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Noninvasive ventilation in cardiogenic pulmonary edema: A multicenter randomized trial
ABSTRACTS
The abstracts and commentaries in this issue were prepared by editorial board members of the Year Book of Emergency Medicine. These selections will appear in the 2005 volume. To order a copy of the entire 2005 Year Book of Emergency Medicine, call Mosby’s toll-free number 800-453-4351 or 314453-4351 outside the United States. Commentaries appearing in Annals of Emergency Medicine may undergo additional editing by the Annals abstract editor.
Reprints not available. Copyright ª 2005 by Mosby, Inc.
Prognostic Value of Myeloperoxidase in Patients With Chest Pain Brennan M-L, Penn MS, Van Lente F, et al (Cleveland Clinic Foundation, Cleveland, OH) N Engl J Med. 2003;349:1595-1604 Background: The leukocyte enzyme myeloperoxidase has been linked to both inflammation and cardiovascular disease. Whether plasma levels of myeloperoxidase might be a marker of major adverse cardiovascular events was investigated. Methods: The subjects were 604 patients (58.6% men; mean age approximately 62 years) seen in the emergency department (ED) with chest pain. Plasma levels of myeloperoxidase, troponin T (TnT), and C-reactive protein (CRP) were measured at baseline. Patients were followed up for 6 months to determine major adverse cardiovascular events (myocardial infarction, reinfarction, need for revascularization, death). Results: Of the 148 patients, 23.5% had myocardial infarction, 37.6% had suspected coronary syndrome, 17.1% had unstable angina, and 21.5% had noncardiac chest pain. Plasma myeloperoxidase levels correlated significantly but weakly with TnT and CRP levels. The incidence of myocardial infarction increased significantly as the baseline myeloperoxidase level increased (13.9% in lowest myeloperoxidase quartile versus 38.4% in highest quartile), even in patients whose baseline TnT level was less than 0.1 ng/mL. The baseline myeloperoxidase level was a significant predictor of a major adverse cardiovascular event at 30 days (unadjusted odds ratio [OR] 4.7, highest versus lowest quartiles) and at 6 months (unadjusted OR 4.7, highest versus lowest quartiles). The baseline myeloperoxidase level remained a significant predictor of 30-day and 6-month major adverse cardiovascular events, even after data adjustment for age, sex, CRP level, hyperlipidemia, revascularization, myocardial infarction, and acute coronary syndrome. In particular, in patients whose TnT levels were persistently less than 0.1 ng/mL, an increasing baseline myeloperoxidase level was significantly associated with major adverse cardiovascular events at 30 days (adjusted ORs 2.2, 4.2, and 4.1, for the second, third, and fourth quartiles versus the first quartile) and at 6 months (adjusted ORs 1.9, 4.4, and 3.9, for the second, third, and fourth quartiles versus the first quartile). Volume 45, no. 2 : February 2005
Conclusion: The baseline plasma myeloperoxidase level is a significant and independent predictor of a major adverse cardiovascular event at 30 days and 6 months, even in patients with negative TnT levels. Comment: The search for cardiac markers/predictors of adverse outcomes in acute coronary syndrome continues. Brennan et al report that a single initial measurement of plasma myeloperoxidase independently predicts early risk of myocardial infarction and risk of major cardiac events within 30 to 60 days of presentation to an ED with chest pain. Although the data support myeloperoxidase as a more sensitive marker than the others, its receiver operating characteristic curves are nothing to write home about. It’s neither sensitive, specific, nor does it boast a good positive or negative prediction value. Clearly, more work needs to be done to determine how or whether myeloperoxidase can be combined with other markers to identify high-risk patients with chest pain in the ED. doi:10.1016/j.annemergmed.2004.10.023
Noninvasive Ventilation in Cardiogenic Pulmonary Edema: A Multicenter Randomized Trial Nava S, Carbone G, DiBattista N, et al (Istituto Scientifico di Pavia, Pavia, Italy; Gradenigo Hospital, Turin, Italy; S Orsola Hospital, Bologna, Italy; et al) Am J Respir Crit Care Med. 2003;168:1432-1437 Background: The rationale for the use of continuous positive airway pressure (CPAP) in patients with acute pulmonary edema is based on the fact that it may limit the decline in functional residual capacity, improve respiratory mechanics and oxygenation, and decrease left ventricular afterload. However, the best therapy for treatment of an episode of acute respiratory failure due to cardiogenic pulmonary edema is controversial. Studies of the use of noninvasive pressure support ventilation (NPSV) in cardiogenic pulmonary edema have been performed in the ICU whenever respiratory failure is already present and in small groups of patients. The purpose of the present study was to compare NPSV with conventional oxygen therapy in the treatment of acute cardiogenic pulmonary edema. Annals of Emergency Medicine 227
Abstracts Methods: This multicenter study was conducted in emergency departments (EDs) and included 130 patients with acute respiratory failure who were randomly assigned to receive medical therapy plus oxygen (65 patients) or NPSV (65 patients). The main outcome measure was the need for intubation. Secondary outcomes were inhospital mortality and changes in some physiologic variables. Results: PaO2/FIO2, respiratory rate, and dyspnea were improved significantly faster with NPSV. Intubation rate, hospital mortality, and duration of hospital stay were similar in the 2 groups. In the subgroup of hypercapnic patients, NPSV provided improvement in PaCO2 significantly faster and reduced the intubation rate in comparison with medical therapy (2 of 33 versus 9 of 31). Adverse events, including myocardial infarction, were evenly distributed in the 2 groups. Conclusion: It would appear from these findings that the early use of NPSV during acute respiratory failure accelerates the improvement of PaO2/FIO2, PaCO2, dyspnea, and respiratory rate but does not affect the overall clinical outcome. However, NPSV does reduce the intubation rate in the subgroup of hypercapnic patients. Comment: Nava et al report that NPSV improves oxygenation, respiratory rate, and dyspnea faster than standard treatment in patients presenting to the ED with cardiac pulmonary edema but doesn’t prevent intubation. In addition, their data suggest that NPSV may be more effective in preventing intubation in hypercapnic patients. However, more investigative work needs to be done in this area because CO2 level was not a significant predictor variable for intubation when entered into a logistic regression model. Many emergency physicians have been using NPSV when treating cardiogenic pulmonary edema for a long time; this study confirms the positive anecdotal experience (ie, patients feel better faster) seen by these emergency physicians. The flip side is that our negative anecdotal experience is also being borne outdsome patients need to be intubated, and nothing we can do will save them from that unpleasant (but life-saving) experience.
greatly improved by the development of an accurate, readily available test for bacteremia for elderly ED patients. The purpose of the present study was to assess serum procalcitonin (PCT) and WBC count for the detection of bacteremia in these patients. Methods: This prospective observational study was conducted among ED patients aged 65 years and older in whom blood cultures were drawn. The setting was an urban, tertiary care, academic ED. Serum for PCT and WBC count was obtained at the time of ED visit. Receiver operating characteristic (ROC) curves, proportions, and likelihood ratios were calculated. Results: The entry criteria were met by 108 patients, of whom 14 had bacteremia. In comparing bacteremic patients with all others, PCT greater than 0.2 ng/mL was 93% sensitive and 38% specific, with a negative likelihood ratio of 0.18. Abnormal WBC count was 64% sensitive and 54% specific, with a negative likelihood ratio of 0.78. The presence of either abnormal WBC count or left shift was 93% sensitive but 11% specific, with a negative likelihood ratio of 0.64. When considering only bacteremic patients versus noninfected patients, PCT at a cutoff of 0.2 ng/mL had a negative likelihood ratio of 0.12. Area under an ROC curve was significantly greater for PCT than for abnormal WBC count. Conclusion: It would appear from these findings that a PCT level of 0.2 ng/mL is sensitive for bacteremia and is moderately helpful in excluding the diagnosis. WBC count with or without left shift performed poorly in this study in the diagnosis of bacteremia. Comment: Emergency physicians should wait for a study with more power before adding procalcitonin to the already long list of unhelpful laboratory tests ordered on sick elders who present to the ED for evaluation. Rita K. Cydulka, MD, MS doi:10.1016/j.annemergmed.2004.10.025
Rita K. Cydulka, MD, MS doi:10.1016/j.annemergmed.2004.10.024
Bacteremic Elder Emergency Department Patients: Procalcitonin and White Count Caterino JM, Scheatzle MD, Forbes ML, et al (Allegheny General Hospital, Pittsburgh, PA) Acad Emerg Med. 2004;11:393-396 Background: It is quite common for elderly patients to present to the emergency department (ED) without common signs and symptoms of bacterial infection. As a result, emergency physicians correctly predict bacteremia in less than two thirds of elderly patients, and this diagnosis requires the results of blood cultures that are not available for 24 to 48 hours. Medical decisionmaking in these patients could be 228 Annals of Emergency Medicine
A Comparison of High-Dose and Standard-Dose Epinephrine in Children With Cardiac Arrest Perondi MBM, Reis AG, Paiva EF, et al (University of S~ a o Paulo, S~ a o Paulo, Brazil; University of Pennsylvania, Philadelphia, PA; University of Arizona, Tucson, AZ) N Engl J Med. 2004;350:1722-1730 Background: It is known that the administration of epinephrine during cardiopulmonary resuscitation (CPR) consistently improves coronary and cerebral perfusion. The American Heart Association (AHA) guidelines for pediatric advanced life support have recommended the use of the standard dose of epinephrine administered intravenously. However, when resuscitation efforts in a pediatric patient with cardiac arrest are unsuccessful despite the administration of an Volume 45, no. 2 : February 2005
The abstracts and commentaries in this issue were prepared by editorial board members of the Year Book of Emergency Medicine. These selections will appear in the 2005 volume. To order a copy of the entire 2005 Year Book of Emergency Medicine, call Mosby’s toll-free number 800-453-4351 or 314453-4351 outside the United States. Commentaries appearing in Annals of Emergency Medicine may undergo additional editing by the Annals abstract editor.
Reprints not available. Copyright ª 2005 by Mosby, Inc.
Prognostic Value of Myeloperoxidase in Patients With Chest Pain Brennan M-L, Penn MS, Van Lente F, et al (Cleveland Clinic Foundation, Cleveland, OH) N Engl J Med. 2003;349:1595-1604 Background: The leukocyte enzyme myeloperoxidase has been linked to both inflammation and cardiovascular disease. Whether plasma levels of myeloperoxidase might be a marker of major adverse cardiovascular events was investigated. Methods: The subjects were 604 patients (58.6% men; mean age approximately 62 years) seen in the emergency department (ED) with chest pain. Plasma levels of myeloperoxidase, troponin T (TnT), and C-reactive protein (CRP) were measured at baseline. Patients were followed up for 6 months to determine major adverse cardiovascular events (myocardial infarction, reinfarction, need for revascularization, death). Results: Of the 148 patients, 23.5% had myocardial infarction, 37.6% had suspected coronary syndrome, 17.1% had unstable angina, and 21.5% had noncardiac chest pain. Plasma myeloperoxidase levels correlated significantly but weakly with TnT and CRP levels. The incidence of myocardial infarction increased significantly as the baseline myeloperoxidase level increased (13.9% in lowest myeloperoxidase quartile versus 38.4% in highest quartile), even in patients whose baseline TnT level was less than 0.1 ng/mL. The baseline myeloperoxidase level was a significant predictor of a major adverse cardiovascular event at 30 days (unadjusted odds ratio [OR] 4.7, highest versus lowest quartiles) and at 6 months (unadjusted OR 4.7, highest versus lowest quartiles). The baseline myeloperoxidase level remained a significant predictor of 30-day and 6-month major adverse cardiovascular events, even after data adjustment for age, sex, CRP level, hyperlipidemia, revascularization, myocardial infarction, and acute coronary syndrome. In particular, in patients whose TnT levels were persistently less than 0.1 ng/mL, an increasing baseline myeloperoxidase level was significantly associated with major adverse cardiovascular events at 30 days (adjusted ORs 2.2, 4.2, and 4.1, for the second, third, and fourth quartiles versus the first quartile) and at 6 months (adjusted ORs 1.9, 4.4, and 3.9, for the second, third, and fourth quartiles versus the first quartile). Volume 45, no. 2 : February 2005
Conclusion: The baseline plasma myeloperoxidase level is a significant and independent predictor of a major adverse cardiovascular event at 30 days and 6 months, even in patients with negative TnT levels. Comment: The search for cardiac markers/predictors of adverse outcomes in acute coronary syndrome continues. Brennan et al report that a single initial measurement of plasma myeloperoxidase independently predicts early risk of myocardial infarction and risk of major cardiac events within 30 to 60 days of presentation to an ED with chest pain. Although the data support myeloperoxidase as a more sensitive marker than the others, its receiver operating characteristic curves are nothing to write home about. It’s neither sensitive, specific, nor does it boast a good positive or negative prediction value. Clearly, more work needs to be done to determine how or whether myeloperoxidase can be combined with other markers to identify high-risk patients with chest pain in the ED. doi:10.1016/j.annemergmed.2004.10.023
Noninvasive Ventilation in Cardiogenic Pulmonary Edema: A Multicenter Randomized Trial Nava S, Carbone G, DiBattista N, et al (Istituto Scientifico di Pavia, Pavia, Italy; Gradenigo Hospital, Turin, Italy; S Orsola Hospital, Bologna, Italy; et al) Am J Respir Crit Care Med. 2003;168:1432-1437 Background: The rationale for the use of continuous positive airway pressure (CPAP) in patients with acute pulmonary edema is based on the fact that it may limit the decline in functional residual capacity, improve respiratory mechanics and oxygenation, and decrease left ventricular afterload. However, the best therapy for treatment of an episode of acute respiratory failure due to cardiogenic pulmonary edema is controversial. Studies of the use of noninvasive pressure support ventilation (NPSV) in cardiogenic pulmonary edema have been performed in the ICU whenever respiratory failure is already present and in small groups of patients. The purpose of the present study was to compare NPSV with conventional oxygen therapy in the treatment of acute cardiogenic pulmonary edema. Annals of Emergency Medicine 227
Abstracts Methods: This multicenter study was conducted in emergency departments (EDs) and included 130 patients with acute respiratory failure who were randomly assigned to receive medical therapy plus oxygen (65 patients) or NPSV (65 patients). The main outcome measure was the need for intubation. Secondary outcomes were inhospital mortality and changes in some physiologic variables. Results: PaO2/FIO2, respiratory rate, and dyspnea were improved significantly faster with NPSV. Intubation rate, hospital mortality, and duration of hospital stay were similar in the 2 groups. In the subgroup of hypercapnic patients, NPSV provided improvement in PaCO2 significantly faster and reduced the intubation rate in comparison with medical therapy (2 of 33 versus 9 of 31). Adverse events, including myocardial infarction, were evenly distributed in the 2 groups. Conclusion: It would appear from these findings that the early use of NPSV during acute respiratory failure accelerates the improvement of PaO2/FIO2, PaCO2, dyspnea, and respiratory rate but does not affect the overall clinical outcome. However, NPSV does reduce the intubation rate in the subgroup of hypercapnic patients. Comment: Nava et al report that NPSV improves oxygenation, respiratory rate, and dyspnea faster than standard treatment in patients presenting to the ED with cardiac pulmonary edema but doesn’t prevent intubation. In addition, their data suggest that NPSV may be more effective in preventing intubation in hypercapnic patients. However, more investigative work needs to be done in this area because CO2 level was not a significant predictor variable for intubation when entered into a logistic regression model. Many emergency physicians have been using NPSV when treating cardiogenic pulmonary edema for a long time; this study confirms the positive anecdotal experience (ie, patients feel better faster) seen by these emergency physicians. The flip side is that our negative anecdotal experience is also being borne outdsome patients need to be intubated, and nothing we can do will save them from that unpleasant (but life-saving) experience.
greatly improved by the development of an accurate, readily available test for bacteremia for elderly ED patients. The purpose of the present study was to assess serum procalcitonin (PCT) and WBC count for the detection of bacteremia in these patients. Methods: This prospective observational study was conducted among ED patients aged 65 years and older in whom blood cultures were drawn. The setting was an urban, tertiary care, academic ED. Serum for PCT and WBC count was obtained at the time of ED visit. Receiver operating characteristic (ROC) curves, proportions, and likelihood ratios were calculated. Results: The entry criteria were met by 108 patients, of whom 14 had bacteremia. In comparing bacteremic patients with all others, PCT greater than 0.2 ng/mL was 93% sensitive and 38% specific, with a negative likelihood ratio of 0.18. Abnormal WBC count was 64% sensitive and 54% specific, with a negative likelihood ratio of 0.78. The presence of either abnormal WBC count or left shift was 93% sensitive but 11% specific, with a negative likelihood ratio of 0.64. When considering only bacteremic patients versus noninfected patients, PCT at a cutoff of 0.2 ng/mL had a negative likelihood ratio of 0.12. Area under an ROC curve was significantly greater for PCT than for abnormal WBC count. Conclusion: It would appear from these findings that a PCT level of 0.2 ng/mL is sensitive for bacteremia and is moderately helpful in excluding the diagnosis. WBC count with or without left shift performed poorly in this study in the diagnosis of bacteremia. Comment: Emergency physicians should wait for a study with more power before adding procalcitonin to the already long list of unhelpful laboratory tests ordered on sick elders who present to the ED for evaluation. Rita K. Cydulka, MD, MS doi:10.1016/j.annemergmed.2004.10.025
Rita K. Cydulka, MD, MS doi:10.1016/j.annemergmed.2004.10.024
Bacteremic Elder Emergency Department Patients: Procalcitonin and White Count Caterino JM, Scheatzle MD, Forbes ML, et al (Allegheny General Hospital, Pittsburgh, PA) Acad Emerg Med. 2004;11:393-396 Background: It is quite common for elderly patients to present to the emergency department (ED) without common signs and symptoms of bacterial infection. As a result, emergency physicians correctly predict bacteremia in less than two thirds of elderly patients, and this diagnosis requires the results of blood cultures that are not available for 24 to 48 hours. Medical decisionmaking in these patients could be 228 Annals of Emergency Medicine
A Comparison of High-Dose and Standard-Dose Epinephrine in Children With Cardiac Arrest Perondi MBM, Reis AG, Paiva EF, et al (University of S~ a o Paulo, S~ a o Paulo, Brazil; University of Pennsylvania, Philadelphia, PA; University of Arizona, Tucson, AZ) N Engl J Med. 2004;350:1722-1730 Background: It is known that the administration of epinephrine during cardiopulmonary resuscitation (CPR) consistently improves coronary and cerebral perfusion. The American Heart Association (AHA) guidelines for pediatric advanced life support have recommended the use of the standard dose of epinephrine administered intravenously. However, when resuscitation efforts in a pediatric patient with cardiac arrest are unsuccessful despite the administration of an Volume 45, no. 2 : February 2005