S. Barra

Atrial fibrillation in acute pulmonary embolism: prognostic considerations

Aims Although it is accepted that atrial fibrillation (AF) may be both the contributing factor and the consequence of pulmonary embolism (PE), data on the prognostic role of AF in patients with acute venous thromboembolism are scarce. Our aim was to study whether AF had a prognostic role in patients with acute PE. Methods Retrospective cohort study involving 270 patients admitted for acute PE. Collected data: past medical history, analytic/gasometric parameters, admission ECG and echocardiogram, thoracic CT angiography. Patients followed for 6 months. An analysis was performed in order to clarify whether history of AF, irrespective of its timing, helps predict intrahospital, 1-month and 6-month all-cause mortality. Results Patients with history of AF, irrespective of its timing (n=57, 21.4%), had higher intrahospital (22.8% vs 13.1%, p=0.052, OR 2.07, 95% CI 0.98 to 4.35), 1-month (35.1% vs 16.9%, p=0.001, OR 3.16, 95% CI 1.61 to 6.21) and 6-month (45.6% vs 17.4%, p<0.001, OR 4.67, 95% CI 2.37 to 9.21) death rates. The prognostic power of AF was independent of age, NT-proBNP values, renal function and admission blood pressure and heart rate and additive to mortality prediction ability of simplified PESI (AF: p=0.021, OR 2.31, CI 95% 1.13 to 4.69; simplified PESI: p=0.002, OR 1.47, CI 95% 1.15 to 1.89). The presence of AF at admission added prognostic value to previous history of AF in terms of 1-month and 6-month all-cause mortality prediction, although it did not increase risk for intrahospital mortality. Conclusions The presence of AF, irrespective of its timing, may independently predict mortality in patients with acute PE. These data should be tested and validated in prospective studies using larger cohorts.

Manchester triage in acute pulmonary embolism: can it unmask the grand impersonator?

Background Acute pulmonary embolism (PE) is associated with high mortality risk. Early diagnosis is difficult because of non-specific clinical presentation and delay in imaging confirmation. Manchester Triage (MT) prioritises patients on the basis of illness severity and potentially recognises those with higher mortality risk. No studies of the role and impact of MT on rapid PE diagnosis and in-hospital mortality (IHM) have been carried out. Objective To assess the appropriateness of MT in this set of patients presenting acutely to the emergency department (ED), and to determine whether it assists in a rapid diagnosis, acts as a protective triage tool and affects short-term mortality. Methods Single-centre retrospective study of 176 consecutive patients with PE, assessed by MT in the ED between January 2006 and October 2010 (mean age 70.5±15.7 years, 38.6% men). The primary outcome measure was all-cause IHM. Results IHM was seen in 30 (17%) patients. More than half of the patients with PE (54%) were classified as target time for first medical observation (MOb) ≤10 min. 73.3% of IHM occurred in this group (p=0.020) with several increased markers of illness severity. MOb ≤10 min was not associated with faster PE imaging confirmation. The average door-to-diagnosis time (PEDx) was 26.8±36.8 h and PEDx >17.0 h was associated with higher IHM (p=0.017). On multivariate analysis, thrombolysis and MOb ≤10 min were included in an IHM predictor model. Conclusion MT has high sensitivity in identifying patients with PE at risk. Those patients assigned as MOb ≤10 min have increased markers of illness severity and higher IHM. MT acts as a protective system in this challenging set and should be used as a patients first assessment, aiding the emergency medical team to recognise those in need of urgent assessment and treatment.

Infecção recorrente em apresentação tardia de taquicardia ventricular polimórfica catecolaminérgica

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is characterized by episodic syncope resulting from fast VT (bidirectional or polymorphic) occurring during exercise/acute emotion in individuals without structural cardiac abnormalities. Mean age of onset is between seven and nine years, although onset as late as the fourth decade of life has been reported. We present the oldest reported patient with index event of CPVT.

Bleed-myocardial infarction score: predicting mid-term post-discharge bleeding events

Purpose: Prediction of hemorrhagic events in the acute/sub-acute phases of a Myocardial Infarction (MI) has already been addressed before. However, prediction of mid- to long-term bleeding has received scarce attention. We aim at deriving and validating a score for the prediction of mid-term bleeding events following discharge for MI. Methods: 917 patients admitted for MI and followed for 19.9±6.7 months were assigned to a derivation cohort. A new risk model, called BLEED-MI, was developed for predicting clinically significant bleeding events during follow-up (primary endpoint) and a composite endpoint of significant hemorrhage plus all-cause mortality (secondary endpoint), incorporating the following variables: Age, Diabetes Mellitus, arterial hypertension, smoking habits, urea, creatinine clearance and hemoglobin at admission, history of stroke, bleeding during hospitalization or previous major bleeding and heart failure during hospitalization. The BLEED-MI model was tested for calibration, accuracy and discrimination in the derivation sample and in a new, independent, validation cohort comprising 798 patients admitted at a later date. Results: The BLEED-MI score showed good calibration in both derivation and validation samples (Hosmer-Lemeshow test p-value 0.350 and 0.514, respectively) and high accuracy within each individual patient (Brier score 0.060 and 0.066, respectively). Its discriminative performance in predicting the primary outcome was relatively high (c-statistic of 0.751±0.031 in the derivation cohort and 0.720±0.036 in the validation sample). Incidence of primary/secondary endpoints increased progressively with increasing BLEED-MI scores. In the validation sample, a BLEED-MI score below 2 had a negative predictive value of 98.7% (152/154) for the occurrence of a clinically significant hemorrhagic episode during follow-up and for the composite endpoint of post-discharge hemorrhage plus all-cause mortality. Conclusions: A new bedside prediction-scoring model for post-discharge mid-term bleeding has been derived and preliminarily validated. This is the first score designed to predict mid- term hemorrhagic risk in patients discharged following admission for acute MI. This model should be externally validated in larger cohorts of patients before its potential clinical implementation.

A perspective on the Crusade and Grace scores - risk assessment combined to optimize global clinical benefit

In acute myocardial infarction (AMI) management it is crucial to estimate patients ischemic risk (GRACE), as well as, anticipate their bleeding risk (CRUSADE). However, given the overlapping ischemic and haemorrhagic risk markers it is sometimes difficult to decide on the best therapeutic strategy. We evaluated the prognostic ability of GRACE combined with CRUSADE score. A population of 1000 patients consecutively admitted for AMI (68.7±13.4 years, 60.2% male, 42.7% STEMI). Mean follow-up=21±7months. The GRACE and CRUSADE scores showed good discriminative ability for follow up mortality (MFUP) (AUC 0.78, p<0.001) and significant inhospital bleeding (AUC 0.70,p<0.001). Subsequently, we divided the sample into 4 groups (G1 – low Grace/low Crusade; G2 – low Grace/high Crusade; G3 – high Grace/low Crusade; G4 – high Grace/high Crusade) and for each group we evaluated the risk of MFUP, reinfarction and significant inhospital haemorrhage. Observing the survival curves (Kaplan-Meier) we found that the combination of GRACE/CRUSADE increased the discriminatory power for MFUP, with G4 patients showing marked decreased in survival when compared to G2 or G3. Moreover, a predictor model for MFUP (Cox) documented that CRUSADE adds mortality predictive value to GRACE score. As for the bleeding endpoint, the risk increases significantly in G4 patients when compared to the other groups (G4: 13.1% vs. remaining groups: 6.6%, HR 2.3,p<0.001). View this table: Mortality risk assessment by GRACE score is strongly complemented by CRUSADE bleeding risk score. In parallel, GRACE increased the predictive capacity for significant bleeding provided by CRUSADE. Moreover, the combination of these 2 risk models may facilitate patient selection to more appropriate management and dosages of antiplatelet and/or anticoagulation therapies.