Early standardized clinical judgement for syncope diagnosis in the emergency department.

BACKGROUND: The diagnosis of cardiac syncope remains a challenge in the emergency department (ED). OBJECTIVE: Assessing the diagnostic accuracy of the early standardized clinical judgement (ESCJ) including a standardized syncope-specific case report form (CRF) in comparison with a recommended multivariable diagnostic score. METHODS: In a prospective international observational multicentre study, diagnostic accuracy for cardiac syncope of ESCJ by the ED physician amongst patients ≥ 40 years presenting with syncope to the ED was directly compared with that of the Evaluation of Guidelines in Syncope Study (EGSYS) diagnostic score. Cardiac syncope was centrally adjudicated independently of the ESCJ or conducted workup by two ED specialists based on all information available up to 1-year follow-up. Secondary aims included direct comparison with high-sensitivity cardiac troponin I (hs-cTnI) and B-type natriuretic peptide (BNP) concentrations and a Lasso regression to identify variables contributing most to ESCJ. RESULTS: Cardiac syncope was adjudicated in 252/1494 patients (15.2%). The diagnostic accuracy of ESCJ for cardiac syncope as quantified by the area under the curve (AUC) was 0.87 (95% CI: 0.84-0.89), and higher compared with the EGSYS diagnostic score (0.73 (95% CI: 0.70-0.76)), hs-cTnI (0.77 (95% CI: 0.73-0.80)) and BNP (0.77 (95% CI: 0.74-0.80)), all P < 0.001. Both biomarkers (alone or in combination) on top of the ESCJ significantly improved diagnostic accuracy. CONCLUSION: ESCJ including a standardized syncope-specific CRF has very high diagnostic accuracy and outperforms the EGSYS score, hs-cTnI and BNP.

Circadian rhythm of cardiac troponin I and its clinical impact on the diagnostic accuracy for acute myocardial infarction.

BACKGROUND: High-sensitivity cardiac troponin T (hs-cTnT) blood concentrations were shown to exhibit a diurnal rhythm, characterized by gradually decreasing concentrations throughout daytime, rising concentrations during nighttime and peak concentrations in the morning. We aimed to investigate whether this also applies to (h)s-cTnI assays and whether it would affect diagnostic accuracy for acute myocardial infarction (AMI). METHODS: Blood concentrations of cTnI were measured at presentation and after 1 h using four different cTnI assays: three commonly used sensitive (s-cTnI Architect, Ultra and Accu) and one experimental high-sensitivity assay (hs-cTnI Accu) in a prospective multicenter diagnostic study of patients presenting to the emergency department with suspected AMI. These concentrations and their diagnostic accuracy for AMI (quantified by the area under the curve (AUC)) were compared between morning (11 p.m. to 2 p.m.) and evening (2 p.m. to 11 p.m.) presenters. RESULTS: Among 2601 patients, AMI was the final diagnosis in 17.6% of patients. Concentrations of (h)s-cTnI as measured using all four assays were comparable in patients presenting in the morning versus patients presenting in the evening. Diagnostic accuracy for AMI of all four (h)s-cTnI assays were high and comparable between patients presenting in the morning versus presenting in the evening (AUC at presentation: 0.90 vs 0.93 for s-cTnI Architect; 0.91 vs 0.94 for s-cTnI Ultra; 0.89 vs 0.94 for s-cTnI Accu; 0.91 vs 0.94 for hs-cTnI Accu). CONCLUSIONS: Cardiac TnI does not seem to express a diurnal rhythm. Diagnostic accuracy for AMI is very high and does not differ with time of presentation. CLINICAL TRIAL REGISTRATION: NCT00470587, http://clinicaltrials.gov/show/NCT00470587.

First wave of the influenza A/H1N1v pandemic in Switzerland.

AIM: To describe the disease burden, clinical pattern and outcome of influenza-related cases presenting to a Swiss Emergency Department (ED), during the first wave of the 2009 pandemic. METHODS: Retrospective analysis of prospectively collected data at the University Hospital of Basel, Switzerland. All patients presenting to the ED with influenza-like symptoms from June 1 to October 23, 2009, were studied. Rate of hospitalisation, demographic characteristics, symptoms, microbiological diagnoses and complications of influenza infection were analysed. RESULTS: One tenth (808 of 8356 patients) of all non-trauma ED presentations, during the study period, were a result of suspected influenza-related illness. Influenza A/H1N1v infection accounted for 5% of these presentations. Patients aged 50 years or less accounted for 87% of these presentations and for 100% of A/H1N1v infection. The highest detection rate of A/H1N1v-infection occurred in July, and the highest rate of clinical presentations occurred in August 2009. Underlying medical disease was observed in 14% of all patients. The presence of fever, cough and myalgia was the prime clinical predictor for the presence of A/H1N1v infection. 16% of patients with this triad suffered from A/H1N1v. CONCLUSION: Suspected A/H1N1v infection contributed to a considerable health care burden in Switzerland. However, the rate of true positivity was low (5%), hospitalisations rare (5%), and mortality did not occur. Therefore, the first wave of the A/H1N1v pandemic in Switzerland was rather media "hype" than real threat.

Hypertrophic cardiomyopathy due to beta-myosin heavy chain mutation with extreme phenotypic variability within a family.

Hypertrophic cardiomyopathy (HCM) affects 1 in 500 persons and shows high variability in severity of disease, in genetic heterogeneity and phenotypic patterns. Many affected individuals remain undetected throughout their lives. In this case report a family with proven beta-myosin heavy chain mutation (MYH7) with 3 affected family members with huge phenotypic variability is described. The index patient (male, age 21 years) has severe phenotypic expression with a pathological ECG and maximal septal wall thickness of 29 mm, there is no significant obstruction in the left ventricular outflow tract. The sister (age 16 years), mutation carrier, has no detectable hypertrophy and no ECG changes. The mother (age 44 years), also carrying the mutation, has a normal ECG and shows only mild septal hypertrophy of 12 mm and systolic anterior motion of her mitral valve chordae with no gradient. The maternal grandmother died suddenly at age 65 years of presumed coronary artery disease, and the maternal great-grandmother had a sudden cardiac death at age 50 years of unknown etiology. To conclude, this family shows impressively the wide spectrum of phenotypic presentation and outcome in one family.

[Therapy-refractory arterial hypertension in a young patient]. / Therapierefraktäre arterielle Hypertonie bei einem jungen Patienten.

We report on a 41-year-old patient admitted for refractory arterial hypertension that had developed after a curative chemotherapy regimen due to seminoma stadium IIb four years ago. After exclusion of secondary forms of arterial hypertension (actually unsuccessfully treated with 5 different antihypertensive drugs) we performed a controlled medication intake-trial in our outpatient clinic. 90 minutes after taking the pills the patient complained of dizziness and perspiration while hypotension and bradycardia were measured simultaneously. Due to the difficult psychosocial situation (conflicts with the insurance and in the family, financial problems) and the suspected narcisstic personality disorder the issue of the proven malcompliance was not openly discussed in order to preserve the patient-doctor alliance. The antihypertensive regimen was then reduced to a double regimen. In the second part of the article the most common reasons for refractory arterial hypertension, especially the problem of treatment malcompliance, are summarized.

[Cholestatic icterus and subsequent diagnostic steps]. / Cholestatischer Ikterus und die weiteren Abklärungsschritte.

We report about a seventy year old patient with painless jaundice, loss of weight and signs of laboratory-confirmed cholestasis. A CT-Scan revealed a tumor mass in the pancreatic head with extensive liver metastasis. We illustrate the required diagnostic steps to assess cholestasis and painless icterus. A definite diagnosis can not always be made even with extensive histological or immunohistochemical workup.

[B-type natriuretic peptide (BNP) in the outpatient clinic--usefulness and pitfalls]. / B-type Natriuretic Peptide (BNP) in der ambulanten Medizin--Nutzen und Tücken.

B-type natriuretic peptide (BNP) is an established biomarker for the differentiation of acute dyspnoea in the emergency department. However, evidence for BNP testing in outpatients is less strong. BNP is not a global test to detect cardiac abnormalities and is only helpful in a few clearly defined clinical settings. Similarly to its use in emergency department patients, BNP is useful in outpatients presenting with dyspnoea to estimate the likelihood of heart failure as the cause of dyspnoea. However, BNP does not provide any reliable information on the underlying cardiac pathology, and in virtually all cases additional examinations are required (primarily echocardiography). In addition, BNP is helpful for risk stratification in patients with heart failure, coronary artery disease and pulmonary artery hypertension.

[Dyspnea on exertion and bihilar space occupying lesion in intravenous cocaine/heroin abuse]. / Belastungsdyspnoe und bihiläre Raumforderung bei i.v.-Kokain/Heroinabusus.

We report about a 44 year old man with intravenous cocaine/heroin abuse with shortness of breath (NYHA III) and prominent bilateral hila. We documented a severe pulmonary hypertension with bilateral dilated pulmonary vessels. Differential diagnosis is broad and further diagnostic evaluation is needed. Therapy includes anticoagulation, diuretics, if necessary oxygen supply and specific inhalative and perorale drugs.

[Heart and sports: when can it be dangerous?]. / Herz und Sport: wann wird es gefährlich?

Performing sports regularly has many positive effects on the cardiovascular and other systems. The shade side of the sport (not only high-performance-, but also amateur sports) is sudden cardia death, a dramatic event for the patient and his family. Many cardiac disorders, which lead to sudden cardiac death, are inherited. One of the most common causes of sudden cardiac death is autosomal-dominant inherited hypertrophic cardiomyopathy characterized by its wide phenotype and genotype heterogeneity. This specific disease will be elucidated in this paper. In order to prevent sudden cardiac death in athletes, a structured cardiovascular screening is mandatory at the beginning of the sport career. If an inherited disorder leading to sudden cardiac death is diagnosed, family screening will be necessary.

[Resistant anemia in resistant patients]. / Resistente Anämie bei resistentem Patienten.

A 93 year old man with a severe anaemia with possible origin in the gastrointestinal tract refused any clarifying examinations except palliative blood transfusions. Within half a year, he received 48 red blood cell transfusions without any diagnostic or other therapeutically steps. To further decide on treatment strategies, we discussed this problematic case with our local ethic committee and found a reasonable treatment solution

["HAART-attack" in young female HIV-patient]. / "HAART-Attack" bei junger HIV-Patientin.

Since the implementation of highly active antiretroviral therapy (HAART) there is a dramatic decline in morbidity and mortality due to reduction of opportunistic infections in HIV-infected patients resulting in improved prognosis. Unfortunately, patients receiving HAART are at risk for metabolic complications, which may induce the development of coronary artery and cerebrovascular disease, particularly in young patients and in the presence of additional cardiovascular risk factors. A 30-years old female HIV-infected patient who developed an acute myocardial infarction is described.