Dyspnea In Emergency Department Research Articles

Development of a clinical prediction score for congestive heart failure diagnosis in the emergency care setting: The Brest score

ObjectiveTo derive and validate a clinical prediction rule of acute congestive heart failure obtainable in the emergency care setting. DesignDerivation of the score was performed on a retrospective 927 patients cohort admitted to our Emergency Department for dyspnea. The prediction model was externally validated on an independent 206-patient prospective cohort. Interventions and MeasuresDuring the derivation phase, variables associated with acute congestive heart failure were included in a multivariate regression model. Logistic regression coefficients were used to assign scoring points to each variable. During the validation phase, every diagnosis was confirmed by an independent adjudication committee. ResultsThe score comprised 11 variables: age ≥65 years (1 point), seizure dyspnea (2 points), night outbreak (1 point), orthopnea (1 point), history of pulmonary edema (2 points), chronic pulmonary disease (−2 points), myocardial infarction (1 point), crackles (2 points), leg edema (1 point), ST-segment abnormality (1 point), atrial fibrillation/flutter (1 point) on electrocardiography. In the validation step, 30 patients (14.6%) had a low clinical probability of acute congestive heart failure (score ≤3), of which only 2 (6.7%) had a proven acute cardiogenic pulmonary edema. The prevalence of acute congestive heart failure was 58.5% in the 94 patients with an intermediate probability (score of 4-8) and 91.5% in the 82 patients (39.8%) with a high probability (score ≥9). ConclusionThis score of acute congestive heart failure based on easily available and objective variables is entirely standardized. Applying the score to dyspneic adult emergency patients may enable a more rapid and efficient diagnostic process.

Congestive Heart Failure: An Uncommon Presentation of Pheochromocytoma

Introduction: Pheochromocytomas are rare catecholamine secreting tumors that arise from the chromaffine tissue of the adrenal medulla. Rarely, these tumors are associated with cardiomyopathy. We herein present a patient with pheochromocytoma presenting initially with congestive heart failure and hypertensive emergency. Case presentation: A 62-year-old female with no past medical history presented to the emergency department for dyspnea and lower extremity edema of 2 weeks duration. The patient was tachycardic at 120 BPM, hypertensive at 197/90 mmHg. She had decreased breath sounds bilaterally. Electrocardiogram showed sinus tachycardia. Chest x-ray revealed bilateral pulmonary infiltrates and effusions. Laboratory testing demonstrated a white blood cell count of 18.06 TH/mm3 , platelet count of 693 TH/mm3 , D-dimer of 540 ng/ml, and a brain natriuretic peptide of 888pg/ml. A lower extremity duplex was negative for venous thromboembolism. Computed tomography scan of the chest ruled out pulmonary embolism. An Echocardiogram showed diffuse hypokinesis, and an estimated ejection fraction of 35 percent. Thyroid stimulating hormone, Urine and plasma metanephrines and renal artery duplex were done as part of the workup. Renal ultrasound and arterial Doppler were negative for renal artery stenosis, but revealed a right upper pole partially solid mass. An MRI of the abdomen confirmed a mass in the upper pole of the right kidney. Initial laboratory tests showed elevated plasma Metanephrines at 8065 pg/ml and urine metanephrines at 1594 mcg/g. The patient was started on Phenoxybenzamine. Surgical resection with histo-pathological examination performed 4 weeks later confirmed the diagnosis of pheochromocytoma. Discussion: Pheochromocytomas are rare tumors, associated with a number of cardiovascular complications. The acute onset of severe congestive heart failure secondary to catecholamine overproduction is a rare entity, and is associated with a poor prognosis.This case teaches us, that in patients presenting with heart failure with no obvious cause, the diagnosis of pheochromocytoma should always be contemplated.

Diagnostic cut-off levels of plasma brain natriuretic peptide to distinguish left ventricular failure in emergency setting.

To determine the diagnostic cut-off values of brain natriuretic (BNP) peptide to establish left ventricular failure in patients presenting with dyspnoea in emergency department. Descriptive study. Ziauddin University Hospital, Karachi, from July to December 2011. BNP estimation was done on Axysm analyzer with kit provided by Abbott diagnostics, while the Doppler echocardiography was done on Toshiba istyle (UICW-660A) using 2.5 MHz and 5.0 MHz probes. Log transformation was done to normalize the original BNP values. A receiver operating curve was plotted to determine the diagnostic cut-off value of BNP which can be used to distinguish CHF from other causes of dyspnoea. Statistical analysis was performed by SPSS version 17. A total of 92 patients presenting with dyspnoea in the emergency department were studied. There were 38/92 (41.3%) males and 54/92 (58.7%) females, and the average age of the study population was 64 ± 14.1 years. These patients had BNP levels and Doppler echocardiography done. The average BNP was found to be 1117.78 ± 1445.74 pg/ml. In log transformation, the average was found to be 2.72 ± 0.58. BNP value of 531 pg/ml was found to be the cut off to distinguish between cardiogenic and non-cardiogenic causes of dyspnoea. BNP value of 531 pg/ml can distinguish CHF from other conditions as a cause of dyspnoea in emergency.

N-terminal proB-type natriuretic peptide testing: practical diagnostic value in a emergency department

Purpose: N-terminal proBNP (NT-proBNP) testing has been proposed as a part of the evaluation of patients with dyspnea in Emergency Department (ED). Observational studies demonstrated that NT-proBNP improved diagnosis and reduced costs. Nevertheless, recent randomized studies failed to confirm the utility of this laboratory test in ED. We sought to evaluate the diagnostic impact of NT-proBNP measurement in patients presenting with acute dyspnea in ED, taking into account clinical and chest x-ray results routinely obtained. Methods: We enrolled 498 consecutive patients presented at our ED for dyspnea (male/female 248/250; mean±SD age 77.3±12) with a single NT-proBNP determination (Elecsys Roche Diagnostics, cutoff: 450 ng/L) at admission. For each patient enrolled, a score was calculated by evaluating the presence or absence of six clinical and radiological findings, such as: 1) history of heart failure; 2) history of ischemic cardiomyopathy; 3) pulmonary rales; 4) leg edema; 5) chest x-ray cardiac enlargement; 6) chest x-ray pulmonary congestion. According to the clinical and radiological score, the patients were divided in three groups: low (A-group), intermediate (B-group), and high (C-group) probability of heart failure. On a second time two cardiologists, rather than knowledge of the results of NT-proBNP, reviewed all other clinical data and made the final diagnosis. Results: NT-proBNP mediane value was 2445 ng/L (lower quartile 631 and upper quartile 5847 ng/L), and the area under the receiver-operating characteristic curves (AUC) was 0.854 for NT-proBNP, 0.921 for clinical/radiological score, and 0.936 for the two in combination (logistic model). The likelihood ratio positive (LR+) was not determinable in the group A, 1.63 in the group B and 1.22 in the group C. The LR- was 1.26 in the group A, 0.16 in the group B and 0.05 in the group C In the B- group (intermediate) NT-proBNP test added correct diagnostic information in 126 subjects with HF and in 53 subjects without a final diagnosis of HF. In A and C-group NT-proBNP test added correct diagnostic information in 1 patient. Conclusions: NT-proBNP did not substantially enhance diagnostic accuracy in all patients with shortness of breath in ED. In patients presenting to an ED with acute dyspnea classifiable in the low or high probability groups this marker keeps its strong discriminating power, but gives poor additional information to clinical standard evaluation. However, in patients with not conclusive clinical and radiological results NT-proBNP determinations improved the percentage of correct diagnosis.

Tracheal Adenoid Cystic Carcinoma Treated by Repeated Bronchoscopic Argon Plasma Coagulation as a Palliative Therapy

Primary tracheal tumors are uncommon, making up only 0.2% of all respiratory malignancies. Adenoid cystic carcinoma (ACC) is the most common tumor, accounting for about 30% of primary tracheal tumors. It is often difficult to manage these tumors surgically, due to its expansion and submucosal invasion, and furthermore, due to the patient's condition. Thus, it is essential to perform palliative treatment in order to maintain the airway through and to control the progress. Herein, we report a case of ACC treated by repeated bronchoscopic argon plasma coagulation (APC) as palliative therapy.A 71-year-old Japanese male was referred to our hospital's emergency department for dyspnea. Bronchoscopic examination revealed expanded intraluminal obstructive bronchial tumors from the left bronchus to right. The patient had undergone bronchoscopic APC treatment several times. The obstruction was improved, and no worsening was seen for 26 months. Repeated bronchoscopic APC as a palliative therapy is promising and useful therapy without heavy adverse reactions to control the tumor growth.

High NT-probnp and Procalcitonin Level Can Predict the Poor Prognosis of Acute Dyspneic Patients

Acute decompensated heart failure is the main cause of acute dyspnea in emergency department and the infection is the main cause of acute decompensate heart failure. NT-proBNP is an independent predictor of high left ventricular end-diastolic pressure and correlate to NYHA classification and the severity of the heart failure. Procalcitonin (PCT) is potentially biomarker of the state of bacterial infection and has excellent specificity and positive predictive value on the disgnosis of ongoing and potentially severe systemic infection.

Diagnostic value of N-terminal ProB-Type Natriuretic Peptide in Emergency Department: Analysis by subgroups

Objectives. Our aim was to evaluate the diagnostic impact of N-terminal pro B-type natriuretic peptide (NT-proBNP) measurement in patients presenting with acute dyspnea in Emergency Department (ED), taking into account clinical and chest x-ray results routinely obtained. Methods. This was a prospective observational study. Four hundred eighty-eight consecutive subjects evaluated for dyspnea in a metropolitan 600 beds hospital ED, entered into the final data analysis. According to a clinical and radiological score, the patients enrolled were divided in three groups: low (A-group), intermediate (B-group), and high (C-group) probability of heart failure. Results. NT-proBNP median value was 2445 ng/L (Inter Quartile Range 631-5847 ng/L), and the area under the receiver-operating characteristic curves (AUC) was 0.854 for NT-proBNP, 0.921 for clinical/radiological score and 0.936 for the two in combination (logistic model). In the B-group (intermediate) NT-proBNP test added correct diagnostic information in 126 subjects with HF and in 53 subjects without a final diagnosis of HF. In A- and C-group NT-proBNP test added correct diagnostic information in 1 patient. Conclusions. NT-proBNP did not substantially enhance diagnostic accuracy in all patients with shortness of breath in ED. However, in patients with not conclusive clinical and radiological results NT-proBNP determinations improved the percentage of correct diagnosis.

Usefulness of chest ultrasonography in detecting pulmonary embolism in patient with chronic obstructive pulmonary disease and chronic renal failure: a case report

We describe the case of a 75-year-old man affected by a chronic obstructive pulmonary disease and chronic renal failure admitted to our emergency department for dyspnea and interscapular stabbing pain. Chest radiography showed diffuse parenchymal consolidation in the lower right lung with bronchiectasis, but the treatment for infection disease did not improve the clinical conditions of the patient. According to Wells score indicating an intermediate risk for pulmonary embolism, we performed a chest ultrasonography that showed ultrasonographic patterns of thromboembolism. Because the presence of chronic renal failure limited the execution of a helical computed tomographic pulmonary angiography, a pulmonary scintigraphy was performed confirming the diagnosis of pulmonary embolism. Our case suggested that chest ultrasonography can be a valuable tool for early detection of pulmonary embolism and to establish immediately an appropriate therapy.

Brain Natriuretic Peptide in the Evaluation of Emergency Department Dyspnea: Is There a Role?

BackgroundAcute decompensated congestive heart failure (ADCHF) is a common etiology of dyspnea in emergency department (ED) patients. Delayed diagnosis of ADCHF increases morbidity and mortality. Two cardiac biomarkers, N-terminal-pro brain natriuretic peptide (NT-proBNP) and brain natriuretic peptide (BNP) have demonstrated excellent sensitivity in diagnostic accuracy studies, but the clinical impact on patient-oriented outcomes of these tests remains in question. Clinical QuestionDoes emergency physician awareness of BNP or NT-proBNP level improve ADCHF patient-important outcomes including ED length of stay, hospital length of stay, cardiovascular mortality, or overall health care costs? Evidence ReviewFive trials have randomized clinicians to either knowledge of or no knowledge of ADCHF biomarker levels in ED patients with dyspnea and some suspicion for heart failure. In assessing patient-oriented outcomes such as length-of-stay, return visits, and overall health care costs, the randomized controlled trials fail to provide evidence of unequivocal benefit to patients, clinicians, or society. ConclusionClinician awareness of BNP or NT-proBNP levels in ED dyspnea patients does not necessarily improve outcomes. Future ADCHF biomarker trials must assess patient-oriented outcomes in conjunction with validated risk-stratification instruments.

Can mainstream end-tidal carbon dioxide measurement accurately predict the arterial carbon dioxide level of patients with acute dyspnea in ED

ObjectiveThis study was designed to determine whether the mainstream end-tidal carbon dioxide (ETCO2) measurement can accurately predict the partial arterial carbon dioxide (Paco2) level of patients presented to emergency department (ED) with acute dyspnea. MethodsThis prospective, observational study was conducted at a university hospital ED, which serves more than 110 000 patients annually. Nonintubated adult patients presented with acute dyspnea who required arterial blood gas analysis were recruited in the study for a 6-month period between January and July 2010. Patients were asked to breathe through an airway adapter attached to the mainstream capnometer. Arterial blood gas samples were obtained simultaneously. ResultsWe included 162 patients during the study period. The mean ETCO2 level was 39.47 ± 10.84 mm Hg (minimum, 19 mm Hg; maximum, 82 mm Hg), and mean Paco2 level was 38.95 ± 12.27 mm Hg (minimum, 16 mm Hg; maximum, 94 mm Hg). There was a positive, strong, statistically significant correlation between ETCO2 and Paco2 (r = 0.911, P < .001). The Bland-Altman plot shows the mean bias ± SD between ETCO2 and Paco2 as 0.5 ± 5 mm Hg (95% confidence interval, −1.3165-0.2680) and the limits of agreement as −10.5 and +9.5 mm Hg. Eighty percent (n = 129) of the ETCO2 measurements were between the range of ±5 mm Hg. ConclusionMainstream ETCO2 measurement accurately predicts the arterial Paco2 of patients presented to ED with acute dyspnea. Further studies comparing mainstream and sidestream methods in these patients are required.

3D Echocardiographic Delineation of Mitral-Aortic Intervalular Fibrosa Pseudoaneurysm Caused by Bicuspid Aortic Valve Endocarditis

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa is a rare complication of infective endocarditis of the aortic valve eventually resulting in coronary artery compression, stroke or rupture into the left atrium, aorta or pericardial space. A prompt diagnosis by either transthoracic or transesophageal echocardiography is mandatory to address the patient to cardiac surgery. We report the clinical case of a 25-year-old white man who was admitted to the emergency department for dyspnoea and fever. Echocardiographic examination showed a bicuspid aortic valve with a huge sessile vegetation and a pseudaneurysm of the mitral-aortic intervalvular fibrosa. In addition to conventional two-dimensional examination, three-dimensional echocardiography provided additional information of this complication, precisely delineating the lesions and addressing the cardiac surgeon in choosing the most appropriate operating strategy. Patient underwent then aortic root replacement and the pseudoaneurysm was closed by means of a bovine pericardial patch.

Use of emergency medical services by patients with decompensated obstructive lung disease

Little information is available about the risk of relapse when patients with decompensated obstructive lung disease are treated in an emergency department for dyspnea. The purpose of our study was to determine if the risk of relapse was related to the severity and type of airway obstruction or to the time and duration of treatment. Over a period of 29 months, 496 patients with decompensated chronic obstructive pulmonary disease (COPD), asthma, or both were seen in the ED of the Albuquerque Veterans Administration Medical Center. Of 868 visits in which patients were treated and released, 244 (28.1%) were followed by a relapse within 14 days. Those who relapsed had a slightly higher one-second forced expiratory volume at baseline than those who did not (50.1 +/- 22.2% versus 45.5 +/- 20.6% predicted, P = .054). For 94 patients (group 1), asthma was the exclusive clinical diagnosis, and all available pulmonary function tests showed a bronchodilator response. For 268 patients (group 2), COPD was the exclusive diagnosis, and all tests showed no bronchodilator response. One hundred thirty-four patients (group 3) were either diagnosed as having both disorders or had varying bronchodilator response on sequential testing. The risk of relapse for group 3 patients (35.6%) was higher than for those in groups 2 (23.1%, P less than .001) or 1 (19.7%, P = .001). The frequency of relapse was higher for nighttime than daytime visits (36.1% versus 24.5%, P = .006) and for weekend than weekday visits (33.6% versus 26.6%, P = .049). Prognosis did not vary with the season or duration of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)