Christian Folli

Thirty and ninety days mortality predictive value of admission and in-hospital procalcitonin and mid-regional pro-adrenomedullin testing in patients with dyspnea. Results from the VERyfing DYspnea trial☆

INTRODUCTION Mid-regional pro-atrial natriuretic peptide (MR-proANP), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) demonstrated usefulness for management of emergency department patients with dyspnea. METHODS To evaluate in patients with dyspnea, the prognostic value for 30 and 90 days mortality and readmission of PCT, MR-proADM, and MR-proANP, a multicenter prospective study was performed evaluating biomarkers at admission, 24 and 72 hours after admission. Based on final diagnosis, patients were divided into acute heart failure (AHF), primary lung diseases, or both (AHF + NO AHF). RESULTS Five hundred one patients were enrolled. Procalcitonin and MR-proADM values at admission and at 72 hours were significantly (P < .001) predictive for 30-day mortality: baseline PCT with an area under the curve (AUC) of 0.70 and PCT at 72 hours with an AUC of 0.61; baseline MR-proADM with an AUC of 0.62 and MR-proADM at 72 hours with an AUC of 0.68. As for 90-day mortality, both PCT and MR-proADM baseline and 72 hours values showed a significant (P < .0001) predictive ability: baseline PCT with an AUC of 0.73 and 72 hours PCT with an AUC of 0.64; baseline MR-proADM with an AUC of 0.66 and 72 hours MR-proADM with an AUC of 0.71. In AHF, group biomarkers predicted rehospitalization and mortality at 90 days, whereas in AHF + NO AHF group, they predict mortality at 30 and 90 days. CONCLUSIONS In patients admitted for dyspnea, assessment of PCT plus MR-proADM improves risk stratification and management. Combined use of biomarkers is able to predict in the total cohort both rehospitalization and death at 30 and 90 days.

Diagnostic role of copeptin in patients presenting with chest pain in the emergency room

BACKGROUND Chest pain is a frequent symptom leading patients to the Emergency Room. Copeptin, the C-terminal fragment of arginin-vasopressin, is a marker of stressful situations. Recent studies showed that normal levels of copeptin combined with normal troponin accurately rule out the diagnosis of acute coronary syndrome (ACS). In this observational, prospective, multicenter study we evaluated if negative levels of copeptin combined with negative troponin (Tn-T) can correctly rule out the diagnosis of ACS and also of other life-threatening causes of chest pain. RESULTS Of 472 enrolled patients (64.6% males, mean age 60.1yrs), 28 (5.9%) were diagnosed with ST-elevation myocardial infarction (STEMI), 28 (5.9%) with non ST-elevation myocardial infarction (NSTEMI), 43 (9.1%) with unstable angina (UA), 13 (2.8%) with potentially life-threatening non-ACS pathologies (aortic dissection, pulmonary embolism, pulmonary edema, sepsis), 360 (76.2%) with benign causes of chest pain. Copeptin levels were significantly higher in ACS patients with STEMI and NSTEMI than in those with other diagnoses, but not in those with UA. The combination of copeptin and troponin-T attained a negative predictive value of 86.6% for ACS, of 97.9% for other potentially life-threatening non-ACS diseases and of 85% for all potentially lethal diseases (ACS plus others). CONCLUSIONS The combined use of troponin and copeptin significantly improved the diagnostic accuracy of troponin alone both in ACS (STEMI and NSTEMI) and in other life-threatening diseases. Measurement of this marker might be therefore considered not only for a rule-out strategy but also as a warning sign of a life-threatening disease.

Usefulness of simplified acute physiology score II in predicting mortality in patients admitted to an emergency medicine ward

The Objective of this prospective observational study was to evaluate the applicability of the simplified acute physiology score (SAPS II) in patients admitted to an Emergency Medicine Ward in the Emergency Medicine Ward of a tertiary university hospital. We studied consecutive patients admitted to an Emergency Medicine Ward from the emergency department. The SAPS II was assessed in predicting overall in-hospital mortality in terms of sensitivity, specificity and receiver operating characteristic (ROC) curve. A total of 211 consecutive patients were admitted over a period of 2 months. Median SAPS II score was 28 (range 6–93), with a mean risk of in-hospital mortality of 0.17 (range 0.01–0.97) for the whole population, and an observed mortality of 15%. The area under the receiver operator curve (ROC) was 0.84 (0.77–0.91). Considering a cut-off value of SAPS II of 49, the sensitivity was 0.50 (95% CI 0.42–0.56), the specificity was 0.95 (0.92–0.98), the positive predictive value (PPV) was 0.64 (0.58–0.71), and the negative predictive value (NPV) was 0.91 (0.87–0.95), the positive likelihood ratio (pLH) was 9.9, and the negative likelihood ratio (nLH) was 0.5. If contrarily a cut-off value of SAPS II of 22 were used, the sensitivity would be 1.0, the specificity would be 0.21 (0.16–0.26), the PPV would be 0.18 (0.13–0.23), the NPV would be 1.0, the pLH would be 1.3, and the nLH would be 0.0. In this preliminary study, SAPS II predicted in-hospital mortality in patients admitted to an Emergency Ward.

Causes and correlates of anemia in 200 patients with acute cardiogenic pulmonary edema

BACKGROUND Acute heart failure has a poor prognosis and the presence of anemia may increase the risk of adverse outcomes. However, the clinical and laboratory characteristics of anemia in acute heart failure are poorly known. We aimed to assess the causes and the clinical and laboratory correlates of anemia in patients with acute cardiogenic pulmonary edema (ACPE). METHODS This observational study, performed in an Emergency Unit, enrolled 200 patients treated with medical therapy and continuous positive airway pressure. RESULTS Anemia was found in 36% of patients (38.5% of females and 32.5% of males) and was severe (hemoglobin <9 g/dL) in 6.9% of cases. The most frequent causes of anemia were chronic renal failure (27.8%), chronic inflammatory states (27.8%) and the clustering of multiple factors (18.1%). A wider spectrum of etiological factors was found in females than in males. Microcytic anemia was observed only in females (20% of those anemic), mainly due to iron deficiency/chronic blood loss. Glomerular filtration rate, serum iron, serum albumin, total cholesterol and diastolic blood pressure were independently associated with hemoglobin levels. CONCLUSIONS The etiology of anemia in ACPE is heterogeneous, with several causal factors besides impaired renal function. The pattern of anemia is different between genders, suggesting that sex-specific diagnostic and therapeutic targets should be implemented.

Thromboembolic and haemorrhagic events in permanent atrial fibrillation: observational study in an emergency department.

BACKGROUND Atrial fibrillation (AF) is the most common arrhythmia in patients admitted to Emergency Departments. However, the management of permanent AF in order to prevent thromboembolism in clinical practice is still widely discussed. We aimed to evaluate this management and the occurrence of clinical events in a cohort of patients with permanent AF admitted to our Emergency Department. METHODS We enrolled in this observational study 582 patients with permanent AF consecutively seen in our Emergency Room. RESULTS Mean age was 80.1 +/- 9.6 years. Two or more comorbidities were present in 67% of patients. 28% of patients were treated with oral anticoagulant therapy (OT) at the time of admission to the Emergency Department, 34.2% with anti-platelet therapy (APT), while 37.8% were taking no anti-thrombotic therapy. There was no correspondence between three observed groups of treatment and the risk stratification according to CHADS2. In the groups of patients at high or intermediate risk a higher number of ischemic stroke was observed in patients taking APT than in OT patients (16.1% vs 31.5%, p=0.001). A low frequency of total and cerebral haemorrhagic events was observed in all groups. Only the non severe bleeds were significantly more frequent in patients on OT. CONCLUSIONS OT is well-tolerated even in elderly patients, with a low rate of haemorrhagic events. In clinical practice OT is underused, in particular in older patients, in spite of a high number of thrombotic events.