Francesca Innocenti

Transthoracic three-dimensional echocardiographic reconstruction of left and right ventricles: In vitro validation and comparison with magnetic resonance imaging

Two-dimensional (2D) echocardiographic and angiographic measurements of ventricular volumes are limited by geometric assumptions concerning cavity shape. We compared in vitro the accuracy of a three-dimensional (3D) echocardiographic system suitable for transthoracic imaging to magnetic resonance imaging (MRI) in the measurement of left and right ventricular volumes. Ventricular cast volumes from 14 excised formalin-fixed sheep hearts filled with an agarose solution were compared with data derived from 3D echocardiography and MRI. Left and right ventricular volumes from 3D echocardiographic reconstructions agreed well with actual volumes without significant underestimation or overestimation. MRI progressively underestimated left ventricular volumes as these increased and systematically underestimated right ventricular volumes. Our echocardiographic system designed for 3D transthoracic imaging combines excellent measurements of left and right ventricular volumes and the computed reconstruction of tomographic slices with the full spatial resolution of the original 2D images. Thus in this in vitro model, 3D echocardiography exhibited greater accuracy than MRI.

Prognostic scores for early stratification of septic patients admitted to an emergency department-high dependency unit.

Objectives The aim of this study was to identify a reliable tool for the early prognostic stratification of septic patients admitted to the emergency department-high dependency unit (ED-HDU), a clinical setting providing a subintensive level of care; we also estimated the cost saving associated with HDU stay compared with ICU stay. Materials and methods Mortality in Emergency Department Sepsis (MEDS), Acute Physiology Age Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), Sequential Organ Failure Assessment (SOFA) score (SOFA-T0) and the Charlson index were calculated at ED admission. SOFA score was also calculated after 24 h (SOFA-T1). The primary outcome was 28 days mortality. Results We admitted 140 patients with severe sepsis or septic shock in our ED-HDU from June 2008 to December 2010; 135 were included in the study. One month’s mortality was 29%. SOFA-T1 was significantly higher in patients who needed an ICU admission (7.5±3.8 vs. 5.3±3.0, P=0.048); it also showed the best mortality prediction ability (area under the curve 0.80, 95% confidence interval 0.70–0.91), compared with MEDS, SAPS, and APACHE score. Troponin and procalcitonin evaluated at ED admission and after 24 h did not show significant differences according to prognosis; patients with lactate more than 2 showed a higher mortality (40 vs. 22%, P=0.034). In a regression analysis adjusted for age, lactate value, and the Charlson index, SOFA-T1 (RR 1.551, 95% confidence interval 1.204–1.998, P<0.001) maintained an independent prognostic value for 28 days mortality. During the 267 days of stay at the ED-HDU, the total saving was &OV0556;460 041, compared with the cost of the same period in the ICU. Conclusion SOFA score is a feasible and accurate tool for an early risk stratification of septic patients admitted to the ED-HDU.

Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED

BACKGROUND: Acute dyspnea is a common symptom in the ED. The standard approach to dyspnea often relies on radiologic and laboratory results, causing excessive delay before adequate therapy is started. Use of an integrated point‐of‐care ultrasonography (PoCUS) approach can shorten the time needed to formulate a diagnosis, while maintaining an acceptable safety profile. METHODS: Consecutive adult patients presenting with dyspnea and admitted after ED evaluation were prospectively enrolled. The gold standard was the final diagnosis assessed by two expert reviewers. Two physicians independently evaluated the patient; a sonographer performed an ultrasound evaluation of the lung, heart, and inferior vena cava, while the treating physician requested traditional tests as needed. Time needed to formulate the ultrasound and the ED diagnoses was recorded and compared. Accuracy and concordance of the ultrasound and the ED diagnoses were calculated. RESULTS: A total of 2,683 patients were enrolled. The average time needed to formulate the ultrasound diagnosis was significantly lower than that required for ED diagnosis (24 ± 10 min vs 186 ± 72 min; P = .025). The ultrasound and the ED diagnoses showed good overall concordance (&kgr; = 0.71). There were no statistically significant differences in the accuracy of PoCUS and the standard ED evaluation for the diagnosis of acute coronary syndrome, pneumonia, pleural effusion, pericardial effusion, pneumothorax, and dyspnea from other causes. PoCUS was significantly more sensitive for the diagnosis of heart failure, whereas a standard ED evaluation performed better in the diagnosis of COPD/asthma and pulmonary embolism. CONCLUSIONS: PoCUS represents a feasible and reliable diagnostic approach to the patient with dyspnea, allowing a reduction in time to diagnosis. This protocol could help to stratify patients who should undergo a more detailed evaluation.

Abnormal troponin level as short-term predictor of poor outcome in acute atrial fibrillation

BACKGROUND The link between minor troponin (cardiac troponin I [cTnI]) elevations and atrial fibrillation (AF) is still debated. METHODS A total of 948 patients with AF lasting less than 48 hours participated in the study and were required to undergo 1-month and 12-month follow-up. The exclusion criteria were represented by younger than 18 years, the presence of hemodynamic instability, or severe comorbidity. Primary end point was the composite of ischemic vascular events inclusive of stroke, acute coronary syndrome, revascularization, and death. RESULTS In the short term, 4 patients (5%) of 78 with abnormal cTnI reached the primary end point (P = .001 vs others). Conversely, in the long term, 13 patients (17%) with abnormal cTnI, 21 (10%) with known ischemic vascular disease, and 50 (5%) aged patients (75 ± 10 years) reached the primary end point (P < .001, P < .001, and P = .002, respectively). At multivariate analysis, abnormal cTnI (hazard ratio [HR], 2.84; 95% confidence interval, 1.38-5.84; P = .005), known ischemic vascular disease (HR, 2.03; 95% confidence interval, 1.11-3.70; P = .021), and age (HR, 1.05; 95 confidence interval, 1.02-1.08; P = .002) were predictors of the primary end point. Minimal or minor cTnI elevation (<0.45 or ≥ 0.45 ng/mL, respectively) showed no differences when associated with the primary end point. The C-statistic demonstrated the significant prognostic value of older age and known ischemic vascular disease, beyond troponin. Clinical parameters inclusive of heart rate, blood pressure, and risk factors for arteriosclerosis showed no relationship with adverse events. Readmission rate did not differ between groups. CONCLUSIONS In patients with acute AF, minor cTnI elevations link to short-term adverse events. Known ischemic vascular disease and older age showed prognostic value only in the long term.

Left Ventricular Systolic Longitudinal Function as Predictor of Outcome in Patients With Sepsis.

Background—In sepsis, whether the assessment of left ventricular global longitudinal systolic strain (GLS) is feasible and prognostically relevant remains controversial. Methods and Results—Consecutive patients admitted to a high-dependency observational unit with sepsis or septic shock were evaluated. Left ventricular ejection fraction (EF) by planimetry and peak GLS by 2D speckle tracking were available at admission in 115 of 149 (77%) patients. Compared with patients included in the study, those excluded (n=34, 23%) showed higher proportion of chronic obstructive pulmonary disease (P<0.01), but with comparable clinical characteristics and mortality rates. GLS showed lowest variability for low EF and highest for higher EF. By day-28 follow-up, all-cause mortality was 30% (n=34 and n=19 within 7 days from hospitalization). GLS and EF were both more abnormal in deceased than in those alive by day-28 follow-up (both P<0.05, findings consistent using day-7 follow-up data). GLS showed a borderline relationship with mortality by day-28 follow-up (hazard ratio 1.16/%, P=0.05), whereas EF did not (hazard ratio 0.99/%, P=0.63) accounting for age; the lack of association of all-cause mortality with EF was consistent at day-7 follow-up (hazard ratio 0.94/%, P=0.9), whereas more abnormal GLS correlated significantly with higher mortality rate (hazard ratio 1.30/%, P=0.03) independent to age. Conclusions—In patients with sepsis assisted in a high-dependency observational unit, feasibility of assessments of left ventricular EF and GLS within 24 h from the hospitalization was acceptable and EF showed no prognostic relevance, whereas GLS showed a correlation with mortality rate potentially relevant in shorter more than in longer follow-ups.

An atypical case of inverted Tako-Tsubo syndrome: case report and review of the literature

Dr. Vicidomini, Dr. Zanobetti, Dr. Innocenti: A 69-yearold Caucasian woman was admitted to our emergency department (ED) for an acute and initial episode of substernal chest pain radiating to the left arm, which had lasted about 1 h, associated with dyspnea and diaphoresis. She had a past medical history of depression and first stage primary biliary cirrhosis. She was taking chronic low-dose sotalol therapy (80 mg PO bid) for a prior episode of supraventricular tachycardia. She had an otherwise normal heart, and was without cardiovascular risk factors. At admission, she denied any recent emotional or stressful event. The first EKG recorded 10 min after the ED admission showed mild ST-segment depression in the precordial leads V5 and V6 (Fig. 1), without significant changes in the inferior, posterior and right precordial leads. The first blood sample analysis exhibited normal values of Troponin-I (cTn-I: 0.10 lg/L, normal range: 0–0.15 lg/L) and CK-MB (1.1 ng/ml, normal range: 0.5–3.6 ng/ml). The patient, fully asymptomatic, was admitted to our intensive observation unit. Based on our protocol, a second blood chemistry control was performed 6 h after the initial results. An elevated cTn-I value of 3.31 lg/L with normal CK-MB value (1.0 ng/ml) was observed. The EKG registered at the same time as the laboratory blood tests showed T-wave inversion in the precordial leads from V1 to V4 (Fig. 2), not present in the first tracing,and a small QT dispersion with a QT interval a bit longer than previous EKG. Trans-thoracic echocardiography showed normal left ventricular internal dimensions; the segmental wall motion analysis revealed akinesis of the basal anterior wall and the entire interventricular septum associated with hypokinesis of the inferior wall basal segments. Posterolateral basal segments and all mid-ventricular and apical segments appeared hyperkinetic.

Prognostic Value of Exercise Stress Test and Dobutamine Stress Echo in Patients with Known Coronary Artery Disease

Background: The aim of this study was to compare the feasibility of dobutamine stress echocardiography (DSE) and exercise stress test (EST) between patients in different age groups and to evaluate their proportional prognostic value in a population with established coronary artery disease (CAD). Methods: The study sample included 323 subjects, subdivided in group 1 (G1), comprising 246 patients aged <75 years, and group 2 (G2), with 77 subjects aged ≥75 years. DSE and EST were performed before enrollment in a cardiac rehabilitation program; for prognostic assessment, end points were all‐cause mortality and hard cardiac events (cardiac death or nonfatal myocardial infarction). Results: During DSE, G2 patients showed worse wall motion score index (WMSI), but the test was stopped for complications in a comparable proportion of cases (54 G1 and 19 G2 patients, P = NS). EST was inconclusive in similarly high proportion of patients in both groups (76% in G1 vs. 84% in G2, P = NS); G2 patients reached a significantly lower total workload (6 ± 1.6 METs in G1 vs. 5 ± 1.2 METs in G2, P < 0.001). At multivariate analysis, a lower peak exercise capacity (HR 0.566, CI 0.351–0.914, P = 0.020) was associated with higher mortality, while a high‐dose WMSI >2 (HR 5.123, CI 1.559–16.833, P = 0.007), viability (HR 3.354, CI 1.162–9.678, P = 0.025), and nonprescription of beta‐blockers (HR 0.328, CI 0.114–0.945, P = 0.039) predicted hard cardiac events. Conclusion: In patients with known CAD, EST and DSE maintain a significant prognostic role in terms of peak exercise capacity for EST and of presence of viability and an extensive wall motion abnormalities at peak DSE.

Short- and long-term cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram

AIM The aim of this study is to evaluate incidence of adverse cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram (ECG) and initial troponin. METHODS Prospective, nonrandomized study enrolled low-risk patients with normal ECG and troponin on admission who underwent observation and/or stress testing by unstandardized clinical judgment. Patients who experienced recurrent angina or positive ECGs or positive troponins during observation or patients with positive stress testing were admitted; otherwise, they were discharged. END POINT The end points are cardiac events at short- and long-term follow-up including cardiovascular death, myocardial infarction, unstable angina, and revascularization. RESULTS Of 5656 patients considered, 1732 with ischemic ECG were initially admitted and, therefore, excluded from the analysis; 2860 with pleuritic chest pain and normal ECG were discharged; 1064 with visceral chest pain and normal ECG were enrolled. Patients with known coronary disease (45%) were older and likely presented known vascular disease. Patients with known vascular disease, older age, female sex, diabetes mellitus, and lower chest pain score were likely managed with observation. In patients with known coronary disease as compared with patients without, overall cardiac events account for 35% vs 14%, respectively (P < .001), as follows: in-hospital, 23% vs 10%, (P < .001); 1 month, 4% vs 2% (P = .133); and 9.9 ± 4.9 months, 8% vs 2%, respectively (P < .001). CONCLUSIONS One-third of patients with chest pain with known coronary disease, negative ECG, and biomarkers were subsequently found to have adverse cardiac events. The value of this research for an emergency medicine audience could be extended to all clinicians and general practitioners beyond cardiologists.

Quality of life after mild to moderate trauma

INTRODUCTION To evaluate potential reduction in health-related quality of life (HRQOL) after a mild to moderate trauma. MATERIALS AND METHODS Follow-up study of a cohort of 153 trauma patients admitted to the High Dependency Unit of the Emergency Department of the University-Hospital of Florence from July 2008 to February 2012. After 6 months from the event, a telephone interview using the Physical (PCS) and Mental (MCS) Health Composite Score (SF12) was conducted. Patients reported their HRQOL both at present and before trauma. Scores ≥ 50 represent no disability; 40-49, mild disability; 30-39, moderate disability; and below 30, severe disability. RESULTS Before the event 143 (93%) subjects reported a normal PCS and MCS. After the events, a significantly lower proportion of patients maintained a normal PCS and MCS values (52 and 68%, all p<0.01). One, two, three and four PCS items worsened in 14%, 15%, 18% and 38% of the study population, while one, two, three or four MCS dimensions worsened in 12%, 19%, 19% and 24%. We identified 109 subjects (N+), which showed normal PCS and MCS values before trauma, in the absence of any pre-existing medical condition. After the event, we observed a significant PCS (before: 54, standard deviation, SD 6; after 43, SD 11, p<0.0001) and MCS (before: 55, SD 7; after 47, SD 11, p<0.0001) worsening among N+ subjects. Distribution across the four disability categories was 52, 24, 17 and 6% for MCS score and 38, 25, 27 and 11% for PCS score: overall 8 (7%) patients reported a moderate disability and 5 (5%) reported a severe disability in both dimensions. Compared with subjects with preserved values, patients with an abnormal (<39) HRQOL were older, showed a higher prevalence of female gender and pre-existing medical conditions and a worst Sequential Organ Failure Assessment score. An advanced age (OR 1.033, 95% CI 1.010-1.057, p=0.005) and a higher SOFA T1 score (OR 1.500, 95% CI 1.027-2.190, p=0.036) were independently associated with a worsening PCS. CONCLUSIONS After a mild trauma, we evidenced a relevant reduction in HRQOL; an advanced age and a higher degree of organ dysfunction were independently associated with HRQOL deterioration.

Long-term prognostic value of stress echocardiography in patients presenting to the ED with spontaneous chest pain

PURPOSE The aims of this study were to evaluate the long-term prognostic value of stress echocardiography (SE) in patients evaluated in emergency department (ED) and to determine SE parameters that best predicted outcome. METHODS Between June 2008 and July 2012, 626 patients with an episode of spontaneous chest pain underwent SE (exercise stress echocardiography or dobutamine stress echocardiography [DSE]). Between December 2012 and January 2013, all patients were contacted to verify the occurrence of cardiac events. Patients were divided in 3 subgroups according to peak stress Wall Motion Score Index (pWMSI): normal peak wall motion (pWMSI, 1; group A1), mild to moderate peak asynergy (pWMSI, 1.1-1.7; group A2), and severe peak asynergy (pWMSI, >1.7; group A3). RESULTS Stress echocardiography showed inducible ischemia in 159 patients (25%); it was negative in 425 (68%) and inconclusive in 42 (7%). Patients with cardiac events more frequently showed inducible ischemia (50% vs 26%; P = .015) compared with patients with good prognosis; a normal SE (14% vs 61%) was significantly less common. At a multivariate regression analysis, an increased pWMSI (relative risk: 9.816, 95% confidence interval: 3.665-26.290; P < .0001) was independently associated with a bad outcome. Cumulative event-free survival was significantly worse with an increasing degree of peak wall motion asynergy (99% in group A1; 96%, group A2; and 88% in group A3; P = .011 between A1 and A2 groups, P = .012 between A2 and A3 groups, and P < .0001 between A1 and A3 groups). CONCLUSIONS Stress echocardiography showed an optimal prognostic value among ED patients evaluated for chest pain. The presence of an extensive asynergic area at peak stress was associated with an adverse prognosis.