David Martí

Troponin-Based Risk Stratification of Patients With Acute Nonmassive Pulmonary Embolism: Systematic Review and Metaanalysis

BACKGROUND Controversy exists regarding the usefulness of troponin testing for the risk stratification of patients with acute pulmonary embolism (PE). We conducted an updated systematic review and a metaanalysis of troponin-based risk stratification of normotensive patients with acute symptomatic PE. The sources of our data were publications listed in Medline and Embase from 1980 through April 2008 and a review of cited references in those publications. METHODS We included all studies that estimated the relation between troponin levels and the incidence of all-cause mortality in normotensive patients with acute symptomatic PE. Two reviewers independently abstracted data and assessed study quality. From the literature search, 596 publications were screened. Nine studies that consisted of 1,366 normotensive patients with acute symptomatic PE were deemed eligible. Pooled results showed that elevated troponin levels were associated with a 4.26-fold increased odds of overall mortality (95% CI, 2.13 to 8.50; heterogeneity chi(2) = 12.64; degrees of freedom = 8; p = 0.125). Summary receiver operating characteristic curve analysis showed a relationship between the sensitivity and specificity of troponin levels to predict overall mortality (Spearman rank correlation coefficient = 0.68; p = 0.046). Pooled likelihood ratios (LRs) were not extreme (negative LR, 0.59 [95% CI, 0.39 to 0.88]; positive LR, 2.26 [95% CI, 1.66 to 3.07]). The Begg rank correlation method did not detect evidence of publication bias. CONCLUSIONS The results of this metaanalysis indicate that elevated troponin levels do not adequately discern normotensive patients with acute symptomatic PE who are at high risk for death from those who are at low risk for death.

Prognostic Significance of Deep Vein Thrombosis in Patients Presenting with Acute Symptomatic Pulmonary Embolism

RATIONALE Concomitant deep vein thrombosis (DVT) in patients with acute pulmonary embolism (PE) has an uncertain prognostic significance. OBJECTIVES In a cohort of patients with PE, this study compared the risk of death in those with and those without concomitant DVT. METHODS We conducted a prospective cohort study of outpatients diagnosed with a first episode of acute symptomatic PE. Patients underwent bilateral lower extremity venous compression ultrasonography to assess for concomitant DVT. MEASUREMENTS AND MAIN RESULTS The primary study outcome, all-cause mortality, and the secondary outcome of PE-specific mortality were assessed during the 3 months of follow-up after PE diagnosis. Multivariate Cox proportional hazards regression was done to adjust for significant covariates. Of 707 patients diagnosed with PE, 51.2% (362 of 707) had concomitant DVT and 10.9% (77 of 707) died during follow-up. Patients with concomitant DVT had an increased all-cause mortality (adjusted hazard ratio [HR], 2.05; 95% confidence interval [CI], 1.24 to 3.38; P = 0.005) and PE-specific mortality (adjusted HR, 4.25; 95% CI, 1.61 to 11.25; P = 0.04) compared with those without concomitant DVT. In an external validation cohort of 4,476 patients with acute PE enrolled in the international multicenter RIETE Registry, concomitant DVT remained a significant predictor of all-cause (adjusted HR, 1.66; 95% CI, 1.28 to 2.15; P < 0.001) and PE-specific mortality (adjusted HR, 2.01; 95% CI, 1.18 to 3.44; P = 0.01). CONCLUSIONS In patients with a first episode of acute symptomatic PE, the presence of concomitant DVT is an independent predictor of death in the ensuing 3 months after diagnosis. Assessment of the thrombotic burden should assist with risk stratification of patients with acute PE.

Global adiposity and thickness of intraperitoneal and mesenteric adipose tissue depots are increased in women with polycystic ovary syndrome (PCOS).

CONTEXT Sexual dimorphism suggests a role for androgens in body fat distribution. Women with polycystic ovary syndrome (PCOS), a mainly androgen excess disorder, often present with abdominal obesity and visceral adiposity. OBJECTIVE We hypothesized that women with PCOS have a masculinized body fat distribution favoring the deposition of fat in visceral and organ-specific adipose tissue depots. DESIGN This was a case-control study. SETTING The study was conducted at an academic hospital. PARTICIPANTS Women with PCOS (n = 55), women without androgen excess (n = 25), and men (n = 26) presenting with similar body mass index participated in the study. INTERVENTIONS There were no interventions. MAIN OUTCOME MEASURES Ultrasound measurements of adipose tissue depots including sc (minimum and maximum), preperitoneal, ip, mesenteric, epicardial, and perirenal fat thickness were obtained and total body fat mass was estimated using a body fat monitor. RESULTS Men and patients with PCOS had increased amounts of total body fat compared with control women. Men had increased thickness of intraabdominal adipose tissue depots compared with the control women, with the women with PCOS showing intermediate values that were also higher than those of control women in the case of ip and mesenteric fat thickness and was close to reaching statistical significance in the case of epicardial fat thickness. Women with PCOS also showed increased minimum sc fat thickness compared with the control women. Obesity increased the thickness of all of the adipose tissue depots in the 3 groups of subjects. CONCLUSIONS Women with PCOS have higher global adiposity and increased amounts of visceral adipose tissue compared with control women, especially in the ip and mesenteric depots.

Short-term clinical outcome after acute symptomatic pulmonary embolism

Though studies have identified clinical variables that predict adverse events in patients with acute pulmonary embolism (PE), they have typically not differentiated short-term from long-term predictors. This multicenter prospective cohort study included consecutive outpatients with objectively confirmed symptomatic acute PE. We analyzed the incidence and time course of death, venous thromboembolism (VTE) recurrence, and major bleeding, and we compared event rates during short-term (first week) and long-term (3 months) follow-up after the diagnosis of PE. We also assessed risk factors for short-term mortality. During the first three months after diagnosis of PE, 142 of 1,338 (10.6%) patients died. Thirty-six deaths (2.7%) occurred during the first week after diagnosis of PE, and 61.1% of these were due to PE. Thirty-eight patients (2.8%) had recurrent VTE during the three-month follow-up, though none of the recurrences occurred during the first week after diagnosis of PE. During the three-month follow-up, major bleeding occurred in 48 patients (3.6%). Twenty-one (1.6%) major bleeds occurred during the first week of follow-up, and nine of these were fatal. Short-term mortality was significantly increased in patients who initially presented with systolic arterial hypotension (odds ratio [OR] 3.35; 95% CI, 1.51-5.41) or immobilization due to a medical illness (OR 2.89; 95% confidence interval [CI], 1.31-6.39). In conclusion, during the first week after the diagnosis of PE, death and major bleeding occur more frequently than recurrent VTE. Patients with systolic arterial hypotension and immobilization at the time of PE diagnosis had an increased risk of short-term mortality.

Incidence of Symptomatic and Asymptomatic Chronic Thromboembolic Pulmonary Hypertension

Abstract Introduction and objectives To assess the incidence of long-term symptomatic and asymptomatic chronic thromboembolic pulmonary hypertension (CTPH) in a cohort of patients with acute symptomatic pulmonary embolism (PE), and the potential risk factors for its diagnosis. Methods We conducted a prospective, long-term, follow-up study in 110 consecutive patients with an acute episode of pulmonary embolism (PE). All patients underwent transthoracic echocardiography (TTE) two years after the diagnosis of PE was made. If systolic pulmonary artery pressure exceeded 40 mm Hg and there was evidence of residual PE either by ventilation-perfusion or CT scan, patients underwent right heart catheterisation to confirm the diagnosis. In asymptomatic patients, right heart catheterisation was performed if a repeated TTE still demonstrated persistent pulmonary hypertension six months after the first. Results CTPH was diagnosed in 10 cases (6 patients during follow-up, and 4 at the end of the study) of the 110 patients (9.1%; 95% confidence interval [CI], 3.7-14.5). All patients had symptoms related to the disease according to a structured questionnaire. In the multivariate regression analysis, only concomitant age (relative risk [RR] 1.2 per age; 95% CI, 1.0-1.3; P=.03) and previous PE (RR 5.7; IC 95%, 1.5-22.0; P=.01) were independent predictors of CTPH. Conclusions The cumulative incidence of CTPH appears to be higher than previously reported. All patients had symptoms related to the disease.

Incidencia de hipertensión pulmonar tromboembólica crónica sintomática y asintomática

INTRODUCTION AND OBJECTIVES To assess the incidence of long-term symptomatic and asymptomatic chronic thromboembolic pulmonary hypertension (CTEPH) in a cohort of patients with acute symptomatic pulmonary embolism (PE), and the potential risk factors for its diagnosis. METHODS We conducted a prospective, long-term, follow-up study in 110 consecutive patients with an acute episode of pulmonary embolism (PE). All patients underwent transthoracic echocardiography (TTE) two years after the diagnosis of PE was made. If systolic pulmonary artery pressure exceeded 40 mm Hg and there was evidence of residual PE either by ventilation-perfusion or CT scan, patients underwent right heart catheterisation to confirm the diagnosis. In asymptomatic patients, right heart catheterisation was performed if a repeated TTE still demonstrated persistent pulmonary hypertension six months after the first. RESULTS CTEPH was diagnosed in 10 (6 patients during follow-up, and 4 at the end of the study) of the 110 patients (9.1%; 95% confidence interval [CI], 3.7 to 14.5%). All patients showed symptoms related to the disease according to a structured questionnaire. In the multivariate regression analysis, only concomitant age (relative risk [RR] 1.2 per age; 95% CI, 1.0 to 1.3; P=0.03) and previous PE (RR 5.7; IC 95%, 1.5 a 22.0; P=0.01) were independent predictors of CTEPH. CONCLUSIONS CTEPH cumulative incidence appears to be higher than previously reported. All patients had symptoms related to the disease.

Prognostic Value of Electrocardiographic Findings in Hemodynamically Stable Patients With Acute Symptomatic Pulmonary Embolism

INTRODUCTION AND OBJECTIVES The aim of this study was to determine the prognostic value of electrocardiography in hemodynamically stable patients with a diagnosis of acute symptomatic pulmonary embolism (PE). METHODS This prospective study included all hemodynamically stable outpatients who were diagnosed with PE at a university hospital. The electrocardiographic abnormalities investigated were: a) sinus tachycardia (>100 beats/min); b) ST-segment or T-wave abnormalities; c) right bundle branch block; d) an S1Q3T3 pattern, and e) recent-onset atrial arrhythmia. RESULTS The study included 644 patients. Overall, 5% of those with an ECG abnormality died due to PE in the 15 days after diagnosis compared with 2% of those with normal ECG findings (relative risk [RR]=2.4; 95% confidence interval [CI], 1-5,8; P=.05). Multivariate analysis showed that sinus tachycardia was associated with a 2.2-fold increased risk of death due to all causes in the month after PE diagnosis. After adjusting for age, a history of cancer, immobility, ECG abnormalities, and sinus tachycardia, the presence of recent-onset atrial arrhythmia was significantly associated with death due to PE in the first 15 days (RR=2.8; 95% CI, 1-8.3; P=.05). The negative predictive value of atrial arrhythmia for 15-day PE-related mortality was 97%, while the negative likelihood ratio was 0.79. CONCLUSIONS In hemodynamically stable patients with acute symptomatic PE, the presence of sinus tachycardia and atrial arrhythmia were independent predictors of a poor prognosis. However, the usefulness of these factors for stratifying risk in PE patients is limited.

Valor pronóstico de los hallazgos electrocardiográficos en pacientes estables hemodinámicamente con tromboembolia de pulmón aguda sintomática

Introduccion y objetivos El objetivo de este estudio es evaluar el valor pronostico del electrocardiograma (ECG) en pacientes estables hemodinamicamente con diagnostico de tromboembolia pulmonar (TEP) aguda sintomatica. Metodos Se incluyo de forma prospectiva a todos los pacientes ambulatorios estables hemodinamicamente diagnosticados de TEP aguda sintomatica en un hospital universitario terciario. Las anomalias electrocardiograficas consideradas fueron: a) taquicardia sinusal (> 100 lat/min); b) alteraciones del segmento ST o de la onda T; c) bloqueo de la rama derecha del haz de His (BRDHH); d) patron S1Q3T3, y e) arritmias auriculares de reciente comienzo. Resultados Se incluyo a 644 pacientes en el estudio. Un 5% de los pacientes con ECG anormal fallecieron por TEP en los 15 dias posteriores al diagnostico, comparado con un 2% de los pacientes con ECG normal (razon de riesgo [RR] = 2,4; intervalo de confianza [IC] del 95%, 1-5,8; p = 0,05). En el analisis multivariable, la taquicardia sinusal multiplico por 2,2 el riesgo de muerte por todas las causas en el mes posterior al diagnostico de TEP. Tras ajustar por edad, antecedentes de cancer, inmovilizacion, un ECG alterado y la presencia de taquicardia sinusal, las arritmias auriculares de reciente diagnostico se asociaron de forma significativa a la muerte por TEP durante los primeros 15 dias (RR = 2,8; IC del 95%, 1–8,3; p = 0,05). Las arritmias auriculares mostraron un alto valor predictivo negativo de muerte por TEP a los 15 dias (97%), pero la razon de probabilidad negativa fue 0,79. Conclusiones En pacientes estables hemodinamicamente con TEP aguda sintomatica, la taquicardia sinusal y las arritmias auriculares son predictoras independientes de mal pronostico. Sin embargo, su utilidad en la estratificacion pronostica de estos pacientes es limitada.

Prevalence of left ventricular hypertrophy detected by Cornell voltage‐duration product in a hypertensive population

Introduction. Detection and treatment of left ventricular hypertrophy (LVH) in hypertension is important in order to reduce cardiovascular risk. The product of QRS voltage and duration (e.g. Cornell voltage‐duration product; CorP), is a good marker of LVH and the current study was designed to determine the prevalence of LVH in patients with essential hypertension treated in general practice. Methods. This study was a multicenter, cross‐sectional survey in outpatient hypertensive patients attending clinics across Spain. The primary endpoint for detection of LVH was a CorP >2.440 mm·ms on ECG recordings, which were independently assessed. Results. Seven hundred and eighty‐two patients were evaluated (66.1±10.4 years; 50.6% males; body mass index 28.2±6.1 kg/m2) with a mean baseline blood pressure (BP) of 155.7±17.7/90.8±10.6 mmHg. Only 13.2% of the study population had BP that was adequately controlled. LVH was detected in 23.4% of patients using the CorP method. Predictors of LVH were prior history of LVH, hypertensive retinopathy, age, grade II hypertension and male gender. Conclusions. Almost one‐quarter of hypertensive patients who attended outpatient clinics in Spain had LVH detected by CorP. The CorP criterion appears to be a useful method for detecting LVH in general practice.

Incidence, angiographic features and outcomes of patients presenting with subtle ST-elevation myocardial infarction

BACKGROUND Borderline electrocardiograms represent a challenge in ST-segment elevation myocardial infarction (STEMI) management and are associated with inappropriate discharges and delays to intervention. OBJECTIVES To assess angiographic characteristics and outcomes of patients presenting with subtle ST-elevation (STE) myocardial infarction. METHODS A total of 504 consecutive patients with suspected STEMI treated by systematic primary percutaneous coronary intervention were prospectively included. Subtle STE was defined as a maximal preinterventional STE of 0.1 to 1 mm. Angiograms were interpreted by investigators unaware of the electrocardiographic data. RESULTS The proportion of patients with subtle STE was 18.3%, 86% of them presented with Thrombolysis In Myocardial Infarction flow grade 0/1 and 91% underwent percutaneous coronary intervention. Despite having smaller infarcts, subtle STE patients associated more frequent multivessel disease (57% vs 44%, P = .02) and larger delays to reperfusion. During a follow-up of 19.0 ± 4.9 months, the rates of death or reinfarction were similar among groups (10.0% vs 12.6%, P = .467). Subtle STE was not associated with better outcomes neither in univariate nor after adjustment in a multivariate analysis (adjusted hazard ratio 0.79, 95% CI 0.37-1.69, P = .546). CONCLUSIONS Subtle STEMI is frequent in clinical practice and is usually associated with acute total coronary occlusion. Therefore, it should be diagnosed and treated in the same expeditiously manner as marked STEMI.