Evaluation of the InterTAK Diagnostic Score in differentiating Takotsubo syndrome from acute coronary syndrome. A single center experience.

BACKGROUND: The aim of this study was to evaluate the usefulness of a novel clinical score - the InterTAK Diagnostic Score in differentiating Takotsubo syndrome (TTS) from acute coronary syndrome (ACS). METHODS: Medical records of 40 consecutive patients with ACS and 20 patients with TTS were managed and retrospectively analyzed at the documented center. Each patient was evaluated using the Inter- TAK Diagnostic Score. To illustrate the diagnostic ability of the score, a receiver operating characteristic (ROC) curve was performed. RESULTS: Takotsube syndrome patients were more often female compared to the ACS group (70% vs. 27.5%, p = 0.002), an emotional trigger was more prevalent among the TTS group (65% vs. 7.5%, p < 0.001). The area under the curve (AUC) for the score was 0.885 (95% confidence interval [CI] 0.78-0.97). Using a cut-off value of 45 points, the sum of sensitivity and specificity was the highest. However, when patients with a score of ≥ 50 were diagnosed as TTS, 85% were diagnosed correctly. When patients with score ≤ 31 were diagnosed as ACS, 92% were diagnosed correctly. CONCLUSIONS: The InterTAK Diagnostic Score might help in differentiating TTS from ACSs with high sensitivity and specificity. This finding requires further investigation to confirm its clinical utility.

Plasma growth differentiation factor 15 levels for predicting serious adverse events and bleeding in acute pulmonary embolism: a prospective observational study.

INTRODUCTION: Growth differentiation factor 15 (GDF­15), a cytokine induced in the myocardium by pressure overload and ischemia, has a well­established prognostic role for diseases of the left ventricle. Plasma GDF­15 concentrations were shown to predict bleeding events in patients with atrial fibrillation on anticoagulation. OBJECTIVES: To investigate the prognostic value of GDF­15 in acute pulmonary embolism (PE). PATIENTS AND METHODS: This was a prospective observational study of 77 patients hospitalized for PE. The median length of hospital stay and follow-up was 9 days. Plasma GDF­15 levels were measured using an automated sandwich electrochemiluminescence immunoassay. The outcome measures were: 1) in­hospital serious adverse events (SAE; death, cardiopulmonary resuscitation, need for urgent reperfusion therapy, catecholamine administration), and 2) major bleeding or nonmajor clinically relevant bleeding. RESULTS: There were 12 SAE and 5 bleeding events. The median (interquartile range) GDF­15 concentration at admission was 2354 ng/l (1151-4750 ng/l). GDF­15 concentrations increased according to risk subgroup. Patients with serious adverse events or bleeding events had higher baseline concentrations of GDF­15 (median [interquartile range], 3460 ng/l [2 531-12 363 ng/l] vs 2034 ng/l [1121-4449 ng/l]; P = 0.01). The area under the curve for GDF­15, high­sensitivity cardiac troponin T, and N­terminal pro-brain natriuretic peptide concentrations for predicting SAE was similar, the area under the curve of GDF­15 levels for predicting bleeding was 0.783 (95% CI, 0.62-0.946; P = 0.001) and 0.71 (95% CI, 0.567-0.853; P = 0.004) for predicting any adverse event. In the multivariable analysis, GDF­15 greater than 1680 ng/l emerged as an independent predictor of adverse outcomes (odds ratio, 8.9; P = 0.047). CONCLUSIONS: Plasma GDF­15 concentrations may be a promising biomarker for predicting hemodynamic destabilization and bleeding complications in PE.

Management of high risk pulmonary embolism - a single center experience.

BACKGROUND AND AIM: Patients with acute pulmonary embolism (APE) associated with hemodynamic instability, i.e. high-risk APE (HR-APE), are at risk for early mortality and require urgent reperfusion therapy with thrombolysis or embolectomy. However, a considerable proportion of HR-APE subjects is not reperfused but only anticoagulated due to high bleeding risk. The aim of the present study was to assess the management of HR-APE in a single large-volume referral center. METHODS: A single-center retrospective study of 32 HR-APE subjects identified among 823 consecutive patients hospitalized for symptomatic APE. RESULTS: Out of 32 subjects with HR-APE (19 women, age 69 ± 19 years), 20 patients were unstable at admission and 12 subsequently deteriorated despite on-going anticoagulation. Thrombolysis was applied in 20 (62.5%) of HR-APE subjects, limited mainly by classical contraindications in the remainder. Percutaneous pulmonary embolectomy was performed in 4 patients. In-hospital PE-related mortality tended to be higher, albeit insignificantly, in the patients who developed hemodynamic collapse during the hospital course compared to those unstable at admission (67% vs. 40%, p = 0.14). Also, survival was slightly better in 22 patients treated with thrombolysis or percutaneous embolectomy in comparison to 10 subjects who received only anticoagulation (54% vs. 40%, p = 0.2). Major non-fatal bleedings occurred in 7 of 20 patients receiving thrombolysis (35%) and in 2 (17%) of the remaining non-thrombolysed 12 HR-APE subjects. CONCLUSIONS: Hemodynamically instability, corresponding to the definition of HR-APE, affects about 4% of patients with APE, developing during the hospital course in approximately one-third of HR-APE subjects. As almost 40% of patients with HR-APE do not receive thrombolytic therapy for fear of bleeding, urgent percutaneous catheter-assisted embolectomy may increase the percentage of patients with HR-APE undergoing reperfusion therapy. Further studies are warranted for a proper identification of initially stable intermediate-risk APE subjects at risk of hemodynamic collapse despite appropriate anticoagulation.

Age­adjusted plasma D­dimer levels in suspected acute pulmonary embolism: a retrospective, single­center study.

INTRODUCTION The conventional D­dimer threshold (CDD) is characterized by high sensitivity and low specificity in diagnosing acute pulmonary embolism (PE) in older patients. A higher cut­off level for D­dimer has been proposed, aiming at increasing the specificity while maintaining high sensitivity. It is calculated by multiplying the patient's age in years by a coefficient of 10 (YADD10). OBJECTIVES The aim of this study was to validate the clinical value of YADD10 in patients with suspected acute PE and to optimize this threshold to achieve increased specificity paired with high sensitivity. PATIENTS AND METHODS The medical records of 1022 patients with suspected acute PE, hospitalized between the years 2014 and 2016, were retrospectively analyzed. Patients older than 50 years, with complete medical records and good quality of multislice computed tomography (CT) scans were enrolled. The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of the proposed thresholds were calculated and compared with those of the CCD. The number of computed tomography scans that could have been avoided with higher thresholds was determined. RESULTS The final analysis included 321 patients (176 women; mean age, 74.2 years; range, 51-101 years). Acute PE was confirmed in 135 patients. The sensitivity of CDD was 100%, and specificity-5.4%. The use of the YADD10 and YADD11 thresholds (obtained by multiplying by the coefficients of 10 and 11, respectively) resulted in maintaining high sensitivity, with increased specificity of 8.6% (YADD10) and 12.4% (YADD11). The number of unnecessary CT scans was reduced by 7%. CONCLUSIONS The YADD thresholds are characterized by high sensitivity and increased specificity when compared with CDD, thus allowing for a safe reduction of the number of CT scans. A prospective study should be conducted to validate these results.

Tricuspid annulus plane systolic excursion (TAPSE) has superior predictive value compared to right ventricular to left ventricular ratio in normotensive patients with acute pulmonary embolism.

INTRODUCTION: Right ventricular dysfunction (RVD) is an indicator of poor prognosis in normotensive patients with acute pulmonary embolism (APE). The aim of this study was to compare right ventricular (RV)/left ventricular (LV) ratio measured by echocardiography and multidetector computed tomography (MDCT) with tricuspid annulus plane systolic excursion (TAPSE) as a prognostic factor of APE-related 30-day mortality. MATERIAL AND METHODS: We examined 76 patients with confirmed APE, hemodynamically stable at admission. We evaluated the prognostic value of RV/LV ratio in the apical 4-chamber view and TAPSE measured at echocardiography and the MDCT RV/LV ratio. RESULTS: Thirty-day APE-related mortality was 10.5% (8 patients). The area under the curve (AUC) for TAPSE in the prediction of APE-related mortality was higher (p < 0.00001) (0.905, 95% CI: 0.828-0.983) than the AUC of the echo RV/LV ratio (0.427, 95% CI: 0.183-0.672) and MDCT RV/LV ratio (0.371, 95% CI: 0.145-0.598). In univariable Cox analysis, TAPSE was the only significant mortality predictor, with hazard ratio (HR) 0.73 (95% CI: 0.62-0.87, p = 0.0004). In multivariable Cox analysis TAPSE was the only significant mortality predictor, with HR 0.62 (95% CI: 0.46-0.85; p = 0.003), while age, heart rate, and RV/LV ratio in echo or MDCT were non-significant. TAPSE ≤ 15 mm was a significant predictor of APE-related mortality, with HR 26.2 (95% CI: 3.2-214.1; p = 0.002), PPV 44% and NPV 98%. CONCLUSIONS: The TAPSE is preferable to echo and MDCT RV/LV ratio for risk stratification in initially normotensive patients with APE. The TAPSE ≤ 15 mm identifies patients with an increased risk of 30-day APE-related mortality.

Acute pulmonary embolism treatment with rivaroxaban results in a shorter duration of hospitalisation compared to standard therapy: an academic centre experience.

BACKGROUND: Depending on the severity of clinical condition, acute pulmonary embolism (APE) is treated with unfraction-ated heparin (UFH), low-molecular weight heparin (LMWH), oral anticoagulants or, in the most severe form, with fibrinolytic agents. Following APE, patients require prolonged anticoagulant therapy for 3-6 months or in some cases indefinitely. Treatment options in this period include vitamin K antagonists (VKA) and non-VKA oral anticoagulants (NOAC) including rivaroxaban. The most recent European Society of Cardiology guidelines on the diagnosis and management of APE recommend use of NOAC in patients at a low-to-moderate risk of early mortality (a class I B recommendation). Rivaroxaban may be used in haemodynamically stable patients since the first day of therapy and was approved for this indication in Poland in December 2012. AIM: To evaluate the rate of rivaroxaban use, characterise patients with APE treated with rivaroxaban, and evaluate potential reduction of the duration of hospitalisation in patients treated with rivaroxaban compared to those receiving VKA. METHODS: We evaluated hospital and postdischarge treatment in 215 consecutive APE patients (105 men, 110 women) at the mean age of 65.0 (range: 19.5-91.9) years. The study included patients hospitalised from January 2013 to November 2014, i.e. in the period immediately following approval of rivaroxaban for the treatment of APE in Poland. In the acute phase, patients were treated with LMWH, UFH, or rivaroxaban, and the treatment was continued with VKA, LMWH, or rivaroxaban. The timing of initiation of oral therapy depended on the haemodynamic stability of the patient. RESULTS: Our study group of 215 APE patients included 157 (73%) moderate-risk patients, 51 (24%) low-risk, and 7 (3.3%) high-risk patients. Treatment was initiated with UFH or LMWH in 208 (96.7%) patients, and with rivaroxaban in 7 (3.3%) patients. In 33 (16.5%) patients, rivaroxaban was started after up to 3 days of heparin therapy. Chronic therapy prescribed at discharge in-cluded VKA in 64 (30.5%) patients, rivaroxaban in 82 (39%) patients, and LMWH in 64 (30.5%) patients. Five patients died during hospital, for the total mortality of 2.3%. Acute high-risk PE was diagnosed on admission in 2 of these patients, and moderate-risk PE in 3 patients. Treatment in this group included enoxaparin in 4 patients and UFH in 1 patient. Patients who were discharged on rivaroxaban stayed in hospital for a significantly shorter time compared to patients discharged on VKA (6 [2-22] vs. 8 [2-17] days, p = 0.0005). Duration of hospital stay was significantly shorter in APE patients with sPESI of 0 who were treated with rivaroxaban compared to those with sPESI of 0 treated with VKA (5 [2-11] vs. 6 [2-12] days, p = 0.002). A significant difference in the duration of hospital stay was also noted in patients with sPESI of ≥ 1 treated with rivaroxaban compared to those treated with VKA (7 [3-22] vs. 9 [3-17] days, p = 0.015). Patients with sPESI of ≥ 1 treated with rivaroxaban were hospitalised for a sig-nificantly longer time compared to those with sPESI of 0 treated with rivaroxaban (7 [3-22] vs. 5 [2-11] days, p = 0.00005). CONCLUSIONS: Rivaroxaban therapy is a useful therapeutic option in patients with APE. Compared to standard therapy, use of rivaroxaban has been associated with a significant reduction of the duration of hospital stay.

Cardiac arrest and electrical storm due to recurrent torsades de pointes caused by concomitant clarithromycin, cotrimoxazole and amiodarone treatment.

Torsades de pointes (TdP) is a rapid, polymorphic and usually self-terminating ventricular tachycardia associated with the long QT syndrome. Many drugs may cause prolongation of QT interval and be the trigger for TdP occurrence. We present the case of 52-year-old male who was treated with clarithromycin due to bilateral atypical pneumonia. However, on the fourth day of hospitalization he deteriorated, developed pulmonary edema and short cardiac arrest. After successful resuscitation, unfortunately amiodarone and co-trimoxazole were given causing the arrhythmic storm which required many defibrillations. The case highlights the importance of careful QT measurement, appropriate TdP treatment and difficulties resulting from the patient's disagreement for invasive treatment. We think, that knowledge of drug-induced long QT syndrome and its consequences should be widely spread not only in cardiologists, but also in others doctors.

Patent foramen ovale increases the risk of acute ischemic stroke in patients with acute pulmonary embolism leading to right ventricular dysfunction.

BACKGROUND: Patent foramen ovale (PFO) is an established risk factor for ischemic stroke. Since acute right ventricular dysfunction (RVD) observed in patients with PE can lead to right-to-left inter-atrial shunt via PFO, we hypothesized that PFO is a risk factor for ischemic stroke in PE with significant right ventricular dysfunction. METHODS: 55 patients (31 F, 24M), median age 49 years (range 19-83 years) with confirmed PE underwent echocardiography for RVD and PFO assessment. High risk acute PE was diagnosed in 3 (5.5%) patients, while 16 (29%) hemodynamically stable with RVD patients formed a group with intermediate-risk PE. PFO was diagnosed in 19 patients (34.5%). Diffusion-weighted MRI of the brain for acute ischemic stroke (AIS) was performed in all patients 4.91 ± 4.1 days after admission. RESULTS: AIS was detected by MRI in 4 patients (7.3%). Only one stroke was clinically overt and resulted in hemiplegia. All 4 AIS occurred in the PFO positive group (4 of 19 patients), and none in subjects without PFO (21.0% vs 0%, p=0.02). Moreover, all AIS occurred in patients with RVD and PFO, and none in patients with PFO without RVD (50% vs 0%, p=0.038). CONCLUSION: Our data suggest that acute pulmonary embolism resulting in right ventricular dysfunction may lead to acute ischemic stroke in patients with patent foramen ovale. However, the clinical significance of such lesions remains to be determined.