Mattia Bonzi

Usefulness of N-Terminal Pro–B-Type Natriuretic Peptide Increase as a Marker for Cardiac Arrhythmia in Patients With Syncope

B-type natriuretic peptides (BNPs) have been investigated as biomarkers for risk stratification of patients with syncope. Their concentration can be influenced by age and co-morbidities. In the present study, we compared the change in N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels within 6 hours in patients with vasovagal and arrhythmic syncope to determine whether this change can predict arrhythmic syncope. Using a case-control design, 33 patients were enrolled. Of the 33 patients, 18 with arrhythmic syncope, as they underwent controlled ventricular tachycardia or ventricular fibrillation (VF) during device safety testing of an implantable cardioverter defibrillator implantation or battery replacement, were compared with 15 patients, who during a tilt-table test were diagnosed with vasovagal syncope (VS). For each patient, a blood sample for NT-proBNP evaluation was collected at baseline and 6 hours after the episode of ventricular tachycardia, VF, or VS. We calculated the percentage of increase in the 6-hour NT-proBNP concentration between the 2 groups using nonparametric techniques. We also calculated the area under a receiver operating characteristic curve with the 95% confidence intervals. The 6-hour change in the NT-proBNP concentrations between patients who had had an episode of ventricular tachycardia or VF and patients with VS was significantly different, with a median increase of 32% in the ventricular tachycardia or VF group versus 5% in the VS group (p <0.01). The area under a receiver operating characteristic curve to predict arrhythmic syncope was 0.8 (95% confidence interval 0.65 to 0.95). In conclusion, the results of the present study suggest that a 6-hour NT-proBNP increase might be able to predict arrhythmic syncope. Future work is needed to confirm these findings in undifferentiated emergency department patients who present with syncope.

Italian guidelines on thrombolysis indications in ischemic stroke have been revised after IST-3 trial and Cochrane revision: cons

One of the milestones of evidence-based medicine is the critical appraisal [1]. Critical appraisal shifts clinical practice from eminence-based medicine (medicine based on authority) to evidence-based medicine (medicine based on the proof and the judgment of the proof). Clinical practice guideline recommendations should be based on the best available evidence. Therapeutic recommendations should be developed upon randomized controlled trials (RCTs) with clinically relevant (defined as ‘‘hard’’) primary end points, low risk of bias, rigorous internal validity and good external validity [2]. The Italian guidelines on thrombolysis indications in ischemic stroke [3] have been revised after the IST-3 trial [4]. Does IST-3 satisfy the above-mentioned RCT characteristics providing the best evidence on which a clinical practice guideline should be modified? When the IST-3 trial was published many considered it the end of the struggle between ‘‘pros’’ and ‘‘cons’’ about thrombolysis [5–7]. Indeed IST-3 is the largest trial on this topic. The Lancet editorial accompanying the IST-3 trial claims ‘‘The role of stroke and emergency physicians is now not to identify patients who will be given rt-PA, but to identify the few who will not’’ [5]. An authoritative IAEM editorial [8] commenting on the IST-3 trial concludes ‘‘We have no longer to ask the age, but just the onset time!’’ However, some weaknesses should be considered [9] and we suggest that there are still some reasons to introduce some notes of caution. If a large trial has some biases, it should not be considered as the ‘‘best’’ evidence and used to change the recommendations of clinical practice guidelines. The aim of this paper is not a comprehensive critical appraisal of the IST-3 trial, already published [10]. We would like just to highlight some major criticisms indicating that maybe the IST-3 trial results are not adequate to change clinical practice.

Predictive accuracy of triage nurses evaluation in risk stratification of syncope in the emergency department

Background Syncope is a common clinical problem that accounts for 1–3% of all emergency department (ED) visits. Its prognosis is extremely variable with a 1-year mortality that may reach 30%. There are no available data about the accuracy of nursing triage in identifying high-risk syncope. The aim of our study was to evaluate the predictive accuracy of nursing triage in identifying high-risk syncope. Methods We conducted a retrospective study on 678 consecutive patients who presented with syncope at four EDs. For each patient, nursing triage, comorbidities, clinical features and adverse events that occurred both in the ED and at 10-day follow-up were assessed. Adverse events included death, readmission to ED, need for major therapeutic procedures, cardiopulmonary resuscitation, intensive care unit admittance, acute antiarrhythmic therapy and major causes of syncope identified during the ED evaluation. Predictive accuracy of nursing triage was evaluated. Results We observed a total of 55 (8.1%) adverse events. Eight of them (9.4%) occurred among the 85 patients who were identified as high priority by nursing triage. Sensitivity (Sn) and specificity (Sp) of urgent nursing triage in identifying adverse outcomes in the ED (19 patients) were 21% (95% CI 3% to 39%) and 88% (95% CI 85% to 90%), while the positive likelihood ratio (LR+) and negative likelihood ratio (LR−) were 1.7 and 0.9, respectively. Sn and Sp for 10-day adverse events were 15% (95% CI 5% to 24%) and 88% (95% CI 85% to 90%), respectively, with a LR+ of 1.18 and a LR− of 0.98. Conclusions Nursing triage was characterised by a low predictive accuracy in identifying high-risk individuals.

Does the Absence of Comorbidities Really Identify Low-Risk Syncope Patients?

We read with great interest the article by Ruwald et al. ([1][1]) on the prognosis among healthy individuals discharged with syncope as the primary diagnosis. However, we wonder whether the subjects enrolled in the study can be effectively considered low-risk patients. Syncope is, most of the time,

Indomethacin prevents post-ERCP pancreatitis in selected high-risk patients

BackgroundPancreatitis is one of the major complications of cholan-giopancreatography (ERCP). It occurs in 1–10 % ofpatients but the incidence may reach 25 % in high-riskpatient populations. Generally post-ERCP pancreatitis(PEP) is mild, but moderate or severe pancreatitis (pan-creas necrosis, pseudocyst formation, need of surgicalintervention, long hospitalization) may arise in 0.5 % ofcases [1, 2].The most common risk factors for this complication areboth patient-related and procedure-related: younger age,female gender, prior ERCP-induced pancreatitis, sphincterof Oddi dysfunction, pancreas divisum, difficulty of can-nulation, biliary sphincterotomy or pancreatic opacification[3]. Although some randomized clinical trials (RCTs) haveshown a potential benefit of gabexate mesilate andsomatostatin in preventing post-ERCP pancreatitis, thereare few data to recommend the use of these drugs; more-over, they require continuous infusion and are quiteexpensive [4, 5].A few RCTs have demonstrated a potential role ofnonsteroidal anti-inflammatory drugs (NSAIDs) as pre-vention for post-ERCP pancreatitis, but before introducingthese prophylactic strategies in clinical practice, morestudies are needed [6, 7].SummaryElmunzer et al. conducted a multicenter, randomized,placebo-controlled, double-blind clinical trial comparingthe use of a single dose of rectal indomethacin versusplacebo for the prevention of post-ERCP pancreatitis inhigh-risk patients. Patients were considered eligible, if theymet at least one major criteria: (clinical suspicion ofsphincter of Oddi dysfunction, a history of PEP, pancreaticsphincterectomy, precut sphincterectomy, more than eightcannulation attempts, pneumatic dilatation of an intactbiliary sphincter or ampullectomy) or two or more minorcriteria (age less than 50 and female gender, a history ofrecurrent pancreatitis, three or more injections of contrastagent into the pancreatic duct, excessive injection of con-trast agent resulting in opacification of pancreatic acini, orthe acquisition of a cytologic specimen from the pancreaticduct using a brush). The main exclusion criteria were:active pancreatitis, contraindication to the use of NSAIDs(creatinine level [1.4 mg per deciliter, or active pepticulcer disease), pre-existing therapy with NSAIDs (exceptfor cardioprotective aspirin), and low risk of post procedurepancreatitis (chronic calcific pancreatitis, biliary stentexchange). After ERCP had been performed, a total of 602patients were randomized to receive either 100 mg of rectalindomethacin or a placebo immediately after the proce-dure. The primary outcome was the development of PEPdefined as new-onset upper abdominal pain associated withan elevation of pancreatic enzymes C3 URL, and hospi-talization for at least two nights. The secondary outcomewas the development of moderate or severe post-ERCPpancreatitis. Patients who were discharged after anuneventful procedure were contacted by telephone after5 days, and again after 30 days to assess for delayedadverse events, and to determine the severity of post-ERCP

Diagnostic accuracy of transthoracic echocardiography to identify native valve infective endocarditis: a systematic review and meta-analysis

Infective endocarditis (IE) is a serious and potentially life-threatening disease, and accurate diagnosis is essential. We performed a systematic review and meta-analysis to assess the diagnostic accuracy of transthoracic echocardiography (TTE), with transesophageal echocardiography (TEE) as the reference standard, in patients with suspected IE of the native valves. We performed a systematic search in MEDLINE, EMBASE and Cochrane Library searching for studies that enrolled adult patients with suspected native valves IE where data about both TTE and TEE could be extracted. We included 11 studies, for a total of 2209 patients. The overall sensitivity, specificity, negative and positive likelihood ratios (LR) of TTE are 0.71 (95% CI 0.56–0.82), 0.80 (95% CI 0.58–0.92), 0.37 (95% CI 0.20–0.68) and 3.56 (95% CI 1.3–9.72), respectively. The subgroup analyses of the studies considering different cut-off levels show that the strict negative criteria (i.e., managing indeterminate results as positive) have the highest sensitivity and the lowest LR−. On the contrary, when managing indeterminate results as negative (standard criteria), the specificity and LR+ are the highest. We observed no differences between the studies performed with older and more recent technologies. In conclusion, our study results support the use of a negative TTE as a single rule-out test in patients with a low pre-test probability. In selected cases, the use of strict negative criteria might exclude IE in intermediate-risk patients, and a positive TTE might be considered as a single rule-in test with no need for TEE if TEE results would not change the patient’s management.

Antibiotic treatment strategies for community-acquired pneumonia in adults

n engl j med 372;14 nejm.org April 2, 2015 1312 From the Julius Center for Health Sciences and Primary Care (D.F.P., C.H.W., M.J.M.B.) and the Departments of Internal Medicine and Infectious Diseases (D.F.P., A.I.M.H., J.J.O.) and Medical Microbiology (M.J.M.B.), University Medical Center Utrecht, and the Departments of Internal Medicine (D.F.P.), Pulmonology (L.J.R.E.), and Medical Microbiology (S.F.T.T.), Diakonessenhuis Utrecht, Utrecht, the Department of Medical Microbiology, Amphia Ziekenhuis Breda, Breda (J.A.J.W.K.), the Department of Pulmonology, Medisch Centrum Alkmaar, Alkmaar (W.G.B.), the Department of Internal Medicine, Kennemer Gasthuis Haarlem, Haarlem (C.J.C.), the Department of Pulmonology, Spaarne Ziekenhuis, Hoofddorp (E.W.), and the Department of Internal Medicine, Academic Medical Center Amsterdam, Amsterdam (J.M.P.) — all in the Netherlands. Address reprint requests to Dr. van Werkhoven at the University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, P.O. Box 85500, 3508 GA Utrecht, the Netherlands, or at c . h . vanwerkhoven@ umcutrecht . nl.

Anti-thrombotic treatment in patients with a long-term indication for anticoagulant therapy undergoing coronary stenting

In patients undergoing percutaneous coronary intervention (PCI) with a stent implantation, double antiplatelet therapy for at least 1 month, according to stent type, is recommended to prevent stent thrombosis [1]. Nevertheless 5–10 % of these patients with ischaemic heart disease have a concomitant indication for oral anticoagulants (OAC) (i.e., mechanical heart valves, atrial fibrillation and venous thromboembolism) [2–4].The association of OAC and antiplatelet agents leads to an increased risk of fatal and non-fatal bleeding events [5]; in particular triple therapy (OAC ? aspirin and clopidogrel) is associated with a prevalence of 12-months major bleeding of 7.4–10.3 % [3]. Nowadays the optimal anti-thrombotic therapy of patients already taking OAC and undergoing a coronary stent implantation is still not well defined when considering both the thrombotic and the bleeding risk. The results of a recent meta-analysis show that triple therapy is associated with a significant reduction in the incidence of thrombotic events even though there is a two-fold increase of bleeding episodes [6]. Despite little evidence being available, experts recommend the implantation of bare-metal stents and prescription of triple anti-thrombotic therapy for as short a period as possible in patients with chronic OAC undergoing coronary stenting. Summary