Adverse In-hospital Outcome In Patients Research Articles

Echocardiography and CHA2DS2-VASc-HS score with adverse in-hospital outcomes in patients with non-st segment elevation myocardial infarction

Background After myocardial infarction, optimal clinical management depends critically on Echocardiography. Echocardiography is a versatile imaging modality for the management of patients with chest pain and assessment of left ventricular systolic function, diastolic function, and even myocardial and coronary perfusion which provides information regarding cardiac function and hemodynamics. Remodelling and heart failure, presence of inducible ischaemia, presence of dysfunctional viable myocardium, future risk of adverse events including risk of ventricular arrhythmias, need for anticoagulation, and other questions should be addressed. But it has some limitations. A clinical scoring is compared with echocardiography. Early detection of patients with non-ST segment elevation myocardial infarction (NSTEMI) who would suffer from adverse in-hospital outcomes is important for the therapeutic decision. Recently it was described that CHA2DS2-VASc-HS and CHA2DS2-VASc score is a predictor for severity and adverse in-hospital outcomes in patients with stable coronary artery disease (CAD) and acute coronary syndrome. The aim of our study was to assess the accuracy of the CHA2DS2-VASc-HS score predicting adverse in-hospital outcomes in NSTEMI patients. Methods 120 patients with NSTEMI were enrolled in this study. The CHA2DS2-VASc-HS score was calculated. The study subjects were divided into two groups. Patients’ with CHA2DS2-VASc-HS score > 4 were put into group I and score≤ 4 into group II. They were treated as per hospital treatment protocol and followed-up for adverse in-hospital outcomes (Heart failure, cardiogenic shock, recurrent ischemic pain, significant arrhythmia and death). Results It was observed that, patients with CHA2DS2-VASc-HS score > 4 had more adverse in-hospital outcomes than CHA2DS2-VASc-HS score ≤ 4 (20% vs. 3.3%, p = 0.01). Group I patients developed cardiogenic shock 10%, heart failure 4%, recurrent ischemia 11.7%, significant arrhythmia 1.7% and death 1.7% than group II patients (1.7%, 3.3%, 3.3%, 0% and 0% respectively). By risk measurement, CHA2DS2-VASc-HS score > 4 emerged as a risk factor for developing adverse in-hospital outcome (Relative risk = 6). Conclusion NSTEMI patients with high CHA2DS2-VASc-HS score have more adverse in-hospital outcomes. This score, which involves only clinical parameters, can be used as a predictor of outcomes in this group of patients.

Positive T wave in lead aVR as an independent predictor for 1-year major adverse cardiac events in patients with first anterior wall ST-segment elevation myocardial infarction.

Positive T wave in lead aVR has been shown to predict an adverse in-hospital outcome in patients with anterior wall ST-segment elevation myocardial infarction (STEMI). However, the prognostic value of positive T wave in lead aVR on a long-term outcome has not been fully explored. We performed a retrospective analysis of 190 consecutive patients with first anterior wall STEMI who underwent an emergent coronary angiogram. Patients were divided into those with positive T wave>0mV and those with negative T wave≦0mV in lead aVR. Baseline and angiographic characteristics, and in-hospital revascularization procedures were recorded. In addition, in-hospital and 1-year major adverse cardiac events (MACE) including death, recurrent myocardial infarction, and target vessel revascularization were recorded. Among 190 patients, 37 patients (19%) had positive T wave and 153 patients (81%) had negative T wave in lead aVR. Patients with positive T wave had higher rate of left main disease defined as stenosis ≥50% (11% vs. 2%, p=.028) than those with negative T wave. Patients with positive T wave had higher rate of 1-year MACE (38% vs. 13%, p<.001) driven by higher all-cause mortality (27% vs. 5%, p<.001). Positive T wave was an independent predictor for 1-year MACE (OR 2.74; 95% CI 1.04-7.15; p=.04). Positive T wave in lead aVR was an independent predictor for 1-year MACE in patients with first anterior wall STEMI.

Third heart sound in hospitalised patients with acute heart failure: insights from the ATTEND study.

Several previous studies have suggested that detection of a third heart sound (S3) in patients with chronic congestive heart failure is associated with adverse long-term outcomes. However, the short-term prognostic value of identifying an S3 on admission in patients with acute heart failure (AHF) is not well established. We therefore analysed the in-hospital prognostic value of detecting an S3 on admission in hospitalised patients with AHF. The Acute Decompensated Heart Failure Syndromes (ATTEND) study investigators enrolled 4107 patients hospitalised with AHF. Investigators evaluated the presence or absence of an S3 during routine physical examination. On admission to hospital, 1673 patients (41%) had an S3. Patients with an S3 had a higher heart rate, higher serum level of B-type natriuretic peptide and higher creatinine levels than patients without an S3. However, there were no significant differences of systolic blood pressure, serum sodium, haemoglobin, C-reactive protein and total bilirubin between the two groups. Multivariate analysis adjusted for various markers of disease severity revealed that only the presence of an S3 was independently associated with an increase of in-hospital all cause death [adjusted odds ratio (OR), 1.69; 95% confidence interval (CI), 1.19-2.41; p=0.003] and cardiac death (adjusted OR, 1.66; 95% CI, 1.08-2.54; p=0.020) among the congestive physical findings related to heart failure (S3, rales, jugular venous distension and peripheral oedema). Detecting an S3 on admission was independently associated with adverse in-hospital outcomes in patients with AHF. Our findings suggest that careful bedside assessment is clinically meaningful.

Extent of ST-Segment Depression Predicts In- Hospital Outcome in Non ST-Segment Elevation Acute Coronary Syndrome

Background: The presence of ischemic ECG changes on admission has been shown to predict outcome, the relationship between the extent of ECG changes and the risk of cardiac events is still ill defined. The severity of ST-segment depression on admission ECG has a strong association with adverse in-hospital outcome in patients with non ST-segment elevation acute coronary syndrome. The study was done to observe the extent of ST-segment depression and in-hospital outcome in patients with non ST-segment elevation acute coronary syndrome. Methods: This study was conducted in the Department of Cardiology in NICVD Dhaka, from January 2006 to December 2007. Considering inclusion and exclusion criteria, a total of 183 patients were evaluated. All the patients were evaluated clinically after admission. ECG, blood biochemistry and echocardiography were done. Patients were categorized into three groups according to the extent of ST- segment depression. Results: In this study, analysis of the baseline parameters revealed no statistically significant difference among the three groups of patients (p&gt;0.05). Mean sum of the ST-segment depression analysis was done and all mean values were more in group III patients. 41.0% patients developed complications during the study period. Acute LVF (22.9%) was the most common complication followed by arrhythmia (11.5%), cardiogenic shock (4.4%) and STEMI (2.2%). All the complications were more in group III patients. During this period 6% patients died and more death (12.3%) was observed in group III patients. Conclusion: The amount of ST-segment depression is a powerful predictor of adverse in-hospital outcome in patients with non ST-segment elevation acute coronary syndrome DOI: http://dx.doi.org/10.3329/cardio.v5i1.12275 Cardiovasc. j. 2012; 5(1): 62-66

Pulmonary Embolism in Heart Failure

Case Presentation: A 71-year-old man with coronary artery disease, left ventricular (LV) systolic dysfunction (ejection fraction, 30%), and recent admission for heart failure presented with acute dyspnea and hypoxemia. A pro-brain–type natriuretic peptide level was elevated at 2450 pg/mL (normal <350 pg/mL). Chest x-ray demonstrated cardiomegaly and small bilateral pleural effusions. After an hour of diuresis, the patient developed systemic arterial hypotension and worsened hypoxemia, prompting cardiology consultation. Based on the absence of rales on physical examination and lack of pulmonary edema on chest x-ray, an alternative diagnosis of pulmonary embolism (PE) was suggested, and contrast-enhanced chest tomography (CT) was obtained. Chest CT demonstrated large bilateral proximal PE. Venous thromboembolism (VTE), which encompasses deep vein thrombosis and PE, is an increasingly common and challenging complication of heart failure. The relative risk of PE is at least double that of patients without heart failure and increases as LV systolic function declines.1 PE patients with heart failure have a higher overall mortality rate than those without heart failure (17% versus 10%).2 In addition, PE is an independent predictor of death or rehospitalization among heart failure patients.3 ### Risk Factors Heart failure patients often have a high medical acuity and multiple risk factors that amplify the risk of VTE.4 The increased risk of VTE observed with heart failure itself has been attributed to reduced flow caused by low cardiac output and abnormalities of hemostasis, platelet function, and endothelial function. Central venous catheters and leads from implantable cardiac defibrillators and pacemakers are common among heart failure patients and have been shown to increase the risk of upper-extremity deep vein thrombosis. Heart failure patients tend to be older, and VTE in the elderly is problematic.5 ### Hemodynamics Acute PE increases pulmonary vascular resistance and right ventricular (RV) afterload through direct physical obstruction, hypoxemia, and pulmonary …

Diagnosis and prognosis of acute pulmonary embolism: focus on serum troponins

Pulmonary embolism is a common disease associated with high mortality. Death due to pulmonary embolism occurs mainly before hospital admission or in the first hours of the hospital stay. Prompt diagnosis and prognostic stratification and more intensive treatment in patients with estimated high risk for adverse outcomes have the potential to reduce mortality due to pulmonary embolism. Significant advances have recently been made in the risk stratification for adverse outcomes in patients with pulmonary embolism and normal blood pressure. In these patients, right ventricle overload assessed by echocardiography and probably by helical computerized tomography is a predictor of in-hospital mortality. Serum troponin is rapidly available in the emergency room, and has a critical role in the management of patients with acute coronary syndromes. The role of serum troponin in patients with pulmonary embolism has been explored recently: it seems to be marginal in diagnosis while it can significantly contribute to prognostic stratification. Elevated serum levels of troponins are associated with right ventricular overload and adverse in-hospital outcomes in patients with pulmonary embolism and normal blood pressure.

Troponin I and right ventricular dysfunction for risk assessment in patients with nonmassive pulmonary embolism in the Emergency Department in combination with clinically based risk score

To determine whether troponin I (cTnI) and right ventricular (RV) dysfunction predict adverse in-hospital outcomes in patients admitted to the Emergency Department (ED) with definite nonmassive pulmonary embolism (PE) independent of and in addition to a recently validated clinical prognostic risk score. From a pool of 168 patients with suspected PE, 89 had nonmassive PE confirmed by spiral lung angio-computed tomography. By the clinical prognostic score, in our study sample, 14% had very low risk; 17% had low risk, 20% had intermediate risk, whereas high risk and very high risk were identified in 29 and 20%, respectively. Prevalence of elevated cTnI (>0.1 microg/L, 57%) at admission was comparable among patients grouped by clinical prognostic score (P = NS); echocardiographic RV dysfunction (54%) was more prevalent with intermediate or high clinical risk score (P < 0.02). Increased cTnI predicted primary end-point (development of hemodynamic instability, overall 33 cases, 37%) independent of and in addition to the clinical risk class and RV dysfunction (P < 0.01 for interaction). Fatal events (12 cases, 14%, 5 definite, 7 possible PE-related) were predicted by higher clinical risk score (P < 0.05). In patients with nonmassive central PE admitted to the ED, increased cTnI contributed to identifying those with increased risk of development of hemodynamic instability independent of and in addition to a validated clinically based risk score.

Acute pulmonary embolism: risk stratification in the emergency department

Pulmonary embolism is a common disease associated with a high mortality rate. Death due to pulmonary embolism occurs more commonly in undiagnosed patients before hospital admission or during the initial in-hospital stay. Thus, mortality could be reduced by prompt diagnosis, early prognostic stratification and more intensive treatment in patients with adverse prognosis. Mortality is particularly high in patients with pulmonary embolism presenting with arterial hypotension or cardiogenic shock. In patients with pulmonary embolism and normal blood pressure, a number of clinical features and objective findings have been associated with a high risk of adverse in-hospital outcome. Advanced age and concomitant cardiopulmonary disease are clinical risk factors for in-hospital mortality. The Bburden of thromboembolism, as assessed by lung scan or spiral CT, and right ventricle overload, as assessed by echocardiography and probably spiral CT, have been claimed to be risk factors for in-hospital mortality. Elevated serum levels of troponins have been shown to be associated with right ventricular overload and adverse in-hospital outcomes in patients with pulmonary embolism. Despite the currently available evidence, no definite prognostic value can be assigned to any of the individual risk factors or cluster of them. Large prospective trials should be carried out to validate individual risk factors or clusters of risk factors able to identify patients with acute pulmonary embolism at high risk for in-hospital mortality. These patients could afford the trade-off of an increased risk of side effects related to a more aggressive treatment, such as thrombolysis or surgical or interventional procedures.

Transient myocardial ischemia is an independent predictor of adverse in-hospital outcomes in patients with acute coronary syndromes treated in the telemetry unit

Objective: The purpose of this study was to determine whether transient myocardial ischemia (TMI) is predictive of adverse in-hospital outcomes among patients admitted to a telemetry unit with acute coronary syndrome (ACS). Design and Setting: The study was designed as a prospective clinical trial in a telemetry unit of a large, urban, university medical center. Sample: The sample was comprised of adult patients admitted to the telemetry unit for treatment of acute myocardial infarction, unstable angina, or coronary artery disease warranting cardiac catheterization or percutaneous coronary intervention. Methods: Continuous 12-lead electrocardiographic (ECG) ST-segment monitoring was initiated in patients admitted to the telemetry unit. TMI was defined as a change in ST amplitude of ≥ 100 μV (elevation or depression) in ≥ 1 ECG lead lasting ≥ 60 seconds, comparing a baseline 12-lead ECG with an event ECG. Frequencies, measurements of central tendency, t test, χ2 test, and logistic regression analysis were used for data analysis. A P value of <.05 was adopted as the critical value to determine statistical significance. Results: In 237 telemetry unit patients, 39 patients (17%) had ischemia. Overall, 46% of the patients with ischemia had in-hospital complications compared with 10% of the group without ischemia (P <.001). After controlling for other predictors of adverse outcomes (eg, age, gender, Norris prognostic indicator), patients with TMI were 8.5 times more likely to have in-hospital complications (95% CI, 3.71 to 19.71). Conclusion: TMI is an independent predictor of in-hospital complications among patients with ACS treated in the telemetry unit setting. Continuous 12-lead ECG ST-segment monitoring provides prognostic information for risk stratification of patients admitted to the hospital for treatment of ACS. (Heart Lung® 2003;32:71-78.)

Risk Factors for Adverse Short-Term Outcome in Patients with Pulmonary Embolism

Pulmonary embolism (PE) is a common and potentially fatal disease. Death usually occurs before hospital admission or in the initial in-hospital phase. A number of clinical and instrumental findings have been associated with a high risk of adverse short-term clinical outcomes in patients with PE. Advanced age, concomitant cardiopulmonary disease, and haemodynamic instability, as well as large perfusion defects at lung scanning and acute right heart dysfunction as assessed by echocardiography, are associated with adverse in-hospital outcome. Elevated serum levels of troponin I have been recently demonstrated to be associated with severe right ventricular dysfunction and adverse in-hospital outcome in patients with PE. Early recurrence of PE is associated with a high mortality rate. Right heart dysfunction, as assessed by echocardiography and an acute fall in platelet count, have been suggested as risk factors for recurrence of PE. A reduction in mortality in the subgroup of patients with a poor prognosis might be achieved by using more aggressive treatments such as thrombolysis and surgical or interventional procedures. However, such treatments are invariably associated with bleeding and other procedural complications.