Gender differences in symptom predictors associated with acute coronary syndrome: A prospective observational study

Signs and symptoms (typical and atypical symptoms) of acute coronary syndromes (ACS) differ between men and women. Identification of gender differences has implications for both health care providers and the general public. The aim of this study was to determine the symptom predictors of the acute coronary syndromes in men and women. In this prospective study, nurse data collectors directly observed 256 men and 182 women (N = 438) with symptoms suggestive of ACS in the Emergency Departments of eight hospitals in Tehran. ACS was eventually diagnosed in 183 (57.2%) men and 137 (42.8%) women on the basis of standard electrocardiogram and cardiac enzyme (CPK-MB) level. In men, chest symptoms (OR = 3.22, CI = 0.137–0.756, P = 0.009), dyspnea (OR = 2.65, CI = 1.78–4.123 P = 0.001) and diaphoresis (OR = 2.175, CI = 1.020–4.639, P = 0.044) were significantly associated with the diagnosis of ACS 3.78, 2.72 and 1.87 times more than in women having these symptoms, respectively. These results indicated that chest symptoms, diaphoresis and dyspnea were the more pronounced typical symptoms of ACS in men compared to women. Additionally, the numbers of typical symptoms can be considered as more predictive of ACS in men (OR = 1.673, CI = 1.211–2.224, P < 0.001) than women (OR = 1.271, CI = 1.157–2.331, P = 0.212). Therefore, clinicians need to take men showing typical symptoms into consideration carefully.     

Factors associated with posttraumatic stress symptoms in a prospective cohort of patients after abdominal sepsis: a nomogram

OBJECTIVE: To determine to what extent patients who have survived abdominal sepsis suffer from symptoms of posttraumatic stress disorder (PTSD) and depression, and to identify potential risk factors for PTSD symptoms. DESIGN AND SETTING: PTSD and depression symptoms were measured using the Impact of Events Scale-Revised (IES-R), the Post-Traumatic Symptom Scale 10 (PTSS-10) and the Beck Depression Inventory II (BDI-II). PATIENTS AND PARTICIPANTS: A total of 135 peritonitis patients were eligible for this study, of whom 107 (80%) patients completed the questionnaire. The median APACHE-II score was 14 (range 12-16), and 89% were admitted to the ICU. MEASUREMENTS AND RESULTS: The proportion of patients with "moderate" PTSD symptom scores was 28% (95% CI 20-37), whilst 10% (95% CI 6-17) of patients had "high" PTSD symptom scores. Only 5% (95% CI 2-12) of the patients expressed severe depression symptoms. Factors associated with increased PTSD symptoms in a multivariate ordinal regression model were younger age (0.74 per 10 years older, p=0.082), length of ICU stay (OR=1.4 per doubling of duration, p=0.003) and having some (OR=4.9, p=0.06) or many (OR=55.5, p<0.001) traumatic memories of the ICU or hospital stay. CONCLUSION: As many as 38% of patients after abdominal sepsis report elevated levels of PTSD symptoms on at least one of the questionnaires. Our nomogram may assist in identifying patients at increased risk for developing symptoms of PTSD.     

Clinical Characteristics of Diabetic vs Nondiabetic Patients Who "Rule-in" for Acute Myocardial Infarction

OBJECTIVE: To compare the clinical characteristics of diabetic vs nondiabetic patients who present to the ED with acute myocardial infarction (AMI). METHODS: This was a prospective, observational study at a suburban, university hospital ED of patients presenting to the ED during study hours between December 1993 and October 1996 with typical and atypical symptoms consistent with cardiac ischemia. Diabetic and nondiabetic patients with AMI were compared. Demographic, historical, and clinical data were recorded by trained research assistants using a standardized, closed-question, data collection instrument. Final discharge diagnosis of AMI was assigned by WHO criteria. Continuous variables were analyzed by t-tests. Clinical variables were analyzed by chi-square tests. All tests were two-tailed with alpha preset at 0.05. RESULTS: There were 216 patients with AMI during the study period; 51 of these patients (24%) were diabetic. For diabetic vs nondiabetic patients with AMI, there was no significant difference in age (64.0 +/- 13 vs 60.0 +/- 14 years, p = 0.13), female gender (37% vs 26%, p = 0.13), and time to presentation from symptom onset (192 +/- 238 vs 251 +/- 456 minutes, p = 0.41). Hypertension was the only cardiac risk factor significantly more prevalent in diabetic vs nondiabetic patients with AMI (77% vs 50%, OR = 1.54, 95% CI = 1.24 to 1.91, p = 0.001), though elevated cholesterol (48% vs 33%, OR = 1.47, 95% CI = 1.02 to 2.12, p = 0.06) tended to be more prevalent in the diabetic group. There was no statistically significant difference between the two groups in terms of the frequency of chest pain (OR = 1.04, 95% CI = 0.95 to 1.14, p = 0.30), associated symptoms, and diagnostic ECGs (OR = 1.16, 95% CI = 0.76 to 1.79, p = 0.53). CONCLUSION: Diabetic patients with AMI may have similar symptoms upon presentation as do nondiabetic patients with AMI. Of the cardiac risk factors, hypertension is more prevalent in diabetic vs nondiabetic patients with AMI.     

The Association Between Emergency Department Crowding and Adverse Cardiovascular Outcomes in Patients with Chest Pain

Objectives: While emergency department (ED) crowding is a worldwide problem, few studies have demonstrated associations between crowding and outcomes. The authors examined whether ED crowding was associated with adverse cardiovascular outcomes in patients with chest pain syndromes (chest pain or related complaints of possible cardiac origin). Methods: A retrospective analysis was performed for patients ≥30 years of age with chest pain syndrome admitted to a tertiary care academic hospital from 1999 through 2006. The authors compared rates of inpatient adverse outcomes from ED triage to hospital discharge, defined as delayed acute myocardial infarction (AMI), heart failure, hypotension, dysrhythmias, and cardiac arrest, which occurred after ED arrival using five separate crowding measures. Results: Among 4,574 patients, 251 (4%) patients developed adverse outcomes after ED arrival; 803 (18%) had documented acute coronary syndrome (ACS), and of those, 273 (34%) had AMI. Compared to less crowded times, ACS patients experienced more adverse outcomes at the highest waiting room census (odds ratio [OR] = 3.7, 95% confidence interval [CI] = 1.3 to 11.0) and patient-hours (OR = 5.2, 95% CI = 2.0 to 13.6) and trended toward more adverse outcomes during time of high ED occupancy (OR = 3.1, 95% CI = 1.0 to 9.3). Adverse outcomes were not significantly more frequent during times with the highest number of admitted patients (OR = 1.6, 95% CI = 0.6 to 4.1) or the highest trailing mean length of stay (LOS) for admitted patients transferred to inpatient beds within 6 hours (OR = 1.5, 95% CI = 0.5 to 4.0). Patients with non-ACS chest pain experienced more adverse outcomes during the highest waiting room census (OR = 3.5, 95% CI = 1.4 to 8.4) and patient-hours (OR = 4.3, 95% CI = 2.6 to 7.3), but not occupancy (OR = 1.8, 95% CI = 0.9 to 3.3), number of admitted patients (OR = 0.6, 95% CI 0.4 to 1.1), or trailing LOS for admitted patients (OR = 1.2, 95% CI = 0.6 to 2.0). Conclusions: There was an association between some measures of ED crowding and a higher risk of adverse cardiovascular outcomes in patients with both ACS-related and non–ACS-related chest pain syndrome.     

Management and outcomes of acute coronary syndrome with minimal myocardial necrosis: analysis of a large prospective registry from a non-interventional centre

The aim of this study was to assess the clinical risk of minimal myonecrosis below the cut-off for acute myocardial infarction (MI) in comparison with other grades of acute coronary syndrome (ACS). One-thousand four hundred and sixty seven consecutive patients with ACS admitted between May 2001 and April 2002 were studied in a non-interventional centre. Patients were divided into unstable angina (UA) (cTnT < 0.01 microg/l), non-ST elevation ACS with minimal myonecrosis (0.01 or= 0.1 microg/L) and ST elevation myocardial infarction (STEMI). UA (n = 638) was associated with the fewest events at 6 months (2% cardiac death or MI). Patients with any myonecrosis (n = 829) had worse outcomes (6-month cardiac death or MI 18.3-23.3%). Compared with ACS patients with minimal myonecrosis, UA patients were at significantly lower risk (OR 0.21, 95% CI 0.12-0.45, p < 0.001), NSTEMI patients were at similar risk (OR 1.45, 95% CI 0.89-2.35, p = 0.13), and STEMI patients were at higher risk (OR 2.12 95% CI 1.26-3.85, p = 0.008) in adjusted analyses. Nearly 85% of cardiac deaths occurred within 6 months. The risk of adverse events was higher among patients managed by non-cardiologists (OR 1.66, 95% CI 1-2.75, p = 0.049). Patients with non-ST elevation ACS and minimal myonecrosis are a high-risk group more comparable with NSTEMI and clearly distinguishable from patients with UA.     

The role of patient demographics and clinical presentation in predicting discharge placement after inpatient stroke rehabilitation: analysis of a large,US data base

Purpose: To determine whether functional ability at admission and demographics predict discharge placement after inpatient rehabilitation for older adults recovering from stroke. Method: In this retrospective study, we examined records of 31,910 adults 65 years of age and older who were admitted for inpatient rehabilitation post-stroke. Binary logistic regression was used with the outcome of placement and potential predictors of the admission Functional Independence Measure (FIM) score, age, sex and marital status. Results: The average admission FIM was 60.0 out of 126; the average FIM at discharge was 84.8. The mean age was 77.7?±?7.3 years, 57% were female and 52.5% were not married. More than three quarters of the patients were discharged to home. Odds ratios (ORs) with 95% confidence intervals (CIs) showed that patients with a FIM score below the mean of our sample (OR = 5.8, CI = 5.5–6.2), older than the mean age of our sample (OR = 1.6, CI = 1.5–1.7), and who were not married (OR = 1.9, CI = 1.8–2.0) (p-values <0.001) were more likely to be discharged to residential care. Sex was not predictive of placement. Conclusion: The admission FIM was an important predictor of discharge placement after rehabilitation in older adults. Age and marital status were also significant predictors of discharge placement. Sex was not a significant predictor.

Implications for Rehabilitation

• Functional ability, age and marital status are significant predictors of discharge placement after stroke rehabilitation.

• Those who have lower admission Functional Independence Measure scores, are older, and are not married are more likely to be discharged to residential care than their counterparts who return home.

• Sex is not a significant predictor of discharge placement after stroke rehabilitation.

• To anticipate discharge placement after inpatient rehabilitation, the clinician should consider the age and marital support system of the patient, as well as the functional presentation at admission.

     

Performance of a Population-based Cardiac Risk Stratification Tool in Asian Patients with Chest Pain

Objectives: Most contemporary cardiac risk stratification tools have been derived and validated in mixed-race populations. Their validity in single-race populations has not been tested. The authors sought to compare the performance of a risk stratification tool between a mixed-race U.S. patient population and an Asian patient population. Methods: This study is an analysis of data from the Internet Tracking Registry for Acute Coronary Syndromes (i*tr ACS ) registry of patients with chest pain presenting to the emergency departments of eight U.S. centers and one site in Singapore. The Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) was computed for included patients, and its performance in predicting acute coronary syndrome (ACS) was compared between patients from the United States and Singapore. Results: Of the 11,991 included patients, 1,120 experienced ACS. Although the ACI-TIPI demonstrated similar accuracy among groups (area under the curve, 0.729 [U.S.] vs. 0.719 [Singapore]; p = 0.5611), sensitivity and specificity were different when equal ACI-TIPI thresholds were considered. Recreating the logistic regression models used to create the ACI-TIPI showed similar results between the derived parameters and the parameters estimated for the U.S. group. In contrast, age older than 50 years (log-odds ratio [LOR], 0.107; 95% confidence interval [CI] = 0.518 to 0.713), male gender (LOR, 0.487; 95% CI = 0.149 to 1.122), and chest pain as a primary complaint (LOR, 0.237; 95% CI = 0.139 to 0.613) had little predictive power in patients from Singapore. Conclusions: Differences exist in presentation and factors associated with ACS among patients from the United States and Singapore that may affect the performance of risk stratification tools. These findings suggest that cardiac clinical decision rules need international validation.     

ED utilization of computed tomography in a poisoned population

The objective of this prospective, analytic study was to identify predictors and describe the demographic and clinical correlates of head computed tomography (CT) evaluation in patients with poisoning or drug overdose and altered mental status. Forty-three patients that were evaluated by head CT and 109 that were not evaluated by head CT were entered into the study at a poison control center. None of the 43 scanned patients had any acute findings on head CT. A logistic regression model yielded 4 predictors that were statistically associated with the ordering of a head CT scan: Glasgow Coma Scale (GCS) < or = 8 (odds ratio [OR]: 2.3; 95% confidence interval [CI] 1.03-5.7); age > or = 41 years (OR 5.3; 95% CI 2.2-13); use of drugs or abuse by history (OR 2.8; 95% CI 1.04-7.6); and witnessed seizure activity (OR 4.8; 95% CI 1.3-17.9). We also tested 2 additional models to identify predictors of hospital admission, 1 with and 1 without CT scan included as a covariate. In the first model, only GCS 相似文献   

Prävalenz beeinträchtigender Bauchschmerzen und Menstruationsbeschwerden

Background

There are no data available on the prevalence of disabling abdominal pain and menstrual cramp in adults in Germany.

Methods

Abdominal pain and menstrual cramp, additional somatic symptoms and depressive symptoms were assessed by the Patient Health Questionnaires (PHQ) 15 and 9 in persons ≥?14 years from a sample representative of the general German population. The association of disabling abdominal and menstrual cramp with demographic and clinical variables was tested by logistic regression analyses.

Results

A total of 2524 out of 4064 (62.1?%) contacted persons participated in the study. Of the participants 11.9?% reported suffering from slight abdominal pain and 0.9?% reported suffering from severe abdominal pain within the last 4 weeks. Female gender with an odds ratio (OR) of 2.23 (95?% confidence interval CI 1.67–2.98, p?<?0.001), younger age (OR 0.97, 95?% CI 0.96–0.98, p?<?0.001), physical symptom burden PHQ 15 (OR 1.33, 95?% CI 1.26–1.40, p?<?0.0001) and depression PHQ 9 (OR 1.13, 95?% CI 1.08–1.77, p?<?0.0001) were predictive for abdominal pain. Of the women aged 14–55 years 19.8?% reported to be slightly troubled by menstrual cramp and 3.9?% reported suffering from severe menstrual cramp within the last 4 weeks. Menstrual cramps were predicted by younger age (OR 0.96, 95?% CI 0.94–0.97, p?<?0.001), somatic symptom burden PHQ 15 (OR 1.24, 1.12–1.36, p?<?0.0001) and depression PHQ 9 (OR 1.08, 95?% CI 1.01–1.15, p?<?0.0001).

Conclusion

Persons in the general German population frequently reported slightly disabling abdominal pain and menstrual cramp; however, severely disabling abdominal pain and menstrual cramp were rarely reported. Abdominal pain and menstrual cramps were associated with additional somatic complaints and depression.     

High prevalence of bronchiectasis in adults: analysis of CT findings in a health screening program

Bronchiectasis is one of the common chronic respiratory diseases and associated with respiratory morbidity and mortality. However, neither its prevalence nor its etiology is well-defined. We aimed to estimate the prevalence and risk factors of bronchiectasis in adults. In a retrospective study, we analyzed radiologic findings on chest computed tomography (CT) images performed as part of a health-screening program. From January to December 2008, 1,409 (24.6%) of 5,727 participants in the screening program of a health promotion center at a university hospital underwent chest CT scans based on the subject's decision. Bronchiectasis was diagnosed, if there was abnormal bronchial dilatation in any area of both lungs on chest CT. Respiratory symptoms, smoking status, and past medical history were also analyzed to define clinical characteristics and risk factors of bronchiectasis. Of 1,409 patients (aged 23-86 years), who were screened for respiratory diseases using chest CT for one year in a health promotion center, 129 patients (9.1%) were diagnosed with bronchiectasis. The prevalence of bronchiectasis was higher in females than in males (11.5% vs. 7.9%, p = 0.022) and increased with age. Respiratory symptoms were reported in 53.7% of subjects. Previous history of tuberculosis (TB) (OR 4.61, 95% CI 2.39-8.88, p = 0.001) and age (OR 2.49, 95% CI 1.56-3.98, p = 0.001) were significantly associated with bronchiectasis. This retrospective analysis of chest CT findings in health screening examinees revealed a very high prevalence of bronchiectasis in adults. Previous TB infection is one of the major causes of bronchiectasis.     

超声造影评价颈动脉粥样硬化斑块的新生血管及其他危险因素与急性冠状动脉综合征的关系

目的 应用实时超声造影技术评价颈动脉粥样硬化斑块新生血管及其他危险因素与急性冠状动脉综合征(ACS)的关系.方法 冠心病伴颈动脉粥样斑块患者128例,斑块厚度均＞2.0 mm.其中ACS组63例,稳定型冠心病组(Scad)组65例.行颈动脉常规超声及超声造影检查,通过肉眼观测及定量分析斑块造影增强情况,并对受检者进行血液生化指标的检测.结果 肉眼观察,ACS 组造影增强比例(62%,39/63)明显高于Scad组(37%,24/65)(P<0.001).定量分析显示,ACS 组斑块增强强度显著高于Scad组(P=0.001);ACS 组斑块增强强度与颈动脉管腔内增强强度比值(ratio)高于Scad组 (P=0.035).Logistic回归分析显示,年龄＞65岁和颈动脉粥样斑块造影增强是ACS发生的独立危险因素(OR=2.630,95%CI 0.933-7.409,P=0.006;OR=2.687,95%CI 1.002-8.025,P=0.047).结论 年龄＞65岁和颈动脉粥样斑块造影增强可作为预测ACS发生的独立危险因素.

Abstract：

Objective To evaluate the relationship between carotid plaque neovascularization and other cardiovascular risk factors and acute coronary syndrome(ACS) using contrast-enhanced ultrasound.Methods The study population consisted of 128 patients with coronary heart disease associated carotid plaque thicker than 2.0mm,including 63 patients with ACS and 65 patients with stable coronary artery disease (sCAD).Contrast-agent enhancement in the plaque was evaluated by visual interpretation and quantitative analysis.All blood samples of the patients were sent to the same hospital laboratory for biochemical detection and correction.Results The percentage of contrast-agent enhancement in patients with ACS was significantly greater than that in patients with sCAD by visual interpretation [63%(39/63) vs 37%(24/65),P<0.001].The quantitative analysis showed that the enhanced intensity in the plaque and the ratio of enhanced intensity in the plaque to that in the carotid artery lumen in patients with ACS were significantly greater than those in patients with sCAD (P=0.001,P=0.035,respectively).Logistic regression analysis revealed that age older than 65 years and contrast-agent enhancement within plaque were independent predictor for patients with ACS(OR=2.630,95%CI 0.933-7.409,P=0.006;OR=2.687,95%CI 1.002-8.025,P=0.047).Conclusions Age older than 65 years and contrast-agent enhancement in the carotid plaque may be used as independent predictors for ACS.     

A comparison of outcomes between diabetic and nondiabetic CAPD patients in India

BACKGROUND: Continuous ambulatory peritoneal dialysis (CAPD) has been an established modality of renal replacement therapy in India for a decade, but there is a paucity of published data on the outcome of CAPD patients in India. We analyzed our data to determine the overall predictors of survival and compared patient survival between diabetic and nondiabetic end-stage renal disease patients on CAPD. METHODS: Of 373 patients, 197 were diabetic (165 males, 32 females) and 176 nondiabetic (104 males, 72 females). Patients were followed for 22 +/- 14 patient-months. Patients were prospectively followed until the study end point or death. RESULTS: Overall median survival was 48 patient-months. Median survival of diabetics (34.5 patient-months) was significantly inferior to nondiabetic patients (59 patient-months) p = 0.001. Overall patient survival at 1, 2, 3, 4, and 5 years was 90%, 72%, 60%, 49%, and 39%, respectively. Patient survival of diabetics versus nondiabetics at 1, 2, 3, 4, and 5 years was 85% versus 96%, 62% vs 82%, 48% vs 72%, 39% vs 62%, and 34% vs 42%, respectively. The relative risk of mortality in nondiabetics (34/176) was less than that in diabetic patients (71/197): odds ratio (OR) 0.43, 95% confidence interval (CI) 0.26 - 0.68; p = 0.001. On Cox regression analysis, diabetes (OR 1.95, 95% CI 1.23 - 3.07; p = 0.004), comorbidities (OR 0.39, 95% CI 0.25 - 0.61; p = 0.001), peritonitis (OR 1.79, 95% CI 1.19 - 2.68; p = 0.005), malnutrition (OR 0.52, 95% CI 0.29 - 0.94; p = 0.03), and residual glomerular filtration rate at initiation of CAPD (OR 0.87, 95% CI 0.81 - 0.93; p = 0.001) were significant predictors of overall mortality. Age (OR 0.68, 95% CI 0.45 - 1.03; p = 0.07), gender (OR 0.66, 95% CI 0.42 - 1.03; p = 0.06), and albumin level at initiation of CAPD (OR 0.92, 95% CI 0.64 - 1.33; p = 0.68) were not predictors of mortality. Age (56 +/- 10 vs 46 +/- 15 years, p = 0.001), comorbidities (51/197 vs 16/176, p = 0.001), peritonitis rate (0.68 vs 0.50 episodes/patient-year, p = 0.056), and severe malnutrition (27/197 vs 10/176, p = 0.002) were higher in diabetic than in nondiabetic patients. CONCLUSION: In India the majority of CAPD patients are diabetic. Patient survival was inferior in diabetic compared to nondiabetic patients on CAPD, but survival was statistically similar after adjustment for comorbidities. Diabetes, comorbidities, residual glomerular filtration rate, peritonitis, and severe malnutrition are predictors of mortality in CAPD patients.     

Does high-sensitivity C-reactive protein add prognostic value to the TIMI-Risk Score in individuals with non-ST elevation acute coronary syndromes?

BACKGROUND: C-reactive protein (CRP) measured at hospital arrival of patients with non-ST elevation acute coronary syndromes (ACS) may add prognostic information to the TIMI-Risk Score. METHODS: Eighty-six consecutive patients admitted with unstable angina or non-ST-elevation acute myocardial infarction and symptoms onset within the prior 48 h were included. Recurrent cardiovascular events during hospitalization were defined as non-fatal myocardial infarction or death. Serum CRP was measured immediately at hospital arrival and its prognostic value in relation to in-hospital cardiovascular events was tested by the area under the ROC curve and adjusted for TIMI risk predictors by logistic regression analysis. In addition, a CRP modified TIMI-Risk score was created by adding 2 points if CRP greater than the cut-off proposed by the ROC curve analysis. The accuracy of this new score was compared with the usual TIMI-Risk Score. RESULTS: A significant predictive value of CRP in relation to in-hospital cardiovascular events was indicated by an area under the ROC curve of 0.80 (95% CI=0.66 to 0.93, p=0.009). C-reactive protein cut-off point of best prognostic performance was 7.2 mg/l. In the multivariate analysis, increased CRP (>7.2 mg/l) remained a significant predictor of events after adjustment for TIMI risk predictors (OR=14; 95% CI=1.6-121; p=0.018). The area under the ROC curve for the TIMI-Risk Score was 0.87 (95% CI=0.76-0.99, p=0.001). The addition of CRP to the TIMI-Risk Score improved its prognostic value (area under the ROC curve=0.93; 95% CI=0.87-0.99, p<0.001). The additional value of the new score is demonstrated by a higher specificity (86% vs. 63%, p<0.001) and positive predictive value (39% vs. 19%) in relation to the TIMI-Risk Score. CONCLUSIONS: CRP measured at admission of patients with non-ST-elevation acute coronary syndromes adds prognostic information to the TIMI-Risk Score. Additionally, the incorporation of this variable into the TIMI-Risk Score calculation is an effective manner to utilize CRP for risk stratification.     

Factors Associated with Prehospital Delay for Acute Stroke in Ulsan, Korea

Background: Early hospital presentation is critical in the treatment of acute ischemic stroke with thrombolysis. Objectives: The aim of this study was to investigate the factors associated with prehospital delay in acute ischemic stroke. Methods: Data were retrospectively collected over a 1-year period from 247 acute ischemic stroke patients who presented to the emergency department (ED) within 7 days after symptom onset. To investigate the factors associated with prehospital delay, sociodemographic data, initial symptoms, risk factor, National Institutes of Stroke Scale in the ED, and use of emergency medical services (EMS) were evaluated. Univariate and multivariate analysis were used to evaluate delay factors. Results: Of 247 patients (mean age 64.4 ± 12.6 years, 149 male patients), the non-delay group (≤ 2 h after symptom onset) included 45 patients (mean age 60.0 ± 13.1 years, 31 male patients) and the delay group (> 2 h after symptom onset) included 202 patients (mean age 65.4 ± 12.3 years, 118 male patients). Advanced age (odds ratio [OR] 1.056, 95% confidence interval [CI] 1.024-1.089), no consciousness disturbance at symptom onset (OR 2.938, 95% CI 1.066-8.104), presentation to ED by self (OR 3.826, 95% CI 1.580-9.624), referral from other hospital (OR 16.787, 95% CI 5.445-51.750), and worsened symptoms at the ED compared to symptom onset (OR 7.708, 95% CI 1.557-38.151) were associated with a prehospital delay. Conclusion: Elderly patients with progressive symptom worsening had delayed arrival, but those who used EMS or had disturbed consciousness at symptom onset had early arrival.     

Screening for nephropathy and antiangiotensin use among diabetic patients in an academic community medical center

The American Diabetes Association recommends routine screening for albuminuria to detect early nephropathy in all patients with diabetes mellitus. If nephropathy is identified, treatment with an antiangiotensin agent decreases progression and improves renal outcomes. Concordance with guidelines for nephropathy screening and antiangiotensin therapy among diabetic patients in a primary care setting of an academic community medical center was evaluated. Medical charts of adult patients with diabetes mellitus from February 2000 through January 2003 were retrospectively reviewed. In part 1 of the study, whether patients were screened for nephropathy at least once was recorded. In part 2 of the study, antiangiotensin prescribing was assessed in all patients and in subgroups stratified by screening. In both parts of the study, patient characteristics and comorbidities were assessed using multivariate analysis to determine their impact on the odds that a patient was screened and that antiangiotensin therapy was prescribed. Among the 329 patients included, 182 patients (55.3%) were screened for nephropathy. Patients who were screened were younger (OR=0.83 for 10-year increase, 95% CI: 0.69-0.99), less likely to have congestive heart failure (OR=0.42, 95% CI: 0.20-0.90), and more likely to be cared for by a resident physician directly supervised by an attending physician (OR=3.03; 95% CI: 1.82-5.03). A total of 215 patients (65.3%) were prescribed antiangiotensin therapy. Hypertension was a predictor of antiangiotensin therapy among all patients who were screened (OR=10.34, 95% CI: 4.45-24.01), those who were screened and negative (OR=15.46, 95% CI: 5.56-42.98), and those who were not screened (OR=10.79, 95% CI: 4.39-26.52). Among patients screened for nephropathy, coronary artery disease (OR=3.01, 95% CI: 1.05-8.63), and the presence of proteinuria (OR=4.26, 95% CI: 1.61-11.24) were predictors of antiangiotensin use. This study found that the likelihood of screening for nephropathy among diabetic patients was inversely associated with a diagnosis of congestive heart failure and increasing age. Conversely, care by a resident physician directly supervised by an attending physician increased the odds that patients would be screened. A diagnosis of hypertension and the presence of albuminuria were each associated with increased use of an antiangiotensin agent.     

Hemoglobin and N-terminal pro-brain natriuretic peptide: Independent and synergistic predictors of mortality in patients with acute heart failure Results from the International Collaborative of NT-proBNP (ICON) Study

BACKGROUND: Hemoglobin and amino-terminal pro-brain natriuretic peptide (NT-proBNP) are both independent predictors of mortality in patients with chronic HF. Their combined predictive power for mortality in the setting of acute HF is uncertain. METHODS: In an international prospective cohort design, we evaluated the relationships between hemoglobin, NT-proBNP, and 60-day mortality in 690 patients with acute HF. RESULTS: The median hemoglobin for the entire cohort was 13.0 g/dL (interquartile range 11.6-14.3). The WHO criterion for anemia was met by 44% (n=305). The 60-day mortality rate for anemic patients was 16.4% vs. 8.8% in non-anemic patients (p<0.001). Anemia was an independent predictor of short-term mortality (OR=1.72, 95% CI=1.05-2.80, p=0.03), as was a NT-proBNP concentration >5180 pg/mL (OR=2.32, 95% CI=1.36-3.94 p=0.002). Consideration of four risk groups: not anemic/low NT-proBNP (reference group, n=220), anemic/low NT-proBNP (n=152), not anemic/high NT-proBNP (n=165), and anemic/high NT-proBNP (n=153) revealed respective 60-day mortality rates of 5.0% (referent), 9.2% (OR=1.93, 95% CI=0.85-4.36; p=0.12), 13.9% (OR=3.07, 95% CI=1.45-6.50, p=0.003), and 23.5% (OR=5.84, 95% CI=2.87-11.89, p<0.001). CONCLUSIONS: Anemia was common in this cohort of subjects with acute HF and was related to adverse short-term outcome. Integrated use of hemoglobin and NT-proBNP measurements provides powerful additive information and is superior to the use of either in isolation.     

The Emergency Department presenting complaint as predictor of in-hospital fatality.

BACKGROUND: The relationship between major discharge diagnoses and prediction of in-hospital death has been intensively studied. The relation between the presenting complaint at the Emergency Department (ED) and in-hospital fatality, however, is less well known. OBJECTIVE: To investigate if presenting complaints add information regarding in-hospital fatality risk for nonsurgical ED patients. METHODS: Investigating the relationship of in-hospital fatality rate and presenting complaint by comparing the presenting complaints, discharge diagnoses and in-hospital fatality for all nonsurgical patients visiting the ED during 1 year. RESULTS: Of 12,995 nonsurgical admissions, 40% were treated as in-hospital patients. Among these, 328 in-hospital deaths occurred. Age was the most powerful predictor of death in hospitalized patients (P<0.0001). After adjustment for age, the female sex was found to be protective [odds ratio (OR) 0.73, 95% confidence interval (CI) 0.58-0.92, P=0.007)]. Compared with the largest complaint group, chest pain with an in-hospital fatality rate of 2.5%, there was a significantly increased risk of dying among those with stroke-like symptoms (OR 2.04, 95% CI 1.35-3.08, P=0.0007), dyspnoea (OR 1.95, 95% CI 1.27-3.00, P=0.002) or general disability (OR 1.81, 95% CI 1.17-2.79, P=0.008). CONCLUSIONS: The presenting complaint at the ED carries valuable information of the risk for in-hospital fatality in nonsurgical patients. This knowledge can be valuable in the prioritization between different patient groups in the process of initiating diagnostics and treatment procedures at the ED.     

Prognostic Value of Symptoms during a Normal or Nonspecific Electrocardiogram in Emergency Department Patients with Potential Acute Coronary Syndrome

Objectives Emergency department (ED) patients with symptoms concerning for acute coronary syndrome (ACS) and a normal electrocardiogram (ECG) are at risk for adverse cardiovascular events. The authors hypothesized that patients with a normal or nonspecific ECG during symptoms have a lower risk for ACS than do those who are asymptomatic.
Methods This was a prospective cohort study of ED patients with potential ACS. Outcomes were acute myocardial infarction (AMI), ACS, and 30-day cardiovascular events (death, AMI, revascularization). Fisher's exact test, t-tests, and logistic regression were used for data analysis.
Results Of 2,593 patient visits, 2,007 patients had normal or nonspecific ECG findings. There were 1,196 who had symptoms during ECG, whereas 811 did not. Patients with symptoms at ECG acquisition were younger (49.9 vs. 55.2 years; p < 0.001) and were more likely to be black (70% vs. 64%; p = 0.002), female (63% vs. 58%; p = 0.03), and to have used cocaine (5% vs. 2%; p = 0.004). They were less likely to have hypertension (49% vs. 58%; p < 0.001), and diabetes (22% vs. 17%; p = 0.002). Patients with and without symptoms were equally likely to have AMI (both 2.8%; p > 0.99), ACS (10.1% vs. 11.5%; p = 0.34), and 30-day adverse outcomes (both 5.3%; p > 0.99). After adjustment for baseline cardiovascular-risk factors, odds ratios for patients with symptoms at the time of ECG acquisition were not significantly different for any of the outcomes: AMI (1.1; 95% confidence interval [CI] = 0.6 to 1.9); ACS (1.1; 95% CI = 0.8 to 1.4); or 30-day events (1.2; 95% CI = 0.8 to 1.9).
Conclusions Patients who are symptomatic during acquisition of a normal or nonspecific ECG have rates of adverse cardiovascular events similar to those of patients without symptoms. Clinicians should not rely on the absence of ECG abnormalities during symptoms to help exclude ACS.