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BACKGROUND@#Acute heart failure (AHF) is the most common disease in emergency departments (EDs). However, clinical data exploring the outcomes of patients presenting AHF in EDs are limited, especially the long-term outcomes. The purposes of this study were to describe the long-term outcomes of patients with AHF in the EDs and further analyze their prognostic factors.@*METHODS@#This prospective, multicenter, cohort study consecutively enrolled 3335 patients with AHF who were admitted to EDs of 14 hospitals from Beijing between January 1, 2011 and September 23, 2012. Kaplan-Meier and Cox regression analysis were adopted to evaluate 5-year outcomes and associated predictors.@*RESULTS@#The 5-year mortality and cardiovascular death rates were 55.4% and 49.6%, respectively. The median overall survival was 34 months. Independent predictors of 5-year mortality were patient age (hazard ratio [HR]: 1.027, 95 confidence interval [CI]: 1.023-1.030), body mass index (BMI) (HR: 0.971, 95% CI: 0.958-0.983), fatigue (HR: 1.127, 95% CI: 1.009-1.258), ascites (HR: 1.190, 95% CI: 1.057-1.340), hepatic jugular reflux (HR: 1.339, 95% CI: 1.140-1.572), New York Heart Association (NYHA) class III to IV (HR: 1.511, 95% CI: 1.291-1.769), heart rate (HR: 1.003, 95% CI: 1.001-1.005), diastolic blood pressure (DBP) (HR: 0.996, 95% CI: 0.993-0.999), blood urea nitrogen (BUN) (HR: 1.014, 95% CI: 1.008-1.020), B-type natriuretic peptide (BNP)/N-terminal pro-B-type natriuretic peptide (NT-proBNP) level in the third (HR: 1.426, 95% CI: 1.220-1.668) or fourth quartile (HR: 1.437, 95% CI: 1.223-1.690), serum sodium (HR: 0.980, 95% CI: 0.972-0.988), serum albumin (HR: 0.981, 95% CI: 0.971-0.992), ischemic heart diseases (HR: 1.195, 95% CI: 1.073-1.331), primary cardiomyopathy (HR: 1.382, 95% CI: 1.183-1.614), diabetes (HR: 1.118, 95% CI: 1.010-1.237), stroke (HR: 1.252, 95% CI: 1.121-1.397), and the use of diuretics (HR: 0.714, 95% CI: 0.626-0.814), β-blockers (HR: 0.673, 95% CI: 0.588-0.769), angiotensin-converting enzyme inhibitors (ACEIs) (HR: 0.714, 95% CI: 0.604-0.845), angiotensin-II receptor blockers (ARBs) (HR: 0.790, 95% CI: 0.646-0.965), spironolactone (HR: 0.814, 95% CI: 0.663-0.999), calcium antagonists (HR: 0.624, 95% CI: 0.531-0.733), nitrates (HR: 0.715, 95% CI: 0.631-0.811), and digoxin (HR: 0.579, 95% CI: 0.465-0.721).@*CONCLUSIONS@#The results of our study demonstrate poor 5-year outcomes of patients presenting to EDs with AHF. Age, BMI, fatigue, ascites, hepatic jugular reflux, NYHA class III to IV, heart rate, DBP, BUN, BNP/NT-proBNP level in the third or fourth quartile, serum sodium, serum albumin, ischemic heart diseases, primary cardiomyopathy, diabetes, stroke, and the use of diuretics, β-blockers, ACEIs, ARBs, spironolactone, calcium antagonists, nitrates, and digoxin were independently associated with 5-year all-cause mortality.
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Humans , Angiotensin Receptor Antagonists , Angiotensin-Converting Enzyme Inhibitors , Beijing/epidemiology , Biomarkers , Cohort Studies , Emergency Service, Hospital , Follow-Up Studies , Heart Failure/mortality , Natriuretic Peptide, Brain , Peptide Fragments , Prognosis , Prospective StudiesABSTRACT
OBJECTIVE: To explore the characteristics of death distribution in emergency critical care patients and guide the distribution of emergency resources.METHODS: Clinical data of all patients who died in the emergency department of Peking University third hospital from 2013 to 2017 were collected.Age,gender composition and time of death were analyzed.Pareto diagram was used to analyze the composition of causes of death.RESULTS:(1)Elderly patients(≥60 years old)accounted for81.0% of the total number of deaths,and the age difference has statistically significant(P<0.05).(2)Pareto diagram analysis showed that respiratory diseases,sudden death,shock and nervous diseases were the main causes of death in critically ill patients.(3)Age was associated with respiratory diseases,cardiovascular diseases,shock,sudden death,nervous diseases and trauma(P<0.05).Gender was associated with respiratory diseases,sudden death and trauma(P<0.05).(4)50.8% the death cases occurred within 24 h after admission,the median time of sudden death patients is the shortest(1 h),followed by shock(24 h).The median time of death of malignant tumor was up to 5040 h.CONCLUSION: Elderly patients are the major death group in the emergency department.Respiratory,circulatory and neurological diseases are the common causes of death.And most patients die in the early stage of treatment.Therefore,it is necessary to reasonably allocate emergency medical resources according to the actual situation.
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With the progresses of aggravation of social population aging degree and elevation of health awareness, the emergency medical resources are difficult to meet the increasing demand for emergency medical services of patients, leading to the increase of congestion in the Department of Emergency that has threatened the safety of the entire medical and health system. Among the patients, because the elderly patient diseases are characterized by coexistence of multiple diseases, the complexity of diagnosis and treatment, etc, they occupy a large number of emergency medical resources, resulting in the main important factor affecting the overcrowding in emergency department. Therefore, we have comprehensively analyzed the domestic and foreign researches related to the overcrowding in emergency departments, summarized the effect of elderly patients on the overcrowding and reviewed the corresponding mitigation measures, expecting to provide a reference for the study of emergency department overcrowding in China.
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Objective To analyze clinical characteristics and risk factors of pulmonary hypertension (PH) in patients with sepsis.Methods According to retrospective analysis of clinical data 136 cases with sepsis were divided into PH group and non-PH group.The clinical data,laboratory findings and ultrasonic cardiographic findings were recorded and compared between two groups.Multi-factors Logistic regression analysis was performed to find the independent risk factors of PH in patients with sepsis,and receiver operating characteristic curve ROC was constructed to indicate the predictable value.Results Of 136 patients with sepsis,32 (23.5％) developed PH.The PH group had higher NT-proBNP [lgNT-proBNP (3.67±0.41) vs.(3.33±0.59),P=0.003],higher E peak [(86.12±30.43) vs.(67.73±21.49),P=0.008],higher E/A peak [(1.09±0.46) vs.(0.83±0.29),P=0.014],higher left atrium diameter (LAD) [(36.49±5.97) vs.(31.32±4.69),P=0.001] and lower oxygenation index [(291.90±51.62) vs.(326.40±88.16),P=0.017] than the non-PH group (P ＜ 0.05).It was shown by multi-factors Logistic regression analysis that LAD (OR=1.198,P=0.010) was an independent risk factor of PH in patients with sepsis.The area under the curve AUC of LAD was 0.723,with the cut-off value of 31 mm (sensibility 82.6％,specificity 49.0％).Conclusions LAD was an independent risk factor of sepsis-associated pulmonary hypertension in sepsis patients.
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Objective To investigate the predictive value of serum N-terminal pro brain natriuretic peptide NT-proBNP in left ventricular diastolic dysfunction(LVDD) in septic shock patients.Methods According to retrospective analysis of clinical data 96 patients with septic shock were divided into LVDD group and non-LVDD group.General clinical data,APACHE scores,NT-proBNP,Troponin I(TNI),creatinine,procalcitonin,D-dimer and lactic acid within the first 24 hours after admission were recorded,and multi-factors logistic regression analysis was conducted to find independent risk factors for left ventricular diastolic dysfunction in septic shock patients Receiver operating characteristic curve ROC was constructed to indicate the predictive value.Results There were no significant differences in general clinical data,procalcitonin,D-dimer and lactic acid between two groups.Compared with non-LVDD group the levels of NT-proBNP [lgNT-proBNP (3.66±0.38) vs.(3.03±0.59),P =0.000],TNI [lgTNI(-1.45±0.86)vs.(-2.36±0.82),P ＜ 0.01] and creatinine [(186.12±124.24)vs.(101.16±57.01),P ＜ 0.01] in LVDD group were significantly higher.It was shown by multi-factors logistic regression analysis that NT-proBNP (OR=8.731,95％CI;1.541-49.466,P=0.014) was an independent risk factor for left ventricular diastolic dysfunction in septic shock patients.The area under the curve AUC of NT-proBNP was 0.813 with the cut-off value of 1 725 pg/μL,sensibility =88.6％,specificity =62.1％.Conclusion NT-proBNP was avaluable indicator in predicting left ventricular diastolic dysfunction in septic shock patients.
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Objective To explore the multiple disciplinary model of emergent extracorporeal membrane oxygenation (ECMO) for cardiac arrest (CA) patients.Methods A retrospective investigation was done to analyze the general material,multiple disciplinary corporations,the complication and its treatment of patients who underwent emergent ECMO for non-surgery CA from January 2016 to August 2017.Results Three patients were all men with mean age 45.3 ± 20.3 years.Their mean cardiopulmonary resuscitation duration was 34 ± 10 min,and 2 patients returned to spontaneous circulation,yet hemodynamics instability.2 patients discharged with cerebral performance category 1-2,however the third died.3 cannulation of femoral artery and venous were all operated by cardiac surgery using surgical exposure via open cutdown.Mean duration of CA to ECMO pump-on was 132 ±93 min,while the mean duration of ECMO was 3 858 ± 1 092min.The implementation and maintenance of ECMO needed collaboration of emergent physicians,cardiovascular medicine and surgeon,anesthetists,nurses and so on.At the same time,incision site oozing blood,platelet counting decreasing,coagulopathy and other complications would occur,which needed interventional vascular surgeon and blood bank to participate in.Conclusions Emergent ECMO for CA patients need corporations of prehospital emergent medical system,emergent physicians,cardiovascular physicians and surgeons,anesthetists,perfusionists,blood bank and so on.Establishing coordination and cooperation model of multiple disciplinary quick response team with emergency department as the guide is the important guarantee for emergent department developing emergent extracorporeal resuscitation.
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<p><b>BACKGROUND</b>Since the 1980s, severity of illness scoring systems has gained increasing popularity in Intensive Care Units (ICUs). Physicians used them for predicting mortality and assessing illness severity in clinical trials. The objective of this study was to assess the performance of Simplified Acute Physiology Score 3 (SAPS 3) and its customized equation for Australasia (Australasia SAPS 3, SAPS 3 [AUS]) in predicting clinical prognosis and hospital mortality in emergency ICU (EICU).</p><p><b>METHODS</b>A retrospective analysis of the EICU including 463 patients was conducted between January 2013 and December 2015 in the EICU of Peking University Third Hospital. The worst physiological data of enrolled patients were collected within 24 h after admission to calculate SAPS 3 score and predicted mortality by regression equation. Discrimination between survivals and deaths was assessed by the area under the receiver operator characteristic curve (AUC). Calibration was evaluated by Hosmer-Lemeshow goodness-of-fit test through calculating the ratio of observed-to-expected numbers of deaths which is known as the standardized mortality ratio (SMR).</p><p><b>RESULTS</b>A total of 463 patients were enrolled in the study, and the observed hospital mortality was 26.1% (121/463). The patients enrolled were divided into survivors and nonsurvivors. Age, SAPS 3 score, Acute Physiology and Chronic Health Evaluation Score II (APACHE II), and predicted mortality were significantly higher in nonsurvivors than survivors (P < 0.05 or P < 0.01). The AUC (95% confidence intervals [CI s]) for SAPS 3 score was 0.836 (0.796-0.876). The maximum of Youden's index, cutoff, sensitivity, and specificity of SAPS 3 score were 0.526%, 70.5 points, 66.9%, and 85.7%, respectively. The Hosmer-Lemeshow goodness-of-fit test for SAPS 3 demonstrated a Chi-square test score of 10.25, P = 0.33, SMR (95% CI) = 0.63 (0.52-0.76). The Hosmer-Lemeshow goodness-of-fit test for SAPS 3 (AUS) demonstrated a Chi-square test score of 9.55, P = 0.38, SMR (95% CI) = 0.68 (0.57-0.81). Univariate and multivariate analyses were conducted for biochemical variables that were probably correlated to prognosis. Eventually, blood urea nitrogen (BUN), albumin,lactate and free triiodothyronine (FT3) were selected as independent risk factors for predicting prognosis.</p><p><b>CONCLUSIONS</b>The SAPS 3 score system exhibited satisfactory performance even superior to APACHE II in discrimination. In predicting hospital mortality, SAPS 3 did not exhibit good calibration and overestimated hospital mortality, which demonstrated that SAPS 3 needs improvement in the future.</p>
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<p><b>BACKGROUND</b>The emergency department (ED) has a pivotal influence on the management of acute heart failure (AHF), but data concerning current ED management are scarce. This Beijing AHF Registry Study investigated the characteristics, ED management, and short- and long-term clinical outcomes of AHF.</p><p><b>METHODS</b>This prospective, multicenter, observational study consecutively enrolled 3335 AHF patients who visited 14 EDs in Beijing from January 1, 2011, to September 23, 2012. Baseline data on characteristics and management were collected in the EDs. Follow-up data on death and readmissions were collected until November 31, 2013, with a response rate of 92.80%. The data were reported as median (interquartile range) for the continuous variables, or as number (percentage) for the categorical variables.</p><p><b>RESULTS</b>The median age of the enrolled patients was 71 (58-79) years, and 46.84% were women. In patients with AHF, coronary heart disease (43.27%) was the most common etiology, and myocardium ischemia (30.22%) was the main precipitant. Most of the patients in the ED received intravenous treatments, including diuretics (79.28%) and vasodilators (74.90%). Fewer patients in the ED received neurohormonal antagonists, and 25.94%, 31.12%, and 33.73% of patients received angiotensin converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and spironolactone, respectively. The proportions of patients who were admitted, discharged, left against medical advice, and died were 55.53%, 33.58%, 7.08%, and 3.81%, respectively. All-cause mortalities at 30 days and 1 year were 15.30% and 32.27%, respectively.</p><p><b>CONCLUSIONS</b>Substantial details on characteristics and ED management of AHF were investigated. The clinical outcomes of AHF patients were dismal. Thus, further investigations of ED-based therapeutic approaches for AHF are needed.</p>
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Objective To investigate the occurrence of thyroid disorders in septic patients and the relationship between thyroid hormone level and the change of left ventricular function.Methods A total of 63 septic patients,43 male and 20 female,aged 50 to 88 years with mean 63.3 ± 18.5,were included in the present study.The thyroid hormone levels and C-reactive protein (CRP) levels were detected in all patients on the next day of admission.Clinical information of each patient was recorded including demographics and co-existed disease,APACHE Ⅱ score at admission and the incidence of shock and subsequent multiple organ dysfunction syndrome (MODS).At 24 hours,the second week and the third week after admission,a serial trans-thoracic echocardiography were performed in all patients to observe changes of left ventricular end diastolic dimension,left ventricular eject fraction and E/A (the ratio between maximal velocity of blood flow at mitral valve orifice in the early diastolic phase and maximal velocity of blood flow of atrium in systolic phase).Another 38 patients with ordinary infections,21 male and 17 female,with mean age 58.6 ± 16.8 (48-84 years) were selected as controls for comparison.The difference in thyroid function between sepsis group and control group was analyzed.The levels of serum thyroid hormone associated with the incidence of shock and MODS were studied among different types of the left ventricular structure and function in sepsis group.Results The levels of serum free tri-iodothyronine (FT3) and free tetra-iodothyronine (FT4) in sepsis group were significantly lower than those in control group (P ＜ 0.05),but there was no difference in level of thyroid stimulating hormone (TSH) between these two groups.The patients with sepsis had three types of the left ventricular dysfunction:diastolic dysfunction without the enlargement of left ventricular (type Ⅰ) in 31 patients,the enlargement of left ventricular with diastolic dysfunction (type Ⅱ) in 18 patients and the enlargement of left ventricular with both systolic and diastolic dysfunction (type Ⅲ) in 14 patients.Compared with the other two types,the type Ⅲ patients had significantly lower levels of FT3 and FT4 and higher incidences of shock and MODS (P ＜ 0.05).No significant difference in TSH level was found among the three types.There were no significantly differences in FT3 and FT4 between type Ⅰ and type Ⅱ,but the higher incidences of shock and MODS were found in type Ⅰ (P ＞ 0.05).Conclusions Most septic patients have thyroid function disorder.Serum thyroid hormone levels in early stage of sepsis have certain role in predicting changes in left ventricular structure and function in the late stage of disease.
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<p><b>BACKGROUND</b>Underlying diseases have a statistically significant positive correlation to sudden death. However, sudden unexplained death (SUD) is different from sudden death, as there is no clinical evidence to support the sudden death due to the original underlying disease, nor a lethal pathological basis to be found during autopsy. In addition, SUD are more common in young, previously healthy individuals, usually without any signs of disease, with no positive lesions found after autopsy. Therefore, a causal relationship between SUD and the underlying disease needs to be further explored. This study aimed to explore the role that common underlying diseases play in patients with SUD and to reveal the correlation between them.</p><p><b>METHODS</b>The medical records, history and case information of 208 patients with SUD were collected for the survey. All these SUD occurred in the emergency room of Peking University Third Hospital from January 2006 to December 2009. The patients were stratified by with and without common underlying diseases. To examine possible associations between the underlying diseases and the cause of unexplained sudden death, the chi-squared and Fisher's exact tests were used.</p><p><b>RESULTS</b>Among the 208 patients, 65 were diagnosed with common underlying diseases while 143 were not. Within these two groups, there were 45 patients for whom the clear cause of death was determined. However, there were no statistically significant differences or strong associations (χ(2) = 1.238, P > 0.05) between the 11 patients with (16.90%) and 34 without (23.78%) common underlying disease among these 45 patients. We also found that occurrence of the common underlying diseases, such as neurological system, cardiovascular and pulmonary system diseases, are not statistically significant (P > 0.05) in the diagnosis of the SUD.</p><p><b>CONCLUSION</b>Common underlying diseases make no obvious contributions to SUD and are not useful in diagnosing the underlying reasons for death.</p>
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Adolescent , Adult , Aged , Female , Humans , Male , Middle Aged , Young Adult , Cause of Death , Death, Sudden , EpidemiologyABSTRACT
<p><b>BACKGROUND</b>Pulmonary embolism (PE) is rare and seldom considered in adolescent patients; however it occurs with a greater frequency than is generally recognized, and it is a potentially fatal condition. The aim of the current study was to understand its epidemiology, clinical features and the cause of delay of its diagnosis in adolescents.</p><p><b>METHODS</b>A retrospective analysis of nine adolescents with acute PE admitted to the Peking University Third Hospital over the past 16-year period was performed. The epidemiology, clinical features and risk factors of the adolescents were described and compared with those of adults and elderly patients. The time to diagnosis and misdiagnosed diseases were analyzed. Pretest probability of PE was assessed retrospectively by the Wells score and revised Geneva score.</p><p><b>RESULTS</b>The incidence of PE was 43.6 per 100 000 hospitalized adolescents in our hospital. The incidence of PE in adolescents was much lower than that in adults and PE is diagnosed in about 1/50 of elderly people. The clinical features in adolescents were similar to those in adults. But fever and chest pain were more common in adolescents (P < 0.05). The major risk factors included surgery, systemic lupus erythematosus (SLE), thrombocytopenia, long-term oral glucocorticoids and trauma. The mean diagnostic time was (7.8 ± 8.4) days. Six cases had a delayed diagnosis. The mean delay time from symptom onset to diagnosis was (11.0 ± 8.8) days. The time of presentation to diagnosis in patients initially admitted to the emergency department was less than one day, and was much shorter than the time in outpatients, (9.4 ± 7.5) days. Most of the patients were initially misdiagnosed with a respiratory tract infection. Most patients' values of Wells score or revised Geneva score were in the moderate or high clinical probability categories; 88% by Well score vs. 100% by revised Geneva score.</p><p><b>CONCLUSIONS</b>PE was seldom considered in the adolescent patients by physicians, especially outpatient physicians, so the diagnosis was often delayed. If adolescent patients complain of dyspnea or chest pain or syncope with/without fever, and they had risk factors such as surgery, thrombocytopenia and trauma, PE should be considered and included in the differential diagnosis.</p>
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Adolescent , Adult , Humans , Male , Diagnosis, Differential , Diagnostic Errors , Probability , Pulmonary Embolism , Diagnosis , Epidemiology , Retrospective Studies , Risk FactorsABSTRACT
Objective To explore the association between ambient average temperature and hospital emergency room visits for cardiovascular diseases(International Classification of Diseases,Tenth Vision ICD-10:I00-I99) in Beijing,China.Methods Data was collected on daily hospital emergency room visits for cardiovascular diseases from Peking University Third Hospital,including meteorological data(daily average temperature,relative humidity,wind speed,and atmospheric pressure) from the China Meteorological Data Sharing Service System,and on air pollution from the Beijing Municipal Environmental Monitoring Center.Time-stratified case-crossover design was used to analyze data on 4 seasolls.Results After adjusting data on air pollution,1 degree(℃) increase of ambient average temperature would associate with the emergency room visits of odds ratio(Ors)as 1.282(95%CI:1.250-1.315).1.027(95%CI:1.001-1.055),0.661(95%CI:0.637-0.687),and 0.960 (95%CI:0.937-0.984) in spring,summer,autumn,and winter respectively.After controlling the influence of relative humidity,wind speed,and atmospheric pressure,1℃ increase in the ambient average temperature would be associated with the emergency room visits on Ors value as 1.423 (95%CI:1.377-1.471).1.082(95%CI:1.041-1.124),0.633(95%CI:0.607-0.660)and 0.971(95%CI:0.944-1.000) in spring,summer,auttmm,and winter respectively.Conclusion These data on outcomes suggested that the elevated level of ambient temperature would increase the hospital emergeney room visits for cardiovascular diseases in spring and summer while the elevated level of ambient temperature would decrease the hospital emergency room visits for the cardiovascular diseases in autumn and winter,suggesting that patients with cardiovascular diseases should pay attention to the climate change.
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<p><b>OBJECTIVE</b>To analyze diagnostic approach to severe acute respiratory syndrome (SARS) according to the diagnostic criteria issued by the Ministry of Health of China (MHC).</p><p><b>METHODS</b>The clinical data and the diagnostic results of 108 cases of SARS were retrospectively reviewed according to the MHC criteria.</p><p><b>RESULTS</b>There were 55 men and 53 women, with a median age of 34.5 years (range, 12 - 78 years). The interval between their first visit and clinical diagnosis was 3 days (range, 0 - 14 days). The diagnosis was made at the first visit in 7 (6.5%, 7/108) cases with a history of exposure to SARS patients and infiltrates on chest radiograph. Eighty-nine (82.4%) and 12 (11.1%) patients were categorized as probable cases and suspected cases respectively at their first visit and a clinical diagnosis of SARS was made subsequently. The interval between first visit and reaching the final diagnosis was 1 - 3 days in 72 (66.7%) cases and 4 days in 29 (26.9%) cases. The final diagnosis was made in 0 - 14 days (median, 2 days) for those (n = 59, 54.6%) with a history of close contact with SARS patients and 2 - 8 days (median, 3 days) for those (n = 49, 45.4%) living in Beijing but without such a history (P = 0.03). The chest radiograph was interpreted as unremarkable in 26 (24.1%) cases at their first visit, and the diagnosis was made in 4 days (range 2 - 8 days), which was significantly longer compared with other cases (P < 0.001). In patients without a history of close contact with SARS patients, all the five criteria were met after combination antibiotic therapy had failed.</p><p><b>CONCLUSIONS</b>A chest radiograph without infiltrates at the early stage of SARS is an important factor responsible for delayed diagnosis. In patients without a history of close contact with SARS cases, antibiotic effect was a major factor influencing doctors' diagnosis.</p>