Cause Of Acute Dyspnea Research Articles

Management challenges of tension bullae in the emergency department: a case report and literature review

Background: Patients with chronic obstructive pulmonary disease (COPD) are at risk for tension bullae, potentially leading to tension pneumothorax. Distinguishing tension bullae from tension pneumothorax in acutely dyspneic COPD patients is essential but challenging. A case was presented where chest tube placement in a tension bulla provided initial benefit but resulted in a bronchopleural fistula. Case Presentation: A middle-aged male with COPD presented to the Emergency Department with severe dyspnea. History, bedside ultrasound, and chest radiograph suggested tension bulla or tension pneumothorax. CT was done which confirmed tension bulla. Despite bullectomy being the preferred treatment, clinical deterioration necessitated urgent chest tube placement, leading to rapid improvement. However, two days later, a bronchopleural fistula developed, requiring thoracotomy. Conclusion: Emergency physicians must be aware of tension bullae as a rare cause of acute dyspnea in COPD. This case underscores the need for specific management protocols, potentially including smaller diameter catheters for stabilization before definitive surgical treatment.

Diagnostic Utility of NT-Pro BNP in Elderly Patients Presenting With Acute Dyspnea in Emergency Department

ABSTRACT
 BACKGROUND: Acute dyspnea may be related to lungs pathology or cardiac pathology or due to involvement of both. Rapid diagnosis of the cause of dyspnea in emergency can help in early start of treatment preventing further progress of the symptoms, prolong hospital stay, need of more invasive medical procedures like intubation and ventilation thereby decrease the morbidity and mortality of the patients.
 METHODOLOGY: The study was conducted for three months i.e, from 16th May 2023 till 17th August 2023. 150 patients fulfilling inclusion criteria were taken. Clinical diagnosis in these patients was established based on medical history as well as echo and chest X-ray. Based on their clinical diagnosis, the patients were divided into three groups: group A diagnosed with pulmonary dyspnea (PD), group B diagnosed with congestive heart failure (CHF), and group C diagnosed with combined dyspnea (CHF+PD). NT-proBNP level in these patients was measured and compared.
 RESULTS: The study population constituted 60% males and 40% female with mean age of 68.9±10.99. Out of 150 patients presenting with acute dyspnea in emergency department, 65 patients were diagnosed with congestive heart failure, 55 patients were diagnosed with pulmonary dyspnea and 30 patients diagnosed with combined dyspnea. Average NT-proBNP among group A patients was (1300±175) ng/l, among group B patients was (275±70) ng/l and among group C patients was (1276±165) ng/l.
 CONCLUSION: NT-proBNP is the reliable marker to differentiate the cardiac and pulmonary causes of acute dyspnea among elderly patients presenting to emergency.
 
 KEY WORDS: N-terminal pro-B-type natriuretic peptide (NT-proBNP), emergency, elderly patients, dyspnea, biomarker

Clinical effect of renal dysfunction on diagnostic and prognostic accuracy of B-type Natriuretic Peptide and N-terminal Pro-B-type Natriuretic Peptide for acute heart failure

Abstract Background Acute heart failure (AHF) continues to have unacceptable high rates of mortality and morbidity. Therefore, accurate and rapid diagnosis of AHF is crucial for the early initiation of effective treatment. Previous studies have shown that plasma concentrations of B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) increase with declining renal function and that renal dysfunction seems to decrease the accuracy of BNP and NT-proBNP in the diagnosis of AHF. Purpose We aimed to directly compare the diagnostic and prognostic accuracy of BNP and NT-proBNP in patients presenting with acute dyspnea, including the effect of renal function. Methods This prospective diagnostic study enrolled unselected patients presenting with acute dyspnea to the emergency department. The final diagnosis was centrally adjudicated by two independent cardiologists using all information including imaging and follow-up. BNP and NT-proBNP plasma levels were determined at presentation. 360 days all-cause mortality was the primary prognostic end point. Results Among 1579 patients, acute heart failure (AHF) was the adjudicated final diagnosis in 865 patients (54.8%). Plasma concentrations of both BNP and NT-proBNP were significantly higher in AHF as compared to other causes of acute dyspnea (both p<0.001). Diagnostic accuracy as quantified by the area under the receiver-operating-characteristics curve (AUC) was 0.948 (95% CI 0.938-0.958) for BNP as compared to 0.921 (95% CI 0.908-0.935) for NT-proBNP, p<0.001. The diagnostic superiority of BNP was consistent among predefined subgroups according to renal function and increased with the extent of renal dysfunction (Figure 1: all patients (A), patients with eGFR≥ 60 ml/min/1,73 m² (B), patients with eGFR 30-59 ml/min/1,73 m² (C), patients with eGFR <30ml/min/1,73 m² (D)). In contrast, prognostic accuracy for the prediction of death at 360 days was higher for NT-proBNP (AUC 0.731, 95% CI 0.702-0.760 versus 0.706, 95%CI 0.676-0.736 for BNP; p<0.001). The diagnostic superiority of NTproBNP was consistent among predefined subgroups according to renal function but decreased with the extent of renal dysfunction. Conclusion In patients with acute dyspnea, BNP and NT-proBNP at presentation both have very high diagnostic accuracy for AHF and moderate prognostic accuracy for death. There is a numerically small, but statistically and possibly also clinically significant diagnostic superiority of BNP and prognostic superiority of NT-proBNP.Diagnostic accuracy for AHF

Does point of care ultrasonography help determine the cause of acute dyspnea in adults?

Does point of care ultrasonography help determine the cause of acute dyspnea in adults?

Imaging in patients with acute dyspnea when cardiac or pulmonary origin is suspected.

A wide spectrum of conditions, from life-threatening to non-urgent, can manifest with acute dyspnea, thus presenting major challenges for the treating physician when establishing the diagnosis and severity of the underlying disease. Imaging plays a decisive role in the assessment of acute dyspnea of cardiac and/or pulmonary origin. This article presents an overview of the current imaging modalities used to narrow the differential diagnosis in the assessment of acute dyspnea of cardiac or pulmonary origin. The current indications, findings, accuracy, and limits of each imaging modality are reported. Chest radiography is usually the primary imaging modality applied. There is a low radiation dose associated with this method, and it can assess the presence of fluid in the lung or pleura, consolidations, hyperinflation, pneumothorax, as well as heart enlargement. However, its low sensitivity limits the ability of the chest radiograph to accurately identify the causes of acute dyspnea. CT provides more detailed imaging of the cardiorespiratory system, and therefore, better sensitivity and specificity results, but it is accompanied by higher radiation exposure. Ultrasonography has the advantage of using no radiation, and is fast and feasible as a bedside test and appropriate for the assessment of unstable patients. However, patient-specific factors, such as body habitus, may limit its image quality and interpretability. Advances in knowledge This review provides guidance to the appropriate choice of imaging modalities in the diagnosis of patients with dyspnea of cardiac or pulmonary origin.

Lung ultrasound for evaluation of dyspnea: a pictorial review.

Lung ultrasound is based on the analysis of ultrasound artifacts generated by the pleura and air within the lungs. In recent years, lung ultrasound has emerged as an important alternative for quick evaluation of the patient at the bedside. Several techniques and protocols for performing lung ultrasound have been described in the literature, with the most popular one being the Bedside Lung Ultrasound in Emergency (BLUE) protocol which can be utilized to diagnose the cause of acute dyspnea at the bedside. We attempt to provide a simplified approach to understanding the physics behind the artifacts used in lung ultrasound, the imaging techniques, and the application of the BLUE protocol to diagnose the commonly presenting causes of acute dyspnea.

A Novel Diagnostic Decision Support System for Medical Professionals: Prospective Feasibility Study

BackgroundContinuously growing medical knowledge and the increasing amount of data make it difficult for medical professionals to keep track of all new information and to place it in the context of existing information. A variety of digital technologies and artificial intelligence–based methods are currently available as persuasive tools to empower physicians in clinical decision-making and improve health care quality. A novel diagnostic decision support system (DDSS) prototype developed by Ada Health GmbH with a focus on traceability, transparency, and usability will be examined more closely in this study.ObjectiveThe aim of this study is to test the feasibility and functionality of a novel DDSS prototype, exploring its potential and performance in identifying the underlying cause of acute dyspnea in patients at the University Hospital Basel.MethodsA prospective, observational feasibility study was conducted at the emergency department (ED) and internal medicine ward of the University Hospital Basel, Switzerland. A convenience sample of 20 adult patients admitted to the ED with dyspnea as the chief complaint and a high probability of inpatient admission was selected. A study physician followed the patients admitted to the ED throughout the hospitalization without interfering with the routine clinical work. Routinely collected health-related personal data from these patients were entered into the DDSS prototype. The DDSS prototype’s resulting disease probability list was compared with the gold-standard main diagnosis provided by the treating physician.ResultsThe DDSS presented information with high clarity and had a user-friendly, novel, and transparent interface. The DDSS prototype was not perfectly suited for the ED as case entry was time-consuming (1.5-2 hours per case). It provided accurate decision support in the clinical inpatient setting (average of cases in which the correct diagnosis was the first diagnosis listed: 6/20, 30%, SD 2.10%; average of cases in which the correct diagnosis was listed as one of the top 3: 11/20, 55%, SD 2.39%; average of cases in which the correct diagnosis was listed as one of the top 5: 14/20, 70%, SD 2.26%) in patients with dyspnea as the main presenting complaint.ConclusionsThe study of the feasibility and functionality of the tool was successful, with some limitations. Used in the right place, the DDSS has the potential to support physicians in their decision-making process by showing new pathways and unintentionally ignored diagnoses. The DDSS prototype had some limitations regarding the process of data input, diagnostic accuracy, and completeness of the integrated medical knowledge. The results of this study provide a basis for the tool’s further development. In addition, future studies should be conducted with the aim to overcome the current limitations of the tool and study design.Trial RegistrationClinicalTrials.gov NCT04827342; https://clinicaltrials.gov/ct2/show/NCT04827342

PoCUS: Just because we can doesn't mean we should.

PoCUS: Just because we can doesn't mean we should.

Lung Ultrasound B-lines as a Surrogate Marker for High Left Ventricular Diastolic Pressures; a bed-side Diagnostic tool

Background: We studied the diagnostic accuracy of B-lines (comet-tail sign) on bedside lung US, NT-proBNP, E/e` on ECHO in differentiation of the causes of acute dyspnea in the emergency setting. Major advantages include bedside availability, no radiation, high feasibility and reproducibility, and cost efficiency. Methods: Our prospective study was performed at the alazhar university hospital, Cairo, Egypt, between July 2019 and March 2020. All patients underwent lung ultrasound examinations, along with TTE, laboratory testing, including rapid NT-proBNP testing. Results: The median E/e’ levels in patients with B-profile were 18, compared with a median of 7.4 in the subjects with A-profile (P =< 0.0001 CI = -9.649 to -7.044). It was found that the sensitivity and the specificity of detecting B-profile on ultrasound is high when E/e’ > 15.5 (95.0% and 83.0% consecutively), which concluded the high correlation between finding B profile on U/S chest and elevated left ventricle filling pressure in a patient presenting with picture of suggestive of heart failure Conclusion: Chest ultrasound can be used as screening test for the evaluation of patients with suspicion of heart failure with excellent sensitivity and good specificity.

Ultrasound guiding the rapid diagnosis and treatment of perioperative pneumothorax: A case report

BACKGROUNDPneumothorax is one of the most common causes of acute dyspnea. In patients under general anesthesia, the symptoms may not be obvious, which may delay diagnosis and treatment. Computed tomography is the gold standard for the diagnosis of pneumothorax, but is not suitable for rapid diagnosis of this complication. In contrast, lung ultrasonography can provide rapid diagnosis and treatment of pneumothorax.CASE SUMMARYThe patient was a 53-year-old man admitted for rupture of the spleen caused by an accidental fall and emergency splenectomy was planned. Anesthesia was induced, and tracheal intubation was performed successfully with a video laryngoscope. About 2 min after tracheal intubation, the airway peak pressure increased to 50 cm H2O and the oxygen saturation dropped to 70%. According to the BLUE protocol, a recommended area of the chest was scanned by ultrasound. The pleural slide sign disappeared and obvious parallel line sign could be seen in the left lung. The boundary of pneumothorax (lung points) were rapidly confirmed by ultrasound. To avoid lung injury, a closed thoracic drainage tube was placed in the involved area. On day 9 after surgery, the patient was discharged from the hospital without any complications.CONCLUSIONPerioperative pneumothorax is rare but dangerous. It can be rapidly diagnosed and treated with ultrasound guidance.

ACUTE RESPIRATORY DISTRESS: A RARE PRESENTATION OF URETERAL RUPTURE

TOPIC: Signs and Symptoms of Chest Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cardiorespiratory disorders usually present with acute respiratory distress; likewise, ureteral rupture usually presents as an acute abdomen [1]. We report a case of ureteral rupture presenting with acute respiratory distress leading to a delayed diagnosis. CASE PRESENTATION: An 82 y/o M with a history of congestive heart failure (CHF), chronic obstructive pulmonary disease, chronic renal failure and recently diagnosed COVID -19 pneumonia, was admitted for progressive dyspnea and abdominal discomfort for 2 days. Arterial blood gas showed hypercapnic hypoxic respiratory failure. Chest computed tomographic (CT) scan without contrast showed moderate right-sided pleural effusion but pulmonary embolism (PE) could not be ruled out. He also had a left leg deep venous thrombosis with worsening renal function and B-type natriuretic peptide (BNP) of 139pg/ml.His symptoms were thought to be due to acute decompensated CHF, COVID-19 pneumonia and possible PE. He failed to improve with intravenous furosemide, bilevel positive airway pressure ventilation and empiric anticoagulation. Due to worsening renal function and abdominal pain, an abdominal CT was done which showed right ureteral rupture with retroperitoneal collection and multiple non-obstructing renal calculi. The patient had placement of a double J stent with prompt resolution of respiratory distress. DISCUSSION: There are very few case reports of ureteral rupture occurring spontaneously and causing marked dyspnea. Respiratory distress may occur if the extravasated urine leads to an urinothorax or abdominal compartment syndrome [1]. Suspicion of non-cardiorespiratory causes of acute dyspnea in patients with underlying congestive heart failure includes respiratory distress disproportionate to the size of pleural effusion, unilateral effusions or effusions of markedly disparate size, absence of pulmonary vascular congestion and cardiomegaly, worsening renal function, ascites, urinary retention or anuria, abdominal pain, failure of the effusion to respond to management of heart failure, fever or pleuritic chest pain, and low or near-normal natriuretic peptides [2,3].When there are concerns for non-cardiorespiratory causes of respiratory distress, the diagnosis can be made with thoracentesis and imaging such as abdominal ultrasound, or CT [2]. CONCLUSIONS: This case illustrates a rare presentation of ureteral rupture causing respiratory distress and the key points that should elicit high clinical suspicion for non-cardiorespiratory causes of acute respiratory distress. When these findings are present, appropriate investigations and urgent intervention may be life-saving. REFERENCE #1: Choi SK, Lee S, Kim S, et al. A rare case of upper ureter rupture: ureteral perforation caused by urinary retention. Korean J Urol. 2012;53(2):131-133. doi:10.4111/kju.2012.53.2.131 REFERENCE #2: Leonidas Laskaridis, Spyridon Kampantais, Chrysovalantis Toutziaris, Basileios Chachopoulos, Ioannis Perdikis, Anastasios Tahmatzopoulos, Georgios Dimitriadis, "Urinothorax—An Underdiagnosed Cause of Acute Dyspnea: Report of a Bilateral and of an Ipsilateral Urinothorax Case", Case Reports in Emergency Medicine, vol. 2012, Article ID 395653, 3 pages, 2012. https://doi.org/10.1155/2012/395653 REFERENCE #3: Porcel JM. Pleural effusions from congestive heart failure. Semin Respir Crit Care Med. 2010 Dec;31(6):689-97. DOI: 10.1055/s-0030-1269828. Epub 2011 Jan 6. PMID: 21213200. DISCLOSURES: No relevant relationships by sharmela Brijmohan, source=Web Response No relevant relationships by Angelica Medina-Pena, source=Web Response No relevant relationships by Noura Semreen, source=Web Response

Plasma calprotectin in the emergency department: a potential clinical biomarker for patients with infectious diseases

Increased levels of plasma calprotectin are reported in patients with infectious diseases. However, the clinical usefulness of calprotectin as a biomarker to identify patients with infectious diseases in the emergency department (ED) setting has not been investigated. To study the ability of calprotectin to discriminate patients with acute infectious diseases and dyspnea from patients with other causes of acute dyspnea in the ED setting. Patients aged ≥18 years seeking ED during daytime on weekdays between March 2013 and July 2018, with acute dyspnea, were included. Participants (n = 1287) were triaged according to Medical Emergency Triage and Treatment System-Adult score (METTS-A) or Rapid Emergency Triage and Treatment System (RETTS), and blood samples were collected. The association between calprotectin and other markers of infectious diseases, i.e. biomarkers (CRP, leucocytes) and body temperature, was studied. The predictive value of calprotectin for the outcome of acute infection was evaluated with receiver operating characteristic (ROC) analysis. Univariate cross-sectional regression showed significant associations between calprotectin and leucocytes, CRP and body temperature. Patients with severe infections including pneumonia (n = 119) had significantly higher concentrations of calprotectin compared to patients with heart failure (n = 162) or chronic obstructive pulmonary disease (n = 183). When tested for the outcome of acute infection (n = 109), the area under the ROC curve (AUROC) was for CRP 0.83 and for calprotectin 0.78. Plasma calprotectin identifies infectious diseases in ED patients with acute dyspnea, and the clinical usefulness of Calprotectin in the ED has to be further studied.

Readmission following both cardiac and non-cardiac acute dyspnoea is associated with a striking risk of death.

AimsReadmission and mortality are the most common and often combined endpoints in acute heart failure (AHF) trials, but an association between these two outcomes is poorly investigated. The aim of this study was to determine whether unplanned readmission is associated with a greater subsequent risk of death in patients with acute dyspnoea due to cardiac and non‐cardiac causes.Methods and resultsDerivation cohort (1371 patients from the LEDA study) and validation cohort (1986 patients from the BASEL V study) included acute dyspnoea patients admitted to the emergency department. Cox regression analysis was used to determine the association of 6 month readmission and the risk of 1 year all‐cause mortality in AHF and non‐AHF patients and those readmitted due to cardiovascular and non‐cardiovascular causes. In the derivation cohort, 666 (49%) of patients were readmitted at 6 months and 282 (21%) died within 1 year. Six month readmission was associated with an increased 1 year mortality risk in both the derivation cohort [adjusted hazard ratio (aHR) 3.0 (95% confidence interval, CI 2.2–4.0), P < 0.001] and the validation cohort (aHR 1.8, 95% CI 1.4–2.2, P < 0.001). The significant association was similarly observed in AHF (aHR 3.2, 95% CI 2.1–4.9, P < 0.001) and other causes of acute dyspnoea (aHR 2.9, 95% CI 1.9–4.5, P < 0.001), and it did not depend on the aetiology [aHR 2.2, 95% CI 1.6–3.1 for cardiovascular readmissions; aHR 4.1, 95% CI 2.9–5.7 for non‐cardiovascular readmissions (P < 0.001 for both)] or timing of readmission.Conclusion​sOur study demonstrated a long‐lasting detrimental association between readmission and death in AHF and non‐AHF patients with acute dyspnoea. These patients should be considered ‘vulnerable patients’ that require personalized follow‐up for an extended period.

Quantifying inflammation using interleukin-6 for improved phenotyping and risk stratification in acute heart failure

Abstract Background Acute heart failure (AHF) is the most common cause of hospital admission and continues to have unacceptable high rates of mortality and morbidity. In contrast to acute myocardial infarction, the pathophysiology of AHF is incompletely understood and risk-prediction is poorly defined. Aim We aimed to quantify systemic inflammation to assess its possible role in the pathophysiology and risk stratification of patients with AHF. Methods Using a novel Interleukin-6 immunoassay with unprecedented sensitivity (limit of detection 0.01ng/l) we quantified systemic inflammation in unselected patients presenting with acute dyspnea to the emergency department in a multicenter study. Plasma concentrations of NT-proBNP (open label) and Interleukin-6 (blinded) were measured at presentation and at discharge. The final diagnosis of AHF and the AHF phenotype were adjudicated by two independent cardiologists. 1-year mortality was the prognostic endpoint. Results Among 2042 patients, 1026 (50.2%) had an adjudicated diagnosis of AHF. Interleukin-6 concentrations were significantly higher in AHF patients compared to patients with other causes of dyspnoea (11.2 [6.1–26.5] ng/l vs 9.0 [3.2–32.3] ng/l, p&amp;lt;0.0005). Among patients with AHF Interleukin-6 concentrations were elevated (&amp;gt;4.45ng/l) in 83.7% of them. Among the different AHF phenotypes, Interleukin-6 concentrations were highest in patients with cardiogenic shock (25.7 [14.0–164.2] ng/l) and lowest in patients with hypertensive HF (9.3 [4.8–21.6] ng/l, p=0.001). Inflammation as quantified by Interleukin-6 was a strong predictor of 1-year mortality both in AHF as well as in other causes of acute dyspnea (Figure). During in-hospital treatment Interleukin-6 concentrations significantly decreased in AHF patients. However, changes in the extend of systemic inflammation (delta Interleukin-6) were poorly correlated with changes in hemodynamic stress as quantified by NT-proBNP (delta NT-proBNP, Φc=0.11, p=0.004). Conclusions An unexpectedly high percentage of patients with AHF have subclinical systemic inflammation that can be quantified by Interleukin-6, which seems to contribute to the AHF phenotype and to the risk of death. Kaplan Meier curves for mortality Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Swiss National Science Foundation, Swiss Heart Foundation, European Union, Stiftung für kardiovaskuläre Forschung Basel, University of Basel, University Hospital Basel

Acute progressive dyspnea in a patient with chronic obstructive pulmonary disease.

The cause of acute dyspnea in chronic obstructive pulmonary disease is challenging. A 69-year old man complained of dyspnea, and cough. He had a diagnosis of chronic obstructive pulmonary disease for 6 years. Oxygen therapy started for respiratory failure. At the 6 th day of hospitalization, dyspnea progressively increased. Chest x-ray showed a right-sided radiolucency. The preliminary diagnosis was spontaneous pneumothorax but chest CT-scan demonstrated a space-occupying lesion in left main bronchus. The latter diagnosis was mucoid impaction but bronchoscopy revealed a malignant lesion. In conclusions, lung cancer can be a rare cause of acute dyspnea.

Diagnostic and prognostic values of the QRS-T angle in patients with suspected acute decompensated heart failure.

AimsThe aim of this study was to investigate the diagnostic and prognostic utility of the QRS‐T angle, an electrocardiogram (ECG) marker quantifying depolarization–repolarization heterogeneity, in patients with suspected acute decompensated heart failure (ADHF).Methods and resultsWe prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of ADHF. The QRS‐T angle was automatically derived from a standard 12‐lead ECG recorded at presentation. The primary diagnostic endpoint was a final adjudicated diagnosis of ADHF. The primary prognostic endpoint was all‐cause mortality during 2 years of follow‐up. Among the 1915 patients enrolled, those with higher QRS‐T angles were older, were more commonly male, and had a higher rate of co‐morbidities such as arterial hypertension, coronary artery disease, or chronic kidney disease. ADHF was the final adjudicated diagnosis in 1140 (60%) patients. The QRS‐T angle in patients with ADHF was significantly larger than in patients with non‐cardiac causes of dyspnoea {median 110° [inter‐quartile range (IQR) 46–156°] vs. median 33° [IQR 15–57°], P < 0.001}. The diagnostic accuracy of the QRS‐T angle as quantified by the area under the receiver operating characteristic curve (AUC) was 0.75 [95% confidence interval (CI) 0.73–0.77, P < 0.001], which was inferior to N‐terminal pro‐B‐type natriuretic peptide (AUC 0.93, 95% CI 0.92–0.94, P < 0.001), but similar to that of high‐sensitivity troponin T (AUC 0.78, 95% CI 0.76–0.80, P = 0.09). The AUC of the QRS‐T angle for discrimination between ADHF and non‐cardiac dyspnoea remained similarly high in subgroups of patients known to be diagnostically challenging, including patients older than 75 years [0.71 (95% CI 0.67–0.74)], renal failure [0.79 (95% CI 0.71–0.87)], and atrial fibrillation at presentation [0.68 (95% CI 0.60–0.76)]. Mortality rates according to QRS‐T angle tertiles were 4%, 6%, and 10% after 30 days (P < 0.001) and 24%, 31%, and 43% after 2 years (P < 0.001). After adjustment for clinical, laboratory, and ECG parameters, the QRS‐T angle remained an independent predictor for 2 year mortality with a 4% increase in mortality for every 20° increase in QRS‐T angle (P = 0.02).ConclusionsThe QRS‐T angle is a readily available and inexpensive marker that can assist in the discrimination between ADHF and non‐cardiac causes of acute dyspnoea and may aid in the risk stratification of these patients.

P5412Prevalence of RV failure assessed by echocardiography in acute dyspnoea cohort

Abstract Introduction Recently more attention has been placed on right ventricle (RV) parameters in acute settings. The present study investigates echocardiographic RV parameters in patients with acute heart failure (AHF) or non-AHF acute dyspnoea. Purpose To determine the patterns of RV injury in different profiles of acute dyspnoea. Methods Prospective multicentre observational study included 1455 acutely dyspnoeic patients from 2015 to 2017. RV focused echocardiography was performed during the first 48 hours in 452 (31%) patients. They were compared in three patient profiles based on cause of dyspnoea and history of chronic HF (CHF): 1) AHF; 2) Non-AHF with CHF (Non-AHF+CHF); 3) other non-AHF patients (Non-AHF+other). Results Significant differences in RV morphology and function were observed in the study groups (Table 1). RV global function assessed by tricuspid annular plane systolic excursion (TAPSE) and RV longitudinal shortening was mostly affected in AHF patients. This was accompanied by more enlarged RV and increased right atrial pressure (RAP), assessed by the inferior vena cava diameter and respiratory collapse. Less severely impaired RV function and increased RAP were also observed in non-AHF+CHF patients indicating RV involvement in the chronic disease. Normal RV parameters dominated in Non-AHF+other group, however pulmonary artery systolic pressure &gt;40 mmHg was observed in all profiles, suggesting similar severity of pulmonary hypertension in cardiac or pulmonary causes of acute dyspnoea. Table 1. RV parameters in acute dyspnoea profiles Parameter AHF (n=291) Non-AHF + CHF (n=73) Non-AHF + other (n=88) p value LVEF, % 38 [25–55] 50 [40–55] 55 [50–55] &lt;0.001 RV basal diameter, cm 4.5 [3.9–5.2] 4 [3.5–4.5] 4 [3.5–4.55] &lt;0.001 TAPSE, cm 1.5 [1.2–1.8] 1.8 [1.6–2] 2 [1.5–2.4] &lt;0.001 RV free wall strain, -% −15.3 [−19; −11.24] −19.3 [−24.5; −15.78] −23 [−24.5; −19.69] &lt;0.001 Entire RV strain, -% −12.03 [−15.17; −9.11] −16.4 [−19.31; −10.5] −18 [−18.75; −16.9] &lt;0.001 PASP &gt;40, % 66% 51% 50% 0.039 IVC diameter, cm 2.4 [2–2.8] 2 [1.7–2.4] 1.8 [1.4–2.3] &lt;0.001 IVC collapse, % 34.9 [19.7–50.2] 44.1 [28.7–59.3] 52.6 [35–72.7] &lt;0.001 LVEF, left ventricular ejection fraction; RV, right ventricle; TAPSE, tricuspid annular plane systolic excursion; PASP, pulmonary artery systolic pressure; IVC, inferior vena cava; AHF, acute heart failure; CHF, chronic heart failure. Conclusions Our data confirm more pronounced acute failure of right ventricle in acute heart failure patients than in chronic heart failure patients admitted due to other causes of dyspnoea. Pulmonary hypertension is present in a majority of the acute dyspnoea patients. Acknowledgement/Funding The work was supported by the Research Council of Lithuania, grant Nr. MIP-049/2015 and approved by Lithuanian Bioethics Committee, Nr. L-15-01.

The relevance of biomarkers in acute heart failure

Biomarkers may help to rapidly differentiate heart failure from noncardiac causes of acute dyspnea. Natriuretic peptides are especially useful for this purpose and should be measured in all patients presenting with acute onset dyspnea. Due to their excellent negative predictive value, anormal serum concentration of natriuretic peptides makes acute heart failure unlikely. Assays exist for B‑type natriuretic peptide (BNP), N‑terminal pro-B-type natriuretic peptide (NT-proBNP) and midregional pro-atrial natriuretic peptide (MR-proANP) with established cut-offs in the acute setting. Importantly, in patients treated with an angiotensin receptor-neprilysin inhibitor (ARNI), NT-proBNP (or MR-proANP) should be used instead of BNP, since the latter is increased by ARNI treatment. Besides their established diagnostic value in heart failure patients, the measurement of natriuretic peptides provides prognostic information and may help in guiding therapy. Additionally, multiple other biomarkers reflect several pathophysiological processes involved in heart failure patients. Their diagnostic and prognostic impact in heart failure needs to be established.

CLINICAL DETERMINANTS OF ANGIOTENSIN CONVERTING ENZYME INHIBITORS/ANGIOTENSIN RECEPTOR BLOCKERS USE IN AN EARLY PHASE AFTER ACUTE HEART FAILURE HOSPITALIZATION

Objective: To investigate which clinical determinants predict the use of angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) in an early phase after acute heart failure (AHF) hospitalization. Design and method: A prospective two-centre observational cohort study enrolled 1433 dyspnoeic patients consecutively admitted to an emergency department. AHF was the cause of acute dyspnoea in 635 patients (44.3%). The mean age was 69.7 ± 12.1; 42% were female. Medication follow up data for 574 and 567 AHF patients were available 1 and 3 months after discharge, respectively. Predictors for ACEi/ARB use were identified by an univariate analysis and multivariate stepwise analysis. Results: The mean systolic blood pressure (SBP) of AHF (n = 635) patients was 139.5 ± 27.8; 59% had a SBP > = 140 mmHg. ACEi/ARB were prescribed in 59.7%, 47.9% and 46.9% of patients at discharge as well as 1 and 3 months after discharge, respectively. SBP of 140 mmHg was identified as a threshold to receive ACEi/ARB at discharge using ROC analysis (area under the curve 0.595). Univariate and independent predictors of ACEi/ARB use are presented in Table 1.Conclusions: Less than half of patients received ACEi/ARB 1 and 3 months after discharge for AHF. SBP, history of hypertension and chronic kidney disease were identified as independent predictors of treatment with ACEi/ARB in an early phase after AHF hospitalization.

NON-INVASIVE ASSESSMENT OF ACUTE DYSPNEA USING LUNG DOPPLER SIGNALS

The diagnosis of acute decompensated heart failure (ADHF) in patients presenting with acute dyspnea is challenging. We tested the feasibility of Lung Doppler Signals (LDS) as a bedside tool to differentiate the cardiogenic from other causes of acute dyspnea. LDS data was acquired from 83 patients