Abstract: OBJECTIVES: Echocardiography is a fundamental tool in the diagnosis of acute left ventricular heart failure (aLVHF). However, a consultative exam is not routinely available in every emergency department (ED). The authors investigated the diagnostic performance of emergency Doppler echocardiography (EDecho) performed by emergency physicians (EPs) for the diagnosis of aLVHF in patients with acute dyspnea. METHODS: A convenience sample of acute dyspneic patients was evaluated. For each patient, the Boston criteria score for heart failure was calculated, and N-terminal prohormone brain natriuretic peptide (NT-proBNP) and EDecho were contemporaneously performed. Four investigators, after a limited echocardiography course, performed EDechos and evaluated for a "restrictive" pattern on pulsed Doppler analysis of mitral inflow and reduced left ventricular (LV) ejection fraction. The final diagnosis, established after reviewing all patient clinical data except NT-proBNP and EDecho results, served as the criterion standard. RESULTS: Among 145 patients, 64 (44%) were diagnosed with aLVHF. The median time needed to perform EDecho was 4 minutes. Pulsed Doppler analysis was feasible in 125 patients (84%). The restrictive pattern was more sensitive (82%) and specific (90%) than reduced LV ejection fraction and more specific than the Boston criteria and NT-proBNP for the diagnosis of aLVHF. Considering noninterpretable values of the restrictive pattern and uncertain values ("gray areas") of Boston criteria (4 < Boston criteria score < 7) and of NT-proBNP (300 < NT-proBNP < 2,200 pg/mL) as false results, the accuracy of the restrictive pattern in the overall population was 75%, compared with accuracy of 49% for both NT-proBNP and Boston criteria. CONCLUSIONS: EDecho, particularly pulsed Doppler analysis of mitral inflow, is a rapid and accurate diagnostic tool in the evaluation of patients with acute dyspnea.
Abstract: OBJECTIVES: To evaluate the accuracy and safety of an emergency duplex ultrasound (EDUS) evaluation performed by emergency physicians in the emergency department. METHODS: Consecutive adult patients suspected of having their first episode of deep vein thrombosis (DVT) presenting to the emergency department were included in the study. All examinations were performed by emergency physicians trained with a 30-hour ultrasound course. Based on EDUS findings, patients were classified into one of three groups: normal, abnormal, and uncertain. Patients with abnormal and uncertain findings were initially treated as having a DVT. Patients with normal EDUS findings were discharged from the emergency department without anticoagulant therapy. A formal duplex ultrasound evaluation was repeated by a radiologist in all patients within 24-48 hours. Patients with normal findings on duplex ultrasound evaluation were followed up for symptomatic venous thromboembolism for up to one month. RESULTS: A total of 399 patients were studied. The EDUS findings were normal in 301 (75%), abnormal in 90 (23%), and uncertain in eight (2%). All abnormal test results were confirmed by the formal duplex ultrasound evaluation, and three patients (0.8%) with uncertain findings on EDUS examination were subsequently diagnosed as having a distal DVT (positive predictive value, 95% [95% confidence interval, 92% to 95%]; negative predictive value, 100% [95% confidence interval = 99% to 100%]). No patients with normal findings on EDUS examination died or experienced venous thromboembolism at the one-month follow-up. CONCLUSIONS: EDUS examination yielded a high negative predictive value and good positive predictive value, allowing rapid discharge and avoiding improper anticoagulant treatment.
Abstract: BACKGROUND: In patients with acute pulmonary embolism, right ventricular dysfunction (RVD) on hospital admission is a predictor of adverse short-term clinical outcome. The aim of this study was to evaluate the prognostic value of RVD persistence at hospital discharge with regard to the likelihood of recurrent venous thromboembolism (VTE). METHODS: Echocardiography was used to assess RVD on admission and before hospital discharge in 301 consecutive patients with the first episode of acute pulmonary embolism occurring from January 1998 through July 2004. Right ventricular dysfunction was diagnosed in the presence of 1 or more of the following: right ventricular dilation (without hypertrophy), paradoxical septal systolic motion, and Doppler evidence of pulmonary hypertension. Patients were followed up at 2, 6, and 12 months and yearly thereafter. The primary end point was symptomatic, recurrent fatal or nonfatal VTE. RESULTS: Patients were categorized as those (1) without RVD (155 patients [51.5%]), (2) with RVD regression (RVD on admission but not at discharge; 87 patients [28.9%]), and (3) with persistent RVD (RVD on admission and at discharge; 59 patients [19.6%]). After a mean +/- SD of 3.1 +/- 2.7 years, patients with RVD persistence showed an increased risk of recurrent VTE (14 patients, 9.2% patient-years) compared with those without RVD (15 patients, 3.1% patient-years) or RVD regression (3 patients, 1.1% patient-years) (P = .001). Six of 8 deaths related to pulmonary embolism occurred in patients with RVD persistence. At multivariate analysis, adjusted by anticoagulant treatment duration, RVD persistence was an independent predictor of recurrent VTE (hazard ratio, 3.79; P<.001). CONCLUSION: Persistent RVD at hospital discharge after an acute pulmonary embolism is associated with recurrent VTE.
Abstract: The risk of overlooking an underlying acute coronary syndrome remains an important challenge in patients complaining of chest pain but who have a non-diagnostic ECG (CP). Indeed, myocardial scintigraphy associated with exercise testing (exercise SPET) represents a valuable tool for excluding coronary artery disease (CAD) especially in patients with CP and delayed presentation to the emergency department. We sought to implement diagnoses of CAD in the early triage of CP patients by exercise gated SPET and compare diagnoses with outcomes. A total of 306 consecutive patients presenting with CP were found to be free of CAD at first line work-up including clinical evaluation, markers of myocardial injury and echocardiogram. These patients were studied initially with exercise SPET, and those with perfusion defects underwent angiography, while those with normal scans were discharged and followed up. Patients with positive scans (34%, n=105) had documented coronary stenoses in 43% (n=45); patients with negative scans (66%, n=201) had evidence of non-fatal coronary events at 6 months in 1.5% (n=3). When imaging was analysed with gating by the presence of transmural perfusion defects associated with wall motion abnormalities (n=86), only one patient, among 19 excluded, was recognized as having coronary stenosis by angiography (SPET vs gated SPET: negative predictive value 98.5% and 98%, respectively, P=NS; diagnostic accuracy 79% and 85%, respectively; P< or =0.03). Therefore, implementation of myocardial perfusion imaging in the early triage of patients with suspected acute coronary syndromes was effectively obtained by early exercise gated SPET, especially in patients with transmural myocardial perfusion defects associated with wall motion abnormalities.
Abstract: In this study, we screened a total of 6723 consecutive patients with chest pain and ECG non-diagnostic for acute myocardial infarction (AMI) on presentation to the emergency department (ED). The aim of the study was to avoid missed AMI, improve safe early discharge and reduce inappropriate coronary care unit (CCU) admission. Chest pain patients were triaged using a clinical chest pain score and managed in a chest pain unit (CPU). Patients with a low clinical chest pain score were considered at very 'low-risk' for cardiovascular events and discharged from the ED; patients with a high chest pain score were submitted to CPU management. Observation and titration of serum markers of myocardial injury were obtained up to 6 hours. Rest or stress myocardial scintigraphy (SPECT) was performed in patients > 40 years or with > or = 2 major coronary risk factors. Exercise Tolerance Test (ETT) or Stress-Echocardiogram (stress-Echo) were performed in younger patients or with < 2 coronary risk factor, or unable to exercise, respectively We discharged directly from the ED the majority of patients (4454; 66%): in this group there was only a 0.2% final diagnosis of coronary artery disease (CAD) at follow-up. The remaining 34% of patients, with non-diagnostic or normal ECG, were managed in the CPU. In this group, 1487 patients (representing 22% of the overall study group) were found positive for CAD, two-thirds because of delayed ECG or serum markers of myocardial injury, and one-third by Echo, SPECT or ETT. In conclusion, CPU based management allowed 22% early detection of myocardial ischaemia and 78% early discharge from the ED avoiding inappropriate CCU admission and optimizing the use of urgent angiography.
