°C and 18°C for 30 minutes. Expression of CD11b, CD54 and CD162 on monocytes was measured using flow cytometry. RESULTS: Expression of CD11b significantly decreased at 18°C and at 28°C compared to 36°C. A significant reduction of CD162 expression was found at 18°C compared to 28°C and 36°C and at 28°C compared to 36°C. No association was found between temperature and expression of CD54. CONCLUSION: Expression of CD11b and CD162 on monocytes has a temperature-dependent regulation, with decreased expression during hypothermia, which may result in an inhibition of leukocyte-endothelial and leukocyte-platelet interaction. This beneficial effect may influence the extracorporeal circulation-related inflammatory response and tissue damage.

Diagnostic performance evaluation of a computer-aided simple triage system for coronary CT angiography in patients with intermediate risk for acute coronary syndrome.

RATIONALE AND OBJECTIVES: Given the significance of coronary artery disease as the most important socioeconomic health care problem in the Western World, the application of computer-aided simple triage (CAST) systems to this disease would be desirable. MATERIALS AND METHODS: In total, 93 patients with acute chest pain and an intermediate risk score for acute coronary syndrome underwent coronary computed tomography angiography (cCTA). Among those, 74 were of adequate image quality for automated analysis by a commercially available CAST system (COR Analyzer, RCADIA, Haifa, Israel). CAST findings were compared to human expert interpretation for the detection of significant stenosis (≥50%) in the left main, left anterior descending, circumflex, right coronary artery, or arterial branches. Further, one inexperienced observer evaluated all studies for significant stenoses alone and after 1 month guided by a CAST system as an initial read. RESULTS: Human expert interpretation identified 37/74 patients with stenosis ≥50%, whereas the CAST detected 45 patients. The CAST system demonstrated a sensitivity of 100%/79% and a specificity of 78%/89% on a per-patient/per-vessel level, respectively. With CAST, the inexperienced readers' per-vessel sensitivity and positive predictive values significantly improved (P = .011, P = .009) from 69% and 41% to 91% and 74%, respectively. CONCLUSIONS: The investigated CAST system for automatic stenosis detection can accurately identify patients with coronary artery stenosis ≥50% and may be of use as initial interpretation and triage of cCTA studies as well as a second reader for inexperienced readers, in absence of expert readers.

Coronary computed tomography and triple rule out CT in patients with acute chest pain and an intermediate cardiac risk profile. Part 1: impact on patient management.

OBJECTIVE: To evaluate the impact of coronary CT angiography (coronary CTA) or "triple-rule-out" CT angiography (TRO-CTA) on patient management in the work-up of patients with acute chest pain and an intermediate cardiac risk profile. MATERIALS AND METHODS: 100 patients with acute chest pain and an intermediate cardiac risk for acute coronary syndrome (ACS) underwent coronary CTA or TRO-CTA for the evaluation of chest pain. Patients with a high and low cardiac risk profile were not included in this study. All patients with significant coronary stenosis >50% on coronary CTA underwent invasive coronary catheterization (ICC). Important other pathological findings were recorded. All patients had a 90-day follow-up period for major adverse cardiac events (MACE). RESULTS: Based on a negative coronary CTA 60 of 100 patients were discharged on the same day. None of the discharged patients showed MACE during the 90-day follow-up. Coronary CTA revealed a coronary stenosis >50% in 19 of 100 patients. ICC confirmed significant coronary stenosis in 17/19 patients. Among the 17 true positive patients, 9 underwent percutaneous coronary intervention with stent implantation, 7 were received intensified medical therapy, and 1 patient underwent coronary artery bypass surgery. A TRO-CTA protocol was performed in 36/100 patients due to elevated d-dimer levels. Pulmonary embolism was present in 5 patients, pleural effusion of unknown etiology in 3 patients, severe right ventricular dysfunction with pericardial effusion in 1 patient, and an incidental bronchial carcinoma was diagnosed in 1 patient. CONCLUSION: Coronary CTA and TRO-CTA allow a rapid and safe discharge in the majority of patients presenting with acute chest pain and an intermediate risk for ACS while at the same time identifies those with significant coronary artery stenosis.

Evaluation of aortic valve stenosis using a hybrid approach of Doppler echocardiography and inert gas rebreathing.

BACKGROUND: Doppler echocardiography is the method of choice for diagnosis and evaluation of aortic stenosis. However, there are well-known limitations to this method in difficult-to-image patients. Flow acceleration in the left ventricular outflow tract (LVOT) can lead to overestimation of stroke volume (SV) and poor acoustic windows may impede the exact measurement of the LVOT. The present study aimed to evaluate the use of inert gas rebreathing (IGR)-derived SV in this situation. PATIENTS AND METHODS: We replaced Doppler-derived SV measurements in the continuity equation (method A) by SV determined by IGR (method B) and by thermodilution during right heart catheterization (method C) to calculate the aortic valve area (AVA) in 21 consecutive patients with moderate or severe aortic stenosis. RESULTS: Mean SV and AVA did not differ between methods at 72±21 ml and 0.71±0.2 cm(2) (method A) vs. 66±18 ml and 0.67±0.21 cm(2) (method B) vs. 64±15 ml and 0.67±0.21 cm(2) (method C), respectively (all p-values >0.05). The mean difference and limits of agreement for AVA were 0.04±0.23 cm(2) and -0.40 to 0.47 cm(2) between methods A and B, 0.05±0.14 cm(2) and -0.26 to 0.27 cm(2) between A and C, and -0.05±0.23 cm(2) and -0.45 to 0.35 cm(2) between B and C, respectively (all p-values >0.05). CONCLUSION: The presented approach is a reliable method for the calculation of AVA and can add a diagnostic option for the use in difficult-to-image patients. Whereas the use of thermodilution is limited due to its invasive nature, IGR allows the fast and non-invasive determination of cardiac function at low cost.

Cardiac computed tomographic angiography in patients with acute chest pain and moderately-increased troponin.

AIM: The aim of the study was to investigate patients with undefined chest pain and moderately increased troponin based on the results of cardiac computed tomographic (CT) angiography (CCTA). PATIENTS AND METHODS: We analysed the cases of 43 patients with acute chest pain and moderately increased troponin in whom CCTA was performed. Patients with suspected stenosis on CCTA underwent percutaneous coronary angiography (PCA). RESULTS: CCTA ruled-out significant coronary stenosis in 32 patients. Eleven patients had suspected significant coronary stenosis on CCTA. Ten patients underwent PCA, which verified significant coronary lesions in nine. Out of these, four patients were treated by percutaneous coronary intervention (PCI). One patient had to undergo coronary artery bypass grafting. A triple-rule-out CT protocol was performed in 18 patients, demonstrating pulmonary embolism in three and pericardial effusion of unknown origin in two. CONCLUSION: CCTA accurately identifies or rules out patients with undefined chest pain and moderately elevated troponin, which require PCA and allows detection of other significant clinical findings.

Triple-rule-out dual-source CT angiography of patients with acute chest pain: dose reduction potential of 100 kV scanning.

PURPOSE: To investigate the dose reduction potential of low kV triple-rule-out dual-source CT angiography (TRO-CTA) in non-obese (BMI ≤ 25 kg/m(2)) patients with acute chest pain. MATERIALS AND METHODS: Sixty consecutive patients were randomly assigned to two different retrospectively ECG-gated TRO-CTA protocols in this prospective trial: Thirty patients were examined with a 120-kV standard protocol (320 reference mAs with automatic tube current modulation, automatically adapted pitch and ECG-pulsing) and served as the control group (group 1), an otherwise identical 100 kV protocol was used in the other thirty patients (group 2) for a radiation dose reduction. Subjective image quality was assessed on a 5 point scale (1: excellent, 5: non-diagnostic) by two blinded observers. Quantitative image analysis assessed vascular attenuation, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) in different vascular segments. The effective dose was calculated from the dose length product (DLP) using a conversion coefficient of 0.017 mSvmGy(-1)cm(-1). RESULTS: There was no significant difference of age, BMI, heart rate, pitch or scan length between both patient groups. Subjective image quality was rated similar in both groups (group 1: 1.2 ± 0.4, group 2: average score=1.3 ± 0.5). Vessel attenuation was significantly higher in group 2 than in group 1 (ascending aorta: 456 ± 83 HU vs. 370 ± 78 HU, p<0.001; pulmonary artery: 468 ± 118 HU vs. 411 ± 91 HU, p=0.03; left coronary artery: 437 ± 110 HU vs. 348 ± 89 HU, p<0.001), however, there was no significant difference in SNR (13.2 ± 7.6 vs. 14.5 ± 7.5, p=0.49) or CNR (13.8 ± 6.6 vs. 15.9 ± 7.7, p=0.25). The effective radiation dose of the 100 kV protocol was significantly lower (9.6 ± 3.2 mSv vs. 18.1 ± 9.4 mSv, p<0.0001). CONCLUSION: TRO-CTA with 100 kV is feasible in non-obese patients and results in diagnostic image quality and significantly reduced radiation dose.

Prognostic value of perfusion defect volume at dual energy CTA in patients with pulmonary embolism: correlation with CTA obstruction scores, CT parameters of right ventricular dysfunction and adverse clinical outcome.

PURPOSE: To investigate the prognostic value of perfusion defect volume (PDvol) at dual-energy-CT-angiography (DE-CTA) in patients with acute pulmonary embolism (PE) by correlating PDvol with CTA-obstruction-scores (OS), CT parameters of right-ventricular-dysfunction (RVD), and adverse-clinical-outcome. MATERIALS AND METHODS: DE-CTA of 60 patients (mean age: 65±14.4 years) with PE were analyzed. Iodine maps were generated, and normalized PDvol--defined as volume of perfusion defects/total lung volume--was quantified. Furthermore, established prognostic parameters (Qanadli and Mastora-OS, and CT parameters of RVD) were obtained. CT parameters of RVD--namely the right ventricle/left ventricle (RV/LV) diameter ratio measured on transverse sections (RV/LVtrans), four-chamber views (RV/LV4ch), and RV/LV volume ratios (RV/LVvol)--were assessed. PDvol was correlated with OS, CT parameters of RVD and adverse clinical outcome (defined as the need for intensive care treatment or death). RESULTS: 10 of 60 patients with PE experienced adverse clinical outcome. Patients with adverse clinical outcome showed significantly higher PDvol (35±11% vs. 23±10%, p=0.002), RV/LV ratios (RV/LV4ch 1.46±0.32 vs. 1.18±0.26, p=0.005; RV/LVvol 2.25±1.33 vs. 1.19±0.56, p=0.002) and higher Mastora global scores (52 vs. 13, p=0.02) compared to those without adverse clinical outcome. A weak correlation was observed between PDvol and the Mastora global score (r=0.5; p=0.0003), as well as between PDvol and RV/LV4Ch (r=0.432, p=0.0006). No correlation was found between PDvol and the Qanadli score or the remainder of the RVD-CT parameters. CONCLUSION: The extent of perfusion defects as assessed by DE-CTA correlates with adverse clinical outcome in patients with PE. Therefore, volumetric quantification of perfusion defects at DE-CTA allows the identification of low-risk patients who do not require intensified monitoring and treatment.

A novel noninvasive ultrasonic cardiac output monitor: comparison with cardiac magnetic resonance.

BACKGROUND: USCOM, a novel continuous wave Doppler (CWD) device, has been introduced for noninvasive determination of cardiac output (CO). The present study aimed to compare the accuracy and reproducibility of the new device, using cardiovascular magnetic resonance imaging (CMR) as the noninvasive gold standard. METHODS AND RESULTS: The CO of 56 consecutive patients was prospectively determined by CWD either before or after CMR imaging. The CWD probe was placed in the suprasternal or supraclavicular notch aiming at the aortic valve. Valid CWD signals could be obtained in 45 patients yielding a CO of 5.3+/-1.1 L/min (range, 3.0-7.5 L/min) by CMR and 4.7+/-1.1 L/min by CWD (2.5-8.0 L/min, P = .004), respectively. CWD measurements showed an acceptable agreement with CMR (bias: 0.6+/-1.1 L/min) and a high reproducibility (bias: 0.1+/-0.4 L/min). Higher CO and body mass index (BMI) were identified as sources of inaccuracy in univariate analysis. By multivariate analysis, only CO(CMR) was found to be independently associated with larger variation. Estimated diameters of the left ventricular outflow tract (LVOT), a prerequisite for CO measurement by CWD, correlated only weakly with those measured by CMR. CONCLUSIONS: Continuous wave Doppler is a feasible technique for measuring cardiac function. Although the overall agreement with CMR was acceptable, CWD showed a trend to underestimate CO. The estimated LVOT diameter by CWD is likely to be an important source of error. Nevertheless, the CWD device could be of clinical use especially for detection of intraindividual hemodynamic changes since a high reproducibility could be demonstrated.

Diagnostic performance and cost effectiveness of measurements of plasma N-terminal pro brain natriuretic peptide in patients presenting with acute dyspnea or peripheral edema.

BACKGROUND: The purpose of this study was to determine the diagnostic power of a newly available assay for amino-terminal pro-brain natriuretic peptide (NT-proBNP) to identify patients with acute heart failure. In addition, the influence of initial NT-proBNP measurements on economic consequences, diagnostic procedures and staff involvement was evaluated. METHODS AND RESULTS: 401 patients presenting with acute dyspnea or peripheral edema in the emergency department were enrolled. NT-proBNP was measured after initial clinical evaluation. Clinical routine care and diagnostic assessment were blinded to NT-proBNP results. Two cardiologists independently validated the period of hospitalization, clinical examinations and medical therapies of each patient considering NT-proBNP results. The median NT-proBNP level among patients with acute congestive heart failure (CHF) (n=122) was 3497 pg/ml as compared to 320 pg/ml in patients without (n=279) (p<0.0001). An NT-proBNP cutoff level <300 pg/ml was optimal to rule out acute CHF (negative predictive value 96%; sensitivity 96%). NT-proBNP >or=300 pg/ml could strongly predict acute CHF when compared to patients' history or physical examination (odds ratio 9.5; p<0.0001) and diagnostic technical findings (odds ratio 14.7; p<0.05). In patients with NT-proBNP<300 pg/ml, 14% of the period of hospitalization could be saved, corresponding to savings of US $481 per patient. In addition, 9% of the number and time of staff involvement of clinical examinations and therapies could be saved, 10% of the costs of clinical examinations. Chest X-rays were saved in 34%, echocardiography in 9%. CONCLUSIONS: Measurement of NT-proBNP leads to multiple saving amounts and optimizes diagnostic pathways and resource allocation.