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Correlates of Delayed Recognition and Treatment of Acute Type A Aortic Dissection: The International Registry of Acute Aortic Dissection (IRAD)
The Journal of Emergency Medicine Comments: This study has the limitations inherent to retrospective analysis. Further, subjects with greater illness had lower temperatures on hospital arrival, which may have confounded initial neurologic examination in these patients. The study was limited to a single site, thereby limiting generalizability. Also, whereas cross-validation was performed using statistical methods (n-fold method), no prospective validation was performed to test or prove the validity of the study findings. Despite its limitations, the study provides a new way to stratify cardiac arrest patients after ROSC and provide prognostic information based on initial illness severity. A prospective validation would be a logical next step. , HOSPITAL COSTS, INCIDENCE, AND INHOSPITAL MORTALITY RATES OF TRAUMATIC SUBDURAL HEMATOMA IN THE UNITED STATES. Kalanithi P, Schubert RD, Lad SP, Harris OA, Boakye M. J Neurosurg 2011;115:1013–8. The Nationwide Inpatient Sample is the largest all-payer inpatient database of nonfederal community hospitals. In this retrospective analysis, the authors analyzed trends in cost and frequency of traumatic subdural hematoma (SDH) from 1993 to 2006 and used a multivariate logistic regression model to analyze cost, morbidity and mortality rate, and identify factors that may affect the mortality rate after surgical intervention from 1993 to 2002. Admissions for traumatic SDH increased 154% from 17,328 in 1993 to 43,996 in 2006. The average costs increased 67% to $47,315 in 2006 from $28,347 in 1993, despite the average length of stay decreasing from 11.5 to 7.1 days during this period. Their data showed the national baseline rate for in-hospital mortality of 14% and the in-hospital mortality for operative traumatic SDH patients to be 14.9%, with an 18% in-hospital complication rate. The presence of coma or more than two comorbidities negatively affected in-hospital mortality (odds ratios = 2.45 and 1.60, respectively). Interestingly, different age groups had significantly different mortality rates, with lower mortality in age groups 45–64 and 65–84 years, compared with ages 18–44 years. The authors conclude that nationally, the frequency of and the cost associated with, traumatic SDH are increasing. [Douglas Melzer, MD Denver Health Medical Center, Denver, CO] Comments: This study gives a picture of the increasing frequency and cost of traumatic SDH. As a retrospective study, it is limited by the quality of the data entered into the database. Nonetheless, it illustrates a potential area for future research for new therapies or for preventative strategies. , CHRONIC KIDNEY DISEASE AND RISK FOR PRESENTING WITH ACUTE MYOCARDIAL INFARCTION VERSUS STABLE EXERTIONAL ANGINA IN ADULTS WITH CORONARY HEART DISEASE. Go AS, Bansal N, Chandra M, et al. J Am Coll Cardiol 2011;58:1600–7. Chronic kidney disease (CKD) and end-stage renal disease (ESRD) are independent, gradient-based risk factors for coronary heart disease (CHD) in both new-onset and recurrent
245 coronary disease. It is not known if increased CHD mortality in CKD is due to the high incidence of CHD events, or if patients with CKD have more severe types of events. The authors of this case-control study compared the incidence of CHD patients presenting with acute myocardial infarction (AMI) vs. incident-stable angina in relation to the occurrence of CKD or ESRD. The study involved adult patients at Kaiser of Northern California facilities between October 2001 and December 2003. Patients were enrolled based upon database searches for discharge diagnosis and cardiac enzymes; exclusion criteria included previous CHD history, chronic dialysis, transplant patients, lack of primary care provider, death, severe psychiatric disease or cognitive impairment, prior nitroglycerin utilization, and death. Authors used serum creatinine and estimated glomerular filtration rate (eGFR) to assign severity stages of CKD. Demographics, comorbidities, medication usage, and previous CKD or CHD factors were also recorded. A total of 803 AMI patients and 419 stable angina patients with eGFR # 130 were enrolled. There were no significant differences between age and racial group. However, stable angina was seen more commonly in women. Patients presenting with AMI tended to have lower eGFRs < 45 (i.e., severe CKD), elevated blood pressures, be smokers, have worse dyslipidemia, and have recent beta-blocker and statin usage. In particular to the study objectives, authors found that after adjusting for demographics, eGFR < 45 was associated with a 2.8-fold increased odds for AMI, with a trend for decreasing odds in increasing eGFRs (i.e., less severe stages of CKD). The authors concluded that patients with CKD and severe CKD, in particular, have an increased risk for higher morbidity and mortality-related events, that is, increased risk for AMI. [Maegan S. Reynolds, MD Denver Health Medical Center, Denver, CO] Comments: Although this study is limited in size and generalizability, it suggests an important association between CKD and risk for CHD, particularly AMI. Due to the design of this study, no definitive conclusions can be made from these results. Nonetheless, prospective observational trials should be done to determine whether emergency physicians need to consider including CKD as a CHD risk factor. , CORRELATES OF DELAYED RECOGNITION AND TREATMENT OF ACUTE TYPE A AORTIC DISSECTION: THE INTERNATIONAL REGISTRY OF ACUTE AORTIC DISSECTION (IRAD). Harris DM, Strauss CE, Eagle KA, et al. Circulation 2011;124:1911–8. This study was a retrospective analysis to identify the most important factors contributing to delays in the diagnosis and treatment of type A aortic dissection (AAD). The International Registry of Acute Aortic Dissection, a collaboration of 24 aortic referral centers in 11 countries, was used to collect patient data for cases between January 1996 and January 2007. Cases of AAD secondary to trauma, and cases without presentation, diagnosis, or surgical times recorded were excluded. Each patient case included 290 data items, including patient demographics, medical history, clinical presentation, physical findings, imaging use and results, medical and surgical management, and
246 outcomes. Multiple linear regressions were performed to determine relative delayed time ratios (DTRs) as determined by the natural log of delay times for individual variables. The patient group consisted of 894 patients with a median age of 62 years; 294 (32.9%) were female; and 653 (73.3%) were transferred from non-tertiary care facilities. The median time from arrival to diagnosis was 4.3 h, and from diagnosis to surgery was 4.3 h. The greatest relative predictors of delay to diagnosis were transfer from outside facility (DTR 3.34; 95% confidence interval [CI] 2.38–4.69), fever (DTR 5.11; 95% CI 2.07– 12.62), and normotension (DTR 2.45; 95% CI 1.80–3.33). Delays in time to diagnosis also occurred in female patients, patients who had undergone prior cardiac surgery, patients with an electrocardiogram suggestive of myocardial ischemia, or patients with a normal chest radiograph (all p < 0.05). Patients with typical symptoms (defined as posterior pain, abrupt pain, and worst pain ever) were diagnosed twice as quickly as others in the cohort. Critically ill patients with hypotension, tamponade, pulse deficits, coma, or altered consciousness were also diagnosed sooner (all p < 0.05). Variables associated with the greatest delay in time to surgery included race other than white (DTR 2.25; 95% CI 0.40–1.22), history of coronary artery bypass surgery (DTR 2.81; 95% CI 0.47–1.60), and time from presentation to diagnosis (DTR 1.35; 95% CI 0.24–0.37). Patients with shock, cardiac tamponade, and diabetes mellitus went to surgery far more rapidly than others in the cohort (all p < 0.05). [Omeed Saghafi, MD Denver Health Medical Center, Denver, CO] Comment: This study validates what the emergency physician would suspect with respect to patients presenting with aortic dissection; when the diagnosis is self evident, delays to therapy are not an issue and when the presentation is atypical, delays become a problem. What was not clear, at least from this study, was whether such delays led to changes in outcomes. Nonetheless, the study findings serve as a reminder that aortic dissection may mimic other pathology and should be considered when appropriate so as to minimize the possibility of delays. , SADDLE PULMONARY EMBOLISM: IS IT AS BAD AS IT LOOKS? A COMMUNITY HOSPITAL EXPERIENCE Sardi A, Gluskin K, Guttentag A, et al. Crit Care Med 2011;39:2413–8.
Abstracts The outcomes and clinical presentation for saddle pulmonary embolism (SPE) vary widely, and there is debate for the use of thrombolytics or catheter thrombectomy based on right heart dysfunction, measures seen on computed tomography angiography (CTA) or cardiac enzyme elevation. In this study, two radiologists retrospectively reviewed and evaluated for clot burden (CB) all CTAs coded for pulmonary embolism (PE) from all patients at a single center from 2004 to 2009. All patient charts were reviewed for echocardiography, treatments, and outcomes. SPE was found in 37 of 680 patients (5.4%), with a median age of 60 years, of whom 41% were male and 83.7% were AfricanAmerican. Of the 37, the most common comorbidities were underlying neurologic disease, recent surgery, smoking (all 24%), and malignancy (22%). Echocardiography was performed in 27 patients (73%). Right heart enlargement and dysfunction occurred in 78%, and elevated pulmonary artery systolic pressure in 67%. The Qanadi scoring system for clot burden and pulmonary artery occlusion defines complete proximal obstruction with a CB of 40 points; CTA demonstrated a high median score of 31 points. There were 2 deaths (5.4%), with CBs of 30 and 31, but the small number of deaths made it impossible to determine which characteristics were associated with mortality. The median right-ventricle-to-left-ventricle diameter ratio was 1.39, and in those given thrombolytics it was 1.86 (p = 0.13), and the median CB of those who received thrombolytics was 34, compared to 31. Inferior vena cava filters were placed in 46%. Unfractionated heparin was administered in 87%, low-molecular-weight heparin in 11%, thrombolytics in 11%, and surgical thrombectomy in 3%. Median length of hospital stay was 9 days. Of the 4 patients who received thrombolytics, major bleeds occurred in 2, one of which died of multi-organ failure on hospital day 13. [Douglas Melzer, MD Denver Health Medical Center, Denver, CO] Comments: This small retrospective study demonstrated that the incidence of saddle pulmonary embolism was very low and that when it did occur, it was almost always amenable to standard therapy. This raises the question of when thrombolysis or more invasive thrombectomy is really needed, especially when 1 of the 2 patients receiving the former died in this cohort. It may be that SPE is not as life-threatening an entity as previously believed. However, larger studies would have to be done to verify this.
245 coronary disease. It is not known if increased CHD mortality in CKD is due to the high incidence of CHD events, or if patients with CKD have more severe types of events. The authors of this case-control study compared the incidence of CHD patients presenting with acute myocardial infarction (AMI) vs. incident-stable angina in relation to the occurrence of CKD or ESRD. The study involved adult patients at Kaiser of Northern California facilities between October 2001 and December 2003. Patients were enrolled based upon database searches for discharge diagnosis and cardiac enzymes; exclusion criteria included previous CHD history, chronic dialysis, transplant patients, lack of primary care provider, death, severe psychiatric disease or cognitive impairment, prior nitroglycerin utilization, and death. Authors used serum creatinine and estimated glomerular filtration rate (eGFR) to assign severity stages of CKD. Demographics, comorbidities, medication usage, and previous CKD or CHD factors were also recorded. A total of 803 AMI patients and 419 stable angina patients with eGFR # 130 were enrolled. There were no significant differences between age and racial group. However, stable angina was seen more commonly in women. Patients presenting with AMI tended to have lower eGFRs < 45 (i.e., severe CKD), elevated blood pressures, be smokers, have worse dyslipidemia, and have recent beta-blocker and statin usage. In particular to the study objectives, authors found that after adjusting for demographics, eGFR < 45 was associated with a 2.8-fold increased odds for AMI, with a trend for decreasing odds in increasing eGFRs (i.e., less severe stages of CKD). The authors concluded that patients with CKD and severe CKD, in particular, have an increased risk for higher morbidity and mortality-related events, that is, increased risk for AMI. [Maegan S. Reynolds, MD Denver Health Medical Center, Denver, CO] Comments: Although this study is limited in size and generalizability, it suggests an important association between CKD and risk for CHD, particularly AMI. Due to the design of this study, no definitive conclusions can be made from these results. Nonetheless, prospective observational trials should be done to determine whether emergency physicians need to consider including CKD as a CHD risk factor. , CORRELATES OF DELAYED RECOGNITION AND TREATMENT OF ACUTE TYPE A AORTIC DISSECTION: THE INTERNATIONAL REGISTRY OF ACUTE AORTIC DISSECTION (IRAD). Harris DM, Strauss CE, Eagle KA, et al. Circulation 2011;124:1911–8. This study was a retrospective analysis to identify the most important factors contributing to delays in the diagnosis and treatment of type A aortic dissection (AAD). The International Registry of Acute Aortic Dissection, a collaboration of 24 aortic referral centers in 11 countries, was used to collect patient data for cases between January 1996 and January 2007. Cases of AAD secondary to trauma, and cases without presentation, diagnosis, or surgical times recorded were excluded. Each patient case included 290 data items, including patient demographics, medical history, clinical presentation, physical findings, imaging use and results, medical and surgical management, and
246 outcomes. Multiple linear regressions were performed to determine relative delayed time ratios (DTRs) as determined by the natural log of delay times for individual variables. The patient group consisted of 894 patients with a median age of 62 years; 294 (32.9%) were female; and 653 (73.3%) were transferred from non-tertiary care facilities. The median time from arrival to diagnosis was 4.3 h, and from diagnosis to surgery was 4.3 h. The greatest relative predictors of delay to diagnosis were transfer from outside facility (DTR 3.34; 95% confidence interval [CI] 2.38–4.69), fever (DTR 5.11; 95% CI 2.07– 12.62), and normotension (DTR 2.45; 95% CI 1.80–3.33). Delays in time to diagnosis also occurred in female patients, patients who had undergone prior cardiac surgery, patients with an electrocardiogram suggestive of myocardial ischemia, or patients with a normal chest radiograph (all p < 0.05). Patients with typical symptoms (defined as posterior pain, abrupt pain, and worst pain ever) were diagnosed twice as quickly as others in the cohort. Critically ill patients with hypotension, tamponade, pulse deficits, coma, or altered consciousness were also diagnosed sooner (all p < 0.05). Variables associated with the greatest delay in time to surgery included race other than white (DTR 2.25; 95% CI 0.40–1.22), history of coronary artery bypass surgery (DTR 2.81; 95% CI 0.47–1.60), and time from presentation to diagnosis (DTR 1.35; 95% CI 0.24–0.37). Patients with shock, cardiac tamponade, and diabetes mellitus went to surgery far more rapidly than others in the cohort (all p < 0.05). [Omeed Saghafi, MD Denver Health Medical Center, Denver, CO] Comment: This study validates what the emergency physician would suspect with respect to patients presenting with aortic dissection; when the diagnosis is self evident, delays to therapy are not an issue and when the presentation is atypical, delays become a problem. What was not clear, at least from this study, was whether such delays led to changes in outcomes. Nonetheless, the study findings serve as a reminder that aortic dissection may mimic other pathology and should be considered when appropriate so as to minimize the possibility of delays. , SADDLE PULMONARY EMBOLISM: IS IT AS BAD AS IT LOOKS? A COMMUNITY HOSPITAL EXPERIENCE Sardi A, Gluskin K, Guttentag A, et al. Crit Care Med 2011;39:2413–8.
Abstracts The outcomes and clinical presentation for saddle pulmonary embolism (SPE) vary widely, and there is debate for the use of thrombolytics or catheter thrombectomy based on right heart dysfunction, measures seen on computed tomography angiography (CTA) or cardiac enzyme elevation. In this study, two radiologists retrospectively reviewed and evaluated for clot burden (CB) all CTAs coded for pulmonary embolism (PE) from all patients at a single center from 2004 to 2009. All patient charts were reviewed for echocardiography, treatments, and outcomes. SPE was found in 37 of 680 patients (5.4%), with a median age of 60 years, of whom 41% were male and 83.7% were AfricanAmerican. Of the 37, the most common comorbidities were underlying neurologic disease, recent surgery, smoking (all 24%), and malignancy (22%). Echocardiography was performed in 27 patients (73%). Right heart enlargement and dysfunction occurred in 78%, and elevated pulmonary artery systolic pressure in 67%. The Qanadi scoring system for clot burden and pulmonary artery occlusion defines complete proximal obstruction with a CB of 40 points; CTA demonstrated a high median score of 31 points. There were 2 deaths (5.4%), with CBs of 30 and 31, but the small number of deaths made it impossible to determine which characteristics were associated with mortality. The median right-ventricle-to-left-ventricle diameter ratio was 1.39, and in those given thrombolytics it was 1.86 (p = 0.13), and the median CB of those who received thrombolytics was 34, compared to 31. Inferior vena cava filters were placed in 46%. Unfractionated heparin was administered in 87%, low-molecular-weight heparin in 11%, thrombolytics in 11%, and surgical thrombectomy in 3%. Median length of hospital stay was 9 days. Of the 4 patients who received thrombolytics, major bleeds occurred in 2, one of which died of multi-organ failure on hospital day 13. [Douglas Melzer, MD Denver Health Medical Center, Denver, CO] Comments: This small retrospective study demonstrated that the incidence of saddle pulmonary embolism was very low and that when it did occur, it was almost always amenable to standard therapy. This raises the question of when thrombolysis or more invasive thrombectomy is really needed, especially when 1 of the 2 patients receiving the former died in this cohort. It may be that SPE is not as life-threatening an entity as previously believed. However, larger studies would have to be done to verify this.