ABSTRACT
BACKGROUND: The aim of this study was to define clinical evidence supporting that triple rule-out computed tomography angiography (TRO CTA) is a comprehensive and feasible diagnostic tool in patients with novel coronavirus disease 2019 (COVID-19) who were admitted to the emergency department (ED) for acute chest pain. Optimizing diagnostic imaging strategies in COVID-19 related thromboembolic events, will help for rapid and noninvasive diagnoses and results will be effective for patients and healthcare systems in all aspects. AIM: To define clinical evidence supporting that TRO CTA is a comprehensive and feasible diagnostic tool in COVID-19 patients who were admitted to the ED for acute chest pain, and to assess outcomes of optimizing diagnostic imaging strategies, particularly TRO CTA use, in COVID-19 related thromboembolic events. METHODS: TRO CTA images were evaluated for the presence of coronary artery disease, pulmonary thromboembolism (PTE), or acute aortic syndromes. Statistical analyses were used for evaluation of significant association between the variables. A two tailed P-value < 0.05 was considered statistically significant. RESULTS: Fifty-three patients were included into the study. In 31 patients (65.9%), there was not any pathology, while PTE was diagnosed in 11 patients. There was no significant relationship between the rates of pathology on CTA and history of hypertension. On the other hand, the diabetes mellitus rate was much higher in the acute coronary syndrome group, particularly in the PTE group (8/31 = 25.8% vs 6/16 = 37.5%, P = 0.001). The rate of dyslipidemia was significantly higher in the group with pathology on CTA while compared to those without pathology apart from imaging findings of the pneumonia group (62.5% vs 38.7%, P < 0.001). Smoking history rates were similar in the groups. Platelets, D-dimer, fibrinogen, C-reactive protein, and erythrocyte sedimentation rate values were higher in COVID-19 cases with additional pathologies. CONCLUSION: TRO CTA is an effective imaging method in evaluation of all thoracic vascular systems at once and gives accurate results in COVID-19 patients.
ABSTRACT
In the Emergency Medicine setting, D-dimer is currently employed in the diagnostic assessment of suspected venous thromboembolism and aortic syndrome. The nonspecific symptoms reported by patients, like chest pain, dyspnea or syncope, uncover a wide range of differential diagnosis, spanning from mild to life-threatening conditions. Therefore, we assumed the perspective of the Emergency Physician and, in this narrative review, we reported a brief presentation of the epidemiology of these symptoms and the characteristics of patients, in whom we could suspect the aforementioned pathologies. We also reported in which patients D-dimer gives useful information. In fact, when the probability of the disease is high, the D-dimer level is futile. On the contrary, given the low specificity of the test, when the probability of the disease is very low, a false-positive value of the D-dimer only increases the risk of overtesting. Patients with low to moderate probability really benefit from the D-dimer testing, in order to prevent the execution of expensive and potentially dangerous imaging tests. In the second part of the review, we focused on the prognostic value of the test in septic patients. The early prognostic stratification of septic patients remains a challenge for the Emergency Physician, in the absence of a definite biomarker or score to rely on. Therefore, we need several parameters for the early identification of patients at risk of an adverse prognosis and the D-dimer may play a role in this demanding task. SARS COVID-19 patients represent an emerging reality, where the role of the D-dimer for prognostic stratification could be relevant. In fact, in patients with severe forms of this disease, the D-dimer reaches very high values, which appear to parallel the course of respiratory failure. Whether the test may add useful information for the management of these patients remains to be determined.
ABSTRACT
OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has posed challenges to health care services across the world. There has been a significant restructuring of health care resources to protect services for patients with COVID-19-related illness and to maintain emergency and urgent medical and surgical activity. This study assessed access to emergency treatment, logistical challenges, and outcomes of patients with acute aortic syndrome during the early months of the COVID-19 pandemic in the United Kingdom. METHODS: This was a multicenter study, from March 1 to May 20, 2020 that included 19 cardiac centers, was a retrospective analysis of prospectively collected data obtained from individual centers' national cardiac surgical databases. Demographic details, choice of treatment, operative details, and outcomes were collected. COVID-19 screening, timing of surgery, and outcomes of COVID-19-positive and -negative patients were also analyzed. RESULTS: In total, 88 patients presented with acute aortic syndrome to participating centers from March 1 to May 20, 2020. There were 79 aortic dissections (89.8%), 7 intramural hematomas (7.9%), and 2 penetrating aortic ulcers (2.3%). Seventy-nine patients (89.8%) underwent surgery. In-hospital mortality was 25.3% (n = 20). Postoperative complications included 13.9% postoperative stroke (11.4% permanent and 2.3% temporary), 16.5% rate of hemofiltration, and 10.1% rate of tracheostomy. Nine patients were treated conservatively with a mortality of 60%. Seven patients were diagnosed with COVID-19, and there was no associated mortality. CONCLUSIONS: Despite extensive restructuring of health care resources, access to emergency and urgent treatment for patients with acute aortic syndrome was maintained in the early months of the COVID-19 pandemic in the United Kingdom. Clinical outcomes were similar to the prepandemic period.