Pulmonary Embolism: Clinical Features and Diagnosis

Pulmonary embolism is a lethal yet treatable disease. Given the significant overlap of symptoms and signs between the presentation of pulmonary embolism and acute coronary syndromes, it becomes clear that emergency room physicians must be familiar with the diagnosis of pulmonary embolism. A critical issue is always to consider pulmonary embolism in the differential diagnosis of chest pain. However, the clinical diagnosis of pulmonary embolism remains problematic due to the nonspecific presenting symptoms, signs, electrocardiographic abnormalities, arterial blood gas and chest X-ray findings. D-dimers are becoming a widely available useful laboratory tool in the diagnosis of suspected pulmonary embolism. In this concise overview, the diagnostic value of clinical assessment in patients with possible pulmonary embolism will be explored

Low-dose adenosine stress echocardiography: Detection of myocardial viability

OBJECTIVE: The aim of this study was to evaluate the diagnostic potential of low-dose adenosine stress echocardiography in detection of myocardial viability. BACKGROUND: Vasodilation through low dose dipyridamole infusion may recruit contractile reserve by increasing coronary flow or by increasing levels of endogenous adenosine. METHODS: Forty-three patients with resting dyssynergy, due to previous myocardial infarction, underwent low-dose adenosine (80, 100, 110 mcg/kg/min in 3 minutes intervals) echocardiography test. Gold standard for myocardial viability was improvement in systolic thickening of dyssinergic segments of ≥ 1 grade at follow-up. Coronary angiography was done in 41 pts. Twenty-seven patients were revascularized and 16 were medically treated. Echocardiographic follow up data (12 ± 2 months) were available in 24 revascularized patients. RESULTS: Wall motion score index improved from rest 1.55 ± 0.30 to 1.33 ± 0.26 at low-dose adenosine (p < 0.001). Of the 257 segments with baseline dyssynergy, adenosine echocardiography identified 122 segments as positive for viability, and 135 as necrotic since no improvement of systolic thickening was observed. Follow-up wall motion score index was 1.31 ± 0.30 (p < 0.001 vs. rest). The sensitivity of adenosine echo test for identification of viable segments was 87%, while specificity was 95%, and diagnostic accuracy 90%. Positive and negative predictive values were 97% and 80%, respectively. CONCLUSION: Low-dose adenosine stress echocardiography test has high diagnostic potential for detection of myocardial viability in the group of patients with left ventricle dysfunction due to previous myocardial infarction. Low dose adenosine stress echocardiography may be adequate alternative to low-dose dobutamine test for evaluation of myocardial viability

P660 Arterial hypertension as confounding factor in the echocardiographic assessment of patients with significant aortic stenosis

Abstract Purpose Increased arterial pressure affects the accuracy of clinical conclusions in a number of cardiac pathologies, including valvulopathies. We investigated the influence of increased blood pressure in the assessment of multiple echo variables in patients with significant aortic stenosis of different physiologies. Methods Seventy two patients (33 women, aged 72 ± 12 years old, EF: 56 ± 9%) with significant aortic stenosis [18 (25%) with low flow low gradient (LFLG) and 7 (10%) with paradoxic LFLG (PLFLG) physiology] and arterial systolic pressure ≥140 mmHg on admission, were assessed with a full 2D and Doppler echocardiographic study including non-invasive assessment of pressure recovery and valvuloarterial impedance (z). Echo study was performed on two occasions during their hospitalization, on admission and after normalization of blood pressure. Arterial pressure was controlled by any therapeutic means at the discretion of the referring physician. Significant serial changes between echo variables were assessed by the Student paired t-test. Results Arterial pressure and heart rate were significantly lowered between the two studies (from 152 ± 13 to 116 ± 11 mmHg and 78 ± 7 to 73 ± 5, p&amp;lt; 0,001 respectively). Differences between the echo variables are depicted in the following table. Conclusions Small but significant changes were noticed in several echo parameters after lowering blood pressure in patients with significant aortic stenosis. These patients should always be assessed after normalization of their blood pressure since the degree of stenosis can be erroneously overestimated and affect clinical decision. p &amp;lt; 0,001 Echo variable 1st study 2nd study Stroke vol index (i) (ml/m2) 37,1 ± 9,5 44,1 ± 10* Mean gradient (mmHg) 42 ± 6,2 44 ± 5,8 * Pressure recovery (mmHg) 8,4 ± 2,5 9,5 ± 2,7* Z (mmHg/mL * m2) 5,4 ± 1,5 3,8 ± 1,1* AVAi (cm2/m2) 0,44 ± 0,06 0,49 ± 0,06* </jats:sec

Neutrophil count on admission predicts major in-hospital events in patients with a non-ST-segment elevation acute coronary syndrome

Background: Inflammation plays a key role in the pathogenesis of acute coronary syndromes (ACS). In this context we assessed neutrophil count as a predictor of major in-hospital events in patients admitted for a non-ST-segment elevation (NSTE) ACS. Methods: We measured neutrophils on admission in 160 patients with a NSTE ACS and we correlated their count with the incidence of a combined in-hospital end point including: cardiac death, acute heart failure, ST-segment elevation myocardial infarction, and recurrent myocardial ischemia. Results: Patients who had a major in-hospital event also had a higher neutrophil count (P = 0.02) and higher serum levels of troponin I (P = 0.04). In the univariate logistic regression analysis, in-hospital major events could be predicted by troponin I &gt;0.07 ng/mL (odds ratio [OR]: 5.65, 95% confidence interval [CI]: 1.26-25.32, P = 0.02), white blood cell count &gt;8650 cells/μL (OR: 2.68, 95% CI: 1.03-6.95, P = 0.04), neutrophil count &gt;6700 cells/μ L (OR: 7.74, 95% CI: 2.79-21.47, P &lt; 0.001), and C-reactive protein &gt;0.97 mg/dL (OR: 3.56, 95% CI: 1.13-11.19, P = 0.02). However, in multivariate regression, neutrophil count &gt;6700 cells/μL (OR: 6.52, 95% CI: 1.56-27.22, P = 0.01) was the only independent in-hospital prognostic factor. Conclusions: In patients with a NSTE ACS of moderate or high risk, neutrophil count on admission may identify those who are at risk of having an adverse in-hospital outcome. © 2009 Wiley Periodicals, Inc