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How Good is Tricuspid Regurgitation Velocity in Excluding Pulmonary Hypertension in Patients with Left Heart Disease
400
Heart, Lung and Circulation 2011;20:376–419
Abstracts
ABSTRACTS
How Good is Tricuspid Regurgitation Velocity in Excluding Pulmonary Hypertension in Patients with Left Heart Disease J. Mazhar ∗ , V. Pera, M. Liang, J. Jayabal, E. Lee, P. Tamuno, R. Fisher Department of Cardiology, Waikato Hospital, Hamilton, New Zealand Background: Pulmonary hypertension (PH) is defined as mean pulmonary artery pressure (mPAP) >25 mmHg. Patients undergoing cardiac surgery have increased mortality if they have significant PH, defined as systolic pulmonary artery pressure (sPAP) >60 mmHg. Our aim was to see if measurement of tricuspid regurgitant velocity (TRVmax) by Doppler echocardiography can exclude PH. Methods: Patients having a transthoracic echocardiogram (TTE) and right heart catheterisation (RHC) within three days of each other were reviewed. TRVmax <2.8 m/s was used as a cut-off to exclude PH as recommended by ESC guidelines for PH. Results: From January 2004 to February 2011, 693 consecutive patients had RHC before cardiac surgery. Out of these 159 patients had TTE within three days of RHC and were used for analysis. Prevalence of PH was 51% in this group. TRVmax was measured in 99(62%) out of 159 patients. Sensitivity, Specificity, Negative predictive value (NPV) and positive predictive value (PPV) for diagnosis of PH (mPAP >25 mmHg) were 66%, 83%, 65% and 84% respectively. Sensitivity, Specificity, NPV and PPV for diagnosis of significant PH (sPAP >60 mmHg) were 80%, 64%, 93% and 36% respectively. TRVmax was not measurable in 60(38%) patients due to no tricuspid regurgitation (TR) or trace TR. Absent/trace TR had a 50% NPV to exclude diagnosis of PH and 93% NPV to exclude significant PH. Conclusion: TRVmax <2.8 m/s has a low sensitivity (66%) and NPV (65%) for diagnosis of PH, but high sensitivity (80%) and NPV (93%) to exclude significant PH. Absent/trace TR has low NPV(50%) for diagnosis of PH but high NPV(93%) to exclude significant PH. Conflict of interest: Nil. doi:10.1016/j.hlc.2011.03.066 Clinical Impact of High Sensitive Troponin T (HsTnT) on Diagnosis of Acute Coronary Syndrome (ACS) J. Mazhar ∗ , V. Pera, A. Siddiqui, J. Bouwhuis, S. DuToit, G. Devlin Department of Cardiology, Waikato Hospital, New Zealand Background: HsTnT assay has a lower cut-off (14 ng/L) resulting in a new clinically challenging group of patients with minimally elevated HsTnT (14–53 ng/L), previously reported as normal with the 4th generation troponin T (4GTnT). A rise and/or fall of HsTnT is important to increase specificity, particularly at lower levels. Our aim was to assess impact of HsTnT on diagnosis of ACS. Methods: 143 consecutive patients admitted with possible ACS were enrolled. Patients were diagnosed and treated
based on 4GTnT. HsTnT was added to all samples and treating cardiologists were blinded to these results. Results: Mean age was 62 with 86 (60%) male. Eighty-nine (62%) had non cardiac chest pain (NCCP), 16 (11%) angina, 11 (8%) unstable angina, 22 (15%) NSTEMI, 5 (3%) STEMI. Using a single HsTnT, identified 21 new patients with elevated HsTnT but normal 4GTnT (see Table). HsTnT ranged from 15 to 52 ng/L. Thirteen patients discharged as NCCP had minimally elevated HsTnT. Stress testing was done in 9 (69%) of this group and was negative in all. Only one of the 21 patients fulfilled the diagnosis of NSTEMI with a rise and/or fall of HsTnT. Diagnosis
Diagnosis based on 4GTnT
HsTnT >14 ng/L in each group
Rise and/or fall of HsTnT
NCCP Angina Unstable angina
89 (62%) 16 (11%) 11 (8%)
13 4 4
0 0 1
Conclusion: Use of HsTnT increases the incidence of troponin positive presentations significantly by detecting levels between 14 and 53 ng/L. Specificity is increased by diagnostic algorithms requiring a rise and/or fall. Education of health professionals in interpretation of HsTnT is essential to avoid unnecessary investigations. Conflict of interest: Nil. doi:10.1016/j.hlc.2011.03.067 ACUTE PREDICT: Initial Experience in the Midland Region. Comparison of Acute Coronary Syndrome (ACS) Management at an Interventional and Non-interventional Centre J. Mazhar 1,∗ , B. Killion 1 , M. Mitchell 2 , I. Ternouth 2 , M. Lee 3 , A.J. Kerr 3 , G. Devlin 1 1 Cardiology
Department, Waikato Hospital, New Zealand Hospital, New Zealand 3 Cardiology Department, Middlemore Hospital, Auckland, New Zealand 2 Taranaki
Background: ACUTE PREDICT, a web based ACS registry, currently been piloted in the Midland region, collects information on management and in-hospital outcomes. We report our initial experience with ACUTE PREDICT on management of patients with ACS at Waikato Hospital (W), an interventional centre and Taranaki Hospital (T) a non-interventional centre. Methods: All patients with ACS admitted to both hospitals (1152 W and 474 T) from January 2008 to July 2010 enrolled in ACUTE PREDICT were included. Results: W patients were more likely to be elderly and present with a NSTEMI (see table). Evidence based care was more evident in W with patients much more likely to undergo both non-invasive and invasive risk stratification following an ACS presentation. As a consequence revascularisation was more frequently performed in W patients. Time to angiography, a potential barrier to referral, was much longer for T patients.
Heart, Lung and Circulation 2011;20:376–419
Abstracts
ABSTRACTS
How Good is Tricuspid Regurgitation Velocity in Excluding Pulmonary Hypertension in Patients with Left Heart Disease J. Mazhar ∗ , V. Pera, M. Liang, J. Jayabal, E. Lee, P. Tamuno, R. Fisher Department of Cardiology, Waikato Hospital, Hamilton, New Zealand Background: Pulmonary hypertension (PH) is defined as mean pulmonary artery pressure (mPAP) >25 mmHg. Patients undergoing cardiac surgery have increased mortality if they have significant PH, defined as systolic pulmonary artery pressure (sPAP) >60 mmHg. Our aim was to see if measurement of tricuspid regurgitant velocity (TRVmax) by Doppler echocardiography can exclude PH. Methods: Patients having a transthoracic echocardiogram (TTE) and right heart catheterisation (RHC) within three days of each other were reviewed. TRVmax <2.8 m/s was used as a cut-off to exclude PH as recommended by ESC guidelines for PH. Results: From January 2004 to February 2011, 693 consecutive patients had RHC before cardiac surgery. Out of these 159 patients had TTE within three days of RHC and were used for analysis. Prevalence of PH was 51% in this group. TRVmax was measured in 99(62%) out of 159 patients. Sensitivity, Specificity, Negative predictive value (NPV) and positive predictive value (PPV) for diagnosis of PH (mPAP >25 mmHg) were 66%, 83%, 65% and 84% respectively. Sensitivity, Specificity, NPV and PPV for diagnosis of significant PH (sPAP >60 mmHg) were 80%, 64%, 93% and 36% respectively. TRVmax was not measurable in 60(38%) patients due to no tricuspid regurgitation (TR) or trace TR. Absent/trace TR had a 50% NPV to exclude diagnosis of PH and 93% NPV to exclude significant PH. Conclusion: TRVmax <2.8 m/s has a low sensitivity (66%) and NPV (65%) for diagnosis of PH, but high sensitivity (80%) and NPV (93%) to exclude significant PH. Absent/trace TR has low NPV(50%) for diagnosis of PH but high NPV(93%) to exclude significant PH. Conflict of interest: Nil. doi:10.1016/j.hlc.2011.03.066 Clinical Impact of High Sensitive Troponin T (HsTnT) on Diagnosis of Acute Coronary Syndrome (ACS) J. Mazhar ∗ , V. Pera, A. Siddiqui, J. Bouwhuis, S. DuToit, G. Devlin Department of Cardiology, Waikato Hospital, New Zealand Background: HsTnT assay has a lower cut-off (14 ng/L) resulting in a new clinically challenging group of patients with minimally elevated HsTnT (14–53 ng/L), previously reported as normal with the 4th generation troponin T (4GTnT). A rise and/or fall of HsTnT is important to increase specificity, particularly at lower levels. Our aim was to assess impact of HsTnT on diagnosis of ACS. Methods: 143 consecutive patients admitted with possible ACS were enrolled. Patients were diagnosed and treated
based on 4GTnT. HsTnT was added to all samples and treating cardiologists were blinded to these results. Results: Mean age was 62 with 86 (60%) male. Eighty-nine (62%) had non cardiac chest pain (NCCP), 16 (11%) angina, 11 (8%) unstable angina, 22 (15%) NSTEMI, 5 (3%) STEMI. Using a single HsTnT, identified 21 new patients with elevated HsTnT but normal 4GTnT (see Table). HsTnT ranged from 15 to 52 ng/L. Thirteen patients discharged as NCCP had minimally elevated HsTnT. Stress testing was done in 9 (69%) of this group and was negative in all. Only one of the 21 patients fulfilled the diagnosis of NSTEMI with a rise and/or fall of HsTnT. Diagnosis
Diagnosis based on 4GTnT
HsTnT >14 ng/L in each group
Rise and/or fall of HsTnT
NCCP Angina Unstable angina
89 (62%) 16 (11%) 11 (8%)
13 4 4
0 0 1
Conclusion: Use of HsTnT increases the incidence of troponin positive presentations significantly by detecting levels between 14 and 53 ng/L. Specificity is increased by diagnostic algorithms requiring a rise and/or fall. Education of health professionals in interpretation of HsTnT is essential to avoid unnecessary investigations. Conflict of interest: Nil. doi:10.1016/j.hlc.2011.03.067 ACUTE PREDICT: Initial Experience in the Midland Region. Comparison of Acute Coronary Syndrome (ACS) Management at an Interventional and Non-interventional Centre J. Mazhar 1,∗ , B. Killion 1 , M. Mitchell 2 , I. Ternouth 2 , M. Lee 3 , A.J. Kerr 3 , G. Devlin 1 1 Cardiology
Department, Waikato Hospital, New Zealand Hospital, New Zealand 3 Cardiology Department, Middlemore Hospital, Auckland, New Zealand 2 Taranaki
Background: ACUTE PREDICT, a web based ACS registry, currently been piloted in the Midland region, collects information on management and in-hospital outcomes. We report our initial experience with ACUTE PREDICT on management of patients with ACS at Waikato Hospital (W), an interventional centre and Taranaki Hospital (T) a non-interventional centre. Methods: All patients with ACS admitted to both hospitals (1152 W and 474 T) from January 2008 to July 2010 enrolled in ACUTE PREDICT were included. Results: W patients were more likely to be elderly and present with a NSTEMI (see table). Evidence based care was more evident in W with patients much more likely to undergo both non-invasive and invasive risk stratification following an ACS presentation. As a consequence revascularisation was more frequently performed in W patients. Time to angiography, a potential barrier to referral, was much longer for T patients.