Enrico Ferri

In-hospital percentage BNP reduction is highly predictive for adverse events in patients admitted for acute heart failure: the Italian RED Study

IntroductionOur aim was to evaluate the role of B-type natriuretic peptide (BNP) percentage variations at 24 hours and at discharge compared to its value at admission in order to demonstrate its predictive value for outcomes in patients with acute decompensated heart failure (ADHF).MethodsThis was a multicenter Italian (8 centers) observational study (Italian Research Emergency Department: RED). 287 patients with ADHF were studied through physical exams, lab tests, chest X Ray, electrocardiograms (ECGs) and BNP measurements, performed at admission, at 24 hours, and at discharge. Follow up was performed 180 days after hospital discharge. Logistic regression analysis was used to estimate odds ratios (OR) for the various subgroups created. For all comparisons, a P value < 0.05 was considered statistically significant.ResultsBNP median (interquartile range (IQR)) value at admission was 822 (412 - 1390) pg\mL; at 24 hours was 593 (270 - 1953) and at discharge was 325 (160 - 725). A BNP reduction of >46% at discharge had an area under curve (AUC) of 0.70 (P < 0.001) for predicting future adverse events. There were 78 events through follow up and in 58 of these patients the BNP level at discharge was >300 pg/mL. A BNP reduction of 25.9% after 24 hours had an AUC at ROC curve of 0.64 for predicting adverse events (P < 0.001). The odds ratio of the patients whose BNP level at discharge was <300 pg/mL and whose percentage decrease at discharge was <46% compared to the group whose BNP level at discharge was <300 pg/mL and whose percentage decrease at discharge was >46% was 4.775 (95% confidence interval (CI) 1.76 - 12.83, P < 0.002). The odds ratio of the patients whose BNP level at discharge was >300 pg/mL and whose percentage decrease at discharge was <46% compared to the group whose BNP level at discharge was <300 pg/mL and whose percentage decrease at discharge was >46% was 9.614 (CI 4.51 - 20.47, P < 0.001).ConclusionsA reduction of BNP >46% at hospital discharge compared to the admission levels coupled with a BNP absolute value < 300 pg/mL seems to be a very powerful negative prognostic value for future cardiovascular outcomes in patients hospitalized with ADHF.

Brain Natriuretic Peptide and N-Terminal Pro-B-Type Natriuretic Peptide Show a Different Profile in Response to Acute Decompensated Heart Failure Treatment

Brain natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are currently used for the diagnosis, prognosis, and therapeutic decision making in heart failure patients. The aim of the study was to compare BNP and NT-proBNP plasma concentration profiles in 42 patients with decompensated heart failure who underwent treatment in the emergency department. A significant decrease in both peptide concentrations fell beyond 24 hours of therapy. BNP concentration underwent a more responsive change from admission (-54.1%+/-8.6% at 72 hours and -57.4%+/-7.6% at discharge) than NT-proBNP concentration (-17.6%+/-5.4% at 72 hours and -18.6%+/-5.6% at discharge). Although BNP and NT-proBNP concentrations were highly correlated, no correlation in their variations was found, a finding that suggests a different kinetic behavior in response to treatment. Sequential measurements of BNP and NT-proBNP provide a reliable marker to confirm clinical improvement after 24 hours of treatment. BNP may show some advantages over NT-proBNP as a more sensitive marker of early stabilization in response to therapy.

Predictive value for death and rehospitalization of 30-day postdischarge B-type natriuretic peptide (BNP) in elderly patients with heart failure. Sub-analysis of Italian RED Study.

Abstract Background: Our aim was to determine if, in elderly heart failure (eHF) patients, serial B-type natriuretic peptide (BNP) assessments obtained during follow-up after hospital discharge could have prognostic utility for death and rehospitalizations. In eHF patients, BNP assessment at hospital discharge has been demonstrated to have a high prognostic value; however, its predictive role for future cardiovascular events in eHF patients, when assessed in the period after discharge, both for the correct timing and cut-off levels, has not been completely elucidated. Methods: This study is a monocentric subanalysis of the Italian RED (Rapid Emergency Department) study. We studied 180 consecutive patients admitted for acute HF through serial BNP assessments: at hospital arrival; at discharge; and at 30, 90, and 180 days follow-up outpatient visit. Results: Both a BNP >400 pg/mL at 30 days after discharge and the percentage variation of BNP from discharge to 30 days (Δ%BNP), compared with a BNP at discharge >400 pg/mL, showed a higher area under the curve (AUC) and odds ratio (OR) in predicting events [AUC=0.842, p<0.0001; OR 7.9 (3.3–19.0), p<0.001 for 30 days BNP and AUC=0.851, p<0.0001; OR 9.5 (4.065–22.572), p<0.0001 for Δ%BNP compared with AUC=0.638, p<0.002; OR 2.4 (1.1–5.3), p=0.032 for BNP at discharge]. Conclusions: In patients at a high risk for future events, BNP levels assessed 30 days after hospital discharge in the absence of signs and symptoms could be predictive of subsequent hospitalization and death. These patients should be considered for closer monitoring and treatment adjustment.

In-hospital brain natriuretic peptide and N-terminal prohormone brain natriuretic peptide variations are predictors of short-term and long-term outcome in acute decompensated heart failure

Acute decompensated heart failure is one of the most important causes of hospitalisation worldwide. Natriuretic peptides have shown their usefulness in the diagnosis and management of heart failure. Their variations during hospitalisation also appear useful to predict outcomes. In particular, data from the literature demonstrate that reduction from admission to discharge of brain natriuretic peptide and N-terminal prohormone brain natriuretic peptide in these patients is a predictor of future cardiovascular events.

Fahr’s disease detected on a head CT scan in patient with “epileptic syncope” in the Emergency Department

Fahr’s disease is a rare neurological disorder characterized by diffuse intracranial calcification with a prevalent involvement of the basal ganglia and dentate nucleus of the cerebellum. It has been reported to be an autosomal dominant inheritance in familial cases, although the causal gene is still unknown, and sporadic types have been described. Most cases initially present with a deterioration of motor function. Later in the development of the disease, other symptoms and signs occur, especially extrapyramidal symptoms. We report a case with an unusual presentation and no extrapyramidal signs: An 58-year-old woman was brought to the Emergency Department (ED) because of a sudden loss of consciousness with seizure and urinary incontinence. She denied chest or abdominal pain, nausea vomiting or diarrhea. Upon falling from the seizure, she sustained cranial trauma (frontal skull). She denied any past medication history, allergies to medications, chest or abdominal pain, nausea, vomiting or diarrhea. There was no family history of mental illness, dementia, or major physical illness. Prior to the present illness, she had been living independently. On physical examination, the patient was a healthy appearing woman who was 155 cm tall, and weighed 49 kg. The vital signs were: blood pressure 140/85 mmHg, pulse 70 beats/min, respirations 12 breaths/min, temperature 37 C. The general physical examination other than the skull contusion was unremarkable. Neurological examination revealed cerebellar ataxia (antagonist hypotonia, asynergy, dismetria and dysdiadochokinesia); there were no extrapyramidal signs, athetosis or dementia; normal cranial nerve functions, and no motor or sensory focal findings. A laboratory screening panel was normal including calcium (8.9 mg/dL) and phosphate (3.1 mg/dL). Because of the new onset seizure activity, a non-contrast head computed tomography (CT scan) was obtained, and revealed extensive and symmetrical hyper-dense lesions over the caudate, dentate nuclei and periventricular white substance (Figs. 1, 2). The patient was admitted to the medicine ward, where other examinations were performed. Routine laboratory investigation confirmed that calcium and phosphate ions were in normal range; also normal were other tests including inflammation indices and coagulation tests. An electroencephalogram (EEG) revealed a normal pattern. Imaging diagnostic procedures gave no evidence of radiographic cardiopulmonary lesions, and there were no tumors of bone or other organs. Magnetic resonance imaging of the head revealed multiple areas of modified intensity signal, hyper-intense in T2, softly hyper-intense in T1 calibrated images and hypointense using the echo gradient technique, localized into peri-ventricular area, semi-oval centers, basal nuclei and cerebellum dentate nucleus. A. Sentimentale (&) M. Matteoli M. Corsino E. Ferri S. Di Somma Department of Emergency Medicine, II Medical School University La Sapienza, Sant’Andrea Hospital, Via di Grottarossa 1035-1039, 00189 Rome, Italy e-mail: alberto.sentimentale@ospedalesantandrea.it

B-Type Natriuretic Peptide and Non-Invasive Haemodynamics and Hydration Status Assessments in the Management of Patients with Acute Heart Failure in the Emergency Department

AbstractIntroduction: An impairment of cardiac haemodynamics and fluid retention may occur in patients with acute heart failure (AHF) because of left ventricular (LV) dysfunction due to volume and/or pressure overload. The measurement of B-type natriuretic peptide (BNP) represents the ‘gold standard’ of biomarker assessment for evaluating LV adaptations to AHF. More recently, Nexfin and bioelectric impedance vector analysis (BIVA) techniques have been proposed for non-invasively assessing haemodynamic and hydration status, respectively. These techniques are rapidly and easily executable and, most importantly, may be repeated over time. Aim: To validate the applicability of Nexfin and BIVA techniques, in association with BNP dosage, and changes of these parameters after treatment during hospitalization in patients with AHF referring to the emergency department (ED). Methods: We enrolled 44 patients (20 female, mean age 77 ± 7.7 years), referring to ED for AHF. During hospitalization (mean ± SD: 4.12 ± 1.45 days), all patients underwent BNP measurements at admission, 24 hours, 72 hours and at discharge. At the same time intervals, Nexfin and BIVA were also performed. According to international guidelines, all patients were treated with optimal pharmacological therapy, independently of other parameters examined during hospitalization. Results: Compared with baseline (747.61 ± 658.54 pg/mL), we observed a statistically significant reduction of BNP levels at 72 hours (357.64 ± 193.81 pg/mL; p < 0.05) and at discharge times (248.57 ± 194.46 pg/mL; p < 0.05). In addition, a significant reduction of hydration status, evaluated through BIVA, was observed at discharge compared with hospital admission (from 79.44 ± 6.47% to 76.35 ± 5.5%; p< 0.05). This was paralleled at Nexfin evaluation by a significant increase of cardiac index (from 2.32 ± 0.95 to 3.9 ± 1.18 L/min/m2) and clinical improvement of New York Heart Association class at discharge compared with hospital admission. Finally, we observed a statistically significant correlation between percentage variation of cardiac index and hydration status from admission to discharge (p < 0.05). Conclusions: In patients with AHF, admitted to ED, simultaneous monitoring of cardiac index and of hydration status by non-invasive methods may be useful for confirming clinical diagnosis, beyond dosages of BNP. These techniques could also be useful for intra-hospital management of AHF patients. In fact, their variations, coupled with the BNP ones, during hospitalization, may be of value in order to easily and rapidly identify clinical and haemodynamic improvements of AHF, which may be of key relevance for appropriate discharges from EDs.

Elevated B-Type Natriuretic Peptide Blood Levels during Hypertensive Crisis

AbstractObjectives: The objectives of this study were: (i) to assess the role of B-type natriuretic peptide (BNP) in the course of hypertensive crisis; (ii) to evaluate the possible role of BNP in the differential diagnosis between hypertensive emergencies (HE) or urgencies (HU); and (iii) to investigate the relationship between BNP concentration and blood pressure (BP) acute burden with consequent myocardial ischaemia or brain damage. Methods: 57 consecutive patients were admitted to the emergency department for acute elevated BP levels (systolic BP [SBP]/diastolic BP [DBP]: 200.7 ± 24.7/121.2 ± 12.4 mmHg) were enrolled. On the basis of clinical data, patients were subdivided into two groups: (i) 25 patients with HE: SBP/DBP 204.16 ± 29.1/123.3 ± 13.0 mmHg with heart (acute coronary syndrome) or brain involvement; (ii) 32 patients with HU: SBP/DBP 198.1 ± 20.7/120 ± 11.7 mmHg, without any acute or ongoing deterioration of target organs. For each patient, a serum dosage of BNP was performed. Results: In the whole population, no significant relationship was found between BP total burden and BNP level. In HE, BNP concentration (113.22 ± 87 pg/mL) was significantly (p < 0.001) higher than in HU (23.5 ± 21.3 pg/mL) patients. There was a significant increase (p < 0.01) of BNP blood level in HE patients with acute coronary syndrome (162.02 ± 95.7 pg/mL) compared with those with neurological complications (80.7 ± 65.2 pg/mL). Moreover, in HU patients, there was a significant relationship (r = 0.37; p < 0.05) between BNP levels and pulse pressure. Conclusions: During hypertensive crisis, BNP blood level increase seems to have a role as a diagnostic tool for the screening of hypertensive emergencies due to an acute coronary or brain injury, and the BNP elevation is greater in the presence of myocardial ischaemia than brain damage.

Celiac Artery Compression by the Median Ligament: An Uncommon Cause of Abdominal Pain in the Emergency Department. Report of a Case~!2009-12-31~!2010-05-06~!2010-07-06~! DONE

The Authors report a case of a patient presenting in the Emergency Department (ED) with severe epigastric pain refractory to therapeutic treatment, with onset after forced ice water ingestion caused by joking compression of a soft PET ® bottle during drinking. The Angio MR and angiography performed, after exclusion of suspected esophagus rupture and other esophago-gastric diseases, to rule out an ischemic origin of the pain demonstrate a stenosis of the celiac artery resulting from median arcu- ate ligament narrowing, the so-called Dunbars Syndrome. The Dunbars Syndrome is uncommon and some aspects such as the vascular etiology of symptoms are still controversial. In this report clinical presentation, differential diagnosis and pathophysiology of this disease are discussed.

MANAGEMENT OF HYPERTENSIVE CRISIS IN THE EMERGENCY DEPARTMENT, AN ITALIAN EPIDEMIOLOGICAL STUDY. PRELIMINARY DATA: PP.28.111

Introduction: Aim of our experimental epidemiological study was to improve the understanding of the clinical condition of acute, severe hypertension managed in the Emergency Department (ED). We evaluated epidemiological data of the in-hospital mortality, end-organ damage, time to achieve controlled blood pressure. We show preliminary data collected in the period October-December 2009. Patients and Methods: 48 patients were studied until now (28F,20 M,mean age 68.6yrs) arriving in ED with elevated blood pressure (BP). We recorded anamnestic data, physical examination, blood tests, levels of BP leading to initiation of treatment, antihypertensive medications used, time required to achieve blood pressure control, in-hospital outcomes. Results: mean Sistolic BP/Diastolic BP(SBP/DBP) at admission was 212.3/105.8 mmHg(mean BP 141.3mmHg), and at pressure control (after mean 5.5 hours) was 143.7/76.5 mmHg(mean BP 98.9mmHg). Medications used for BP control were in 93.7% of cases intravenous drugs (iv), and in a short percentage of cases oral drugs (6.3%). Patients presented history of hypertension 70.8%, diabetes 20.8%, cardiac ischemic disease 25%, chronic cerebro-vascular disease 6.2%, chronic kidney failure 2%. The in-hospital outcomes consist mainly in hospitalization (66.7%) for complications, or for those cases of poor pressure control after more than 24 hours of stay in ED (8 patients). No patients died in ED. 29/48 patients completed a 30-days follow-up, and no events have been recorded until now. Conclusions: Preliminary data, show that hypertensive crisis is 1% of the total visits in our ED in a period of 3 months. In ED it is treated mainly with iv drugs, but also oral drugs are used. This indicates that ED physicians decision making for hypertension therapy is not standardized yet. The time required in pressure control is 5.5 hours, and this mirrors the different behaviours of ED physicians based on individual skill and experience. We are continuing the study to achieve a larger number of data useful to build a sort of “standardized protocol” for the diagnosis and treatment of hypertensive crisis in ED.