Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Pectus excavatum with right ventricular compression-induced ventricular arrhythmias

A 33-year-old woman, with palpitations since the age of 15, was referred to a cardiology consultation due to very frequent ventricular extrasystoles with morphology of left bundle branch block, inferior frontal axis, late precordial transition, rS in V1, R in V6 and rS in DI. She had pectus excavatum. The cardiac magnetic resonance showed severe pectus excavatum associated with exaggerated cardiac levoposition, compression and deformation of the right cardiac chambers. However, the patient became pregnant, and follow-up was delayed.

Should we be afraid of watching sport events?

Funding Acknowledgements

Type of funding sources: None.

Background

Behavioral and emotional factors may trigger cardiovascular events (CVE). Watching sports when there is an emotional connection between the supporters and the supportive team, is believed to be potentially associated with CVE. However, epidemiological studies have been inconsistent, with several studies showing an increase in CVE, while others reporting a protective effect.

Purpose

To assess the effect of watching sport events on the incidence of cardiovascular events.

Methods

Pubmed, and Embase were systematically searched to identify appropriate articles. Reference lists were then hand searched for additional relevant articles. To be included, articles had to assess the association between CVE and sport events supporters (adeptos). Pooled association measures, using random effects analysis, were calculated for mortality; arrhythmias; myocardial infarction (MI). Subgroup analysis was conducted based on gender. Publication bias and between-study heterogeneity were evaluated.

Results

There were nineteen studies included in the analysis. The pooled relative risks for mortality, arrhythmias and MI were 1.45(0.98-2.15; 95%CI; I2=70%; p=0.02); 1.31(0.98-1.77; 95%CI; I2=85%; p&lt;0.01); 1.11(0.98-1.24; 95%CI; I2=91%; p&lt;0.01) respectively (Figure 1A). The null association persisted in the subgroup analyses by gender for mortality (Figure 1B) as well as for MI and for the combined endpoint MI/stroke (non significant relative risks).

Conclusions

Overall this analysis suggests that watching sport events does not increase cardiovascular events regardless of gender.

Genetic diversity and population structure of Cynara cardunculus L. in southern Portugal

Cynara cardunculus L. is a cardoon species native to the Mediterranean region, which is composed of three botanical taxa, each having distinct biological characteristics. The aim of this study was to examine wild populations of C. cardunculus established in Portugal, in order to determine their genetic diversity, geographic distribution, and population structure. Based on SSR markers, 121 individuals of C. cardunculus from 17 wild populations of the Portuguese Alentejo region were identified and analysed. Ten SSRs were found to be efficient markers in the genetic diversity analysis. The total number of alleles ranged from 9 to 17 per locus. The expected and observed means in heterozygosity, by population analysed, were 0.591 and 0.577, respectively. The wild population exhibited a high level of genetic diversity at the species level. The highest proportion of genetic variation was identified within a geographic group, while variation was lower among groups. Geographic areas having highest genetic diversity were identified in Alvito, Herdade da Abóboda, Herdade da Revilheira and Herdade de São Romão populations. Moreover, significant genetic differentiation existed between wild populations from North-Alentejo geographic locations (Arraiolos, Évora, Monte da Chaminé) and Centro Hortofrutícola, compared with other populations. This study reports genetic diversity among a representative number of wild populations and genotypes of C. cardunculus from Portugal. These results will provide valuable information towards future management of C. cardunculus germplasm.

The values of low-density lipoprotein cholesterol and acute coronary syndrome

Funding Acknowledgements

Type of funding sources: None.

Introduction

All individuals with a history of acute coronary syndrome (ACS) should receive intensive statin therapy in order to achieve the desirable low-density lipoprotein cholesterol (LDL-C) values recently modified in the guidelines of the European Society of Cardiology.

Purpose

To evaluate the lipid profile control of ACS patients with 6 year follow-up.

Methods

Retrospective study of 138 consecutive patients (P) admitted in our hospital for ACS during one year: 63 ± 13 years, 76.8% male, 26.9% with history of coronary artery disease and 56.5% of dyslipidemia. A 6 year follow-up was performed and a therapeutic goal was defined as LDL-C values below 55mg/dL and an LDL-C reduction of ≥50% from baseline, according to the guidelines of the European Society of Cardiology. High/moderate/low intensity statins were defined according to the therapeutic recommendations of the American College of Cardiology. Univariate analysis was performed.

Results

The mean LDL-C value at ACS admission was 112.5 ± 36.9mg/dL. 96.4% of patients were discharged on statins: 41.3% with rosuvastatin 10mg, 15.2% with simvastatin 20mg, 15.2% with atorvastatin 10mg, 10.9% with pitavastatin 2mg and 6.5% with atorvastatin 20mg.

Antidislipidemic therapy was changed in 7.9% of patients in the scheduled evaluation 1 month after discharge.

The mean LDL-C value after a 6 year follow-up was 83.6 ± 27.2mg/dL, with 85.8% P not meeting the defined therapeutic goal. Most of them (97.5%) continued medicated with statin, however, only 28.3% of P were on high-intensity statins and 3.8% were on low-intensity statins, despite the verified statistically significant association between LDL-C values and statin type used (high/medium/low intensity, p &lt; 0.05).

Conclusion

Despite the proven benefit of statins, especially in high-risk patients, there are still aspects to improve, notably in the establishment of more effective therapies in order to achieve the desired new goals.

Consensus document on chronic coronary syndrome assessment and risk stratification in Portugal: A position paper statement from the [Portuguese Society of Cardiology's] Working Groups on Nuclear Cardiology, Magnetic Resonance and Cardiac Computed Tomography, Echocardiography, and Exercise Physiology and Cardiac Rehabilitation

Despite constant medical evolution, the reimbursement policy of Portuguese National Health Service (NHS) for the study and risk stratification of coronary heart disease has remained unchanged for several decades. Lack of adjustment to contemporary clinical practice has long been evident. However, the recent publication of the European Guidelines for diagnosis and treatment of chronic coronary syndromes further highlighted this gap and the urgent need for a change. Prompted by these Guidelines, the Working Group on Nuclear Cardiology, Cardiac Magnetic Resonance and Cardiac CT, the Working Group on Echocardiography and the Working Group on Stress Pathophysiology and Cardiac Rehabilitation of the Portuguese Society of Cardiology, began a process of joint reflection on the current limitations and how these recommendations could be applied in Portugal. To this end, the authors suggest that the new imaging methods (stress echocardiogram, cardiac computed tomography and cardiac magnetic resonance), should be added to exercise treadmill stress test and myocardial perfusion scintigraphy in the available exam portfolio within the Portuguese NHS. This change would allow full adoption of European guidelines and a better use of tests, according to clinical context, availability and local specificities. The adoption of clinical guidance standards, based on these assumptions, would translate into a qualitative improvement in the management of these patients and would promote an effective use of the available resources, with potential health and financial gains.

Worsening or 'pseudo-worsening' renal function? The prognostic value of hemoconcentration in patients admitted with acute heart failure

INTRODUCTION

Renal insufficiency, as evidenced by an increase in creatinine, is associated with higher mortality in patients with acute heart failure (AHF). Conversely, hemoconcentration (HC) in AHF is associated with lower mortality, but can also cause an increase in creatinine. Our aim was to assess the prognosis of HC in patients hospitalized for AHF presenting with or without worsening renal function (WRF).

METHODS

A total of 618 consecutive patients admitted for AHF were included. WRF was defined according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria and HC was defined as an elevation of hemoglobin during hospitalization compared to the admission value. Six-month all-cause mortality was analyzed.

RESULTS

The patients' mean age was 79±11 years; 58% were women. Mortality at six months was 38% and 49% of patients had WRF. HC occurred in 38.9% of patients with WRF and was associated with improved survival (HR 1.6, 95% CI 1.10-2.34; p=0.02) compared to WRF without HC. HC was associated with better survival in KDIGO stages 1 and 2 (HR 1.8; 95% CI 1.1-2.8; p=0.01). For patients without chronic kidney disease (CKD) with WRF in stages 1 and 2, HC was associated with significantly better survival (HR 2.3; 95% CI 1.2-4.2; p=0.01).

CONCLUSION

In patients admitted for AHF without renal failure or CKD, WRF with HC is associated with a better prognosis, similar to that of patients without WRF, and should therefore be reclassified as 'pseudo-WRF'.

Portuguese recommendations for the prevention, diagnosis and management of primary osteoporosis - 2018 update

BACKGROUND

Advances in osteoporosis (OP)case definition, treatment options, optimal therapy duration and pharmacoeconomic evidence in the national context motivated the Portuguese Society of Rheumatology (SPR) to update the Portuguese recommendations for the diagnosis and management of osteoporosis published in 2007.

METHODS

SPR bone diseases' working group organized meetings involving 55 participants (rheumatologists, rheumatology fellows and one OP specialist nurse) to debate and develop the document. First, the working group selected 11 pertinent clinical questions for the diagnosis and management of osteoporosis in standard clinical practice. Then, each question was investigated through literature review and draft recommendations were built through consensus. When insufficient evidence was available, recommendations were based on experts' opinion and on good clinical practice. At two national meetings, the recommendations were discussed and updated. A draft of the recommendations full text was submitted to critical review among the working group and suggestions were incorporated. A final version was circulated among all Portuguese rheumatologists before publication and the level of agreement was anonymously assessed using an online survey.

RESULTS

The 2018 SPR recommendations provide comprehensive guidance on osteoporosis prevention, diagnosis, fracture risk assessment, pharmacological treatment initiation, therapy options and duration of treatment, based on the best available evidence. They attained desirable agreement among Portuguese rheumatologists. As more evidence becomes available, periodic revisions will be performed. Target audience and patient population: The target audience for these guidelines includes all clinicians. The target patient population includes adult Portuguese people. Intended use: These recommendations provide general guidance for typical cases. They may not be appropriate in all situations - clinicians are encouraged to consider this information together with updated evidence and their best clinical judgment in individual cases.

Molecular and epidemiologic study of Clostridium difficile reveals unusual heterogeneity in clinical strains circulating in different regions in Portugal

Clostridium difficile infection (CDI) represents a great healthcare burden in developed countries. The emergence of the epidemic PCR ribotype (RT) 027 and its acquired fluoroquinolones resistance have accentuated the need for an active surveillance of CDI. Here we report the first countrywide study of CDI in Portugal with the characterization of 498 C. difficile clinical isolates from 20 hospitals in four regions in Portugal regarding RT, virulence factors and antimicrobial susceptibility. We identified 96 RTs with marked variations between and within regions, as only six RTs appeared in all four regions. RT027 was the most frequent RT overall (18.5%) and among healthcare facility-associated isolates (19.6%), while RT014 was the most common among community-associated isolates (12%). The north showed a high RT diversity among isolates and a low moxifloxacin (MXF) resistance rate (11.9%), being the only region in which RT027 was not predominant. In contrast, the isolates from the centre presented the highest RT027 frequency, and 53.4% were resistant to MXF. Overall, MXF resistance (33.2%) was associated (p <0.001) with the presence of binary toxin genes and mutations in tcdC regardless of the RT. Both traits appeared in almost 30% of the strains. RT027 showed a reduced susceptibility to metronidazole (p <0.01), and RT126 had higher minimum inhibitory concentrations to vancomycin (p = 0.03) compared to other RTs. The present study highlights an unusual heterogeneity of RTs in Portugal, with a high frequency of hypervirulent RTs and the emergence of virulence factors in non-027 RTs, emphasizing the need for a surveillance system for CDI in Portugal.

Additional value of associating aortic valve calcification to coronary calcium as a gatekeeper for coronary tomography angiography

BACKGROUND

Aortic valve calcification shares risk factors with coronary artery disease. Coronary calcium has been used has a gatekeeper to performing coronary tomography angiography. The aim of this study was to evaluate aortic valve calcification as a predictor of obstructive coronary artery disease by computed tomography, and its possible usefulness, alongside with coronary calcium, to improve the decision of whether or not to proceed with computed tomography angiography.

METHODS

Transversal case-control study including 154 consecutive patients (62 ± 12 years, 57.6 % female, without known coronary or valve disease) undergoing calcium scoring and angiography through computed tomography (Phillips Brilliance, 16-slice). Predictors of aortic valve calcification and obstructive coronary artery disease were identified. Usefulness of aortic valve calcification when added to calcium score for prediction of obstructive coronary artery disease was assessed by binary logistic regression and net reclassification index.

RESULTS

Aortic valve calcification was associated with higher coronary calcium, extent and prevalence of obstructive coronary disease, which was identified in 22.1 % of patients and was discriminated by aortic valve calcium with an area under curve 0.749 (p < 0.001, Youden index: 61). A higher discriminative power was achieved with a model based on coronary and aortic valve calcification (AUC 0.900, p < 0.001). Compared with calcium score >400 as a gatekeeper to angiography, the association of aortic calcium >61 allowed a net reclassification index of +7.7 % of patients.

CONCLUSIONS

Aortic valve calcification is associated with the prevalence and extent of obstructive coronary artery disease by computed tomography angiography and is an easy, fast and useful method to improve the selection of patients for angiography.

Clinicopathological significance of immunoexpression of claudin-1 and claudin-7 in feline mammary carcinomas

Claudins (CLDNs) are tight junction proteins that have a role in regulating cell adhesion and polarity, paracellular permeability, proliferation and differentiation. Several immunohistochemical studies have shown reduced expression of CLDN-1 and CLDN-7 in human and canine mammary carcinomas, suggesting that these proteins may participate in mammary carcinogenesis, invasion and metastasis. The present study characterizes expression of CLDN-1 and CLDN-7 in feline mammary carcinomas (n = 52) and their metastases (n = 29). There was an inverse association between CLDN-7 expression and histological grade of tumour. Reduced expression of CLDN-7 was significantly associated with decreased tubule formation, high proliferative activity and metastasis. No significant associations were found between CLDN-1 expression and any of these features. Evaluation of expression of CLDN-7, but not CLDN-1, may therefore provide prognostic information, assisting in the diagnosis of a subgroup of aggressive feline mammary carcinomas that share some features with the recently described 'claudin-low' subgroup of human breast cancer.

Which method of left atrium size quantification is the most accurate to recognize thromboembolic risk in patients with non-valvular atrial fibrillation?

BACKGROUND

Left atrial (LA) size is a predictor of cardiovascular outcomes in patients in sinus rhythm, whereas conflicting results have been found in atrial fibrillation (AF). This study aims to: (1) Evaluate the accuracy of LA size to identify surrogate markers of an increased thromboembolic risk in patients with AF; (2) Assess the best method to evaluate LA size in this setting.

METHODS

Cross-sectional study enrolling 500 consecutive patients undergoing transthoracic and transesophageal echocardiography evaluation during a non-valvular AF episode. LA size was measured on transthoracic echocardiography using several methods: anteroposterior diameter, area in four-chamber view, and volumes by the ellipsoid, single- and biplane area-length formulas. Surrogate markers of stroke were evaluated by transesophageal echocardiography: LA appendage (LAA) thrombus, LAA low flow velocities, dense spontaneous echocardiographic contrast and LA abnormality.

RESULTS

Except for non-indexed anteroposterior diameter, increased LA size quantified by all the other methods showed a moderate to high discriminatory power to identify all the surrogate markers of stroke. A higher accuracy was observed for indexed LA area in four-chamber view (LAA thrombus: AUC = 0.708, CI95% 0.644- 0.772, p<0.001; LAA low flow velocities: AUC = 0.733, CI95% 0.674- 0.793, p<0.001; dense spontaneous echocardiographic contrast: AUC = 0.693, CI95% 0.638- 0.748, p<0.001; LA abnormality: AUC = 0.705, CI95% 0.654-0.755, p<0.001), indexed single-plane area-length volume (LAA thrombus: AUC = 0.701, CI95% 0.633-0.770, p<0.001; LAA low flow velocities: AUC = 0.726, CI95% 0.660-0.792, p<0.001; dense spontaneous echocardiographic contrast: AUC = 0.673, CI95% 0.611-0.736, p<0.001; LA abnormality: AUC = 0.687, CI95% 0.629-0.744, p<0.001), and indexed biplane area-length volume (LAA thrombus: AUC = 0.707, CI95% 0.626-0.788, p<0.001; LAA low flow velocities: AUC = 0.737, CI95% 0.664-0.810, p<0.001; dense spontaneous echocardiographic contrast: AUC = 0.651, CI95% 0.578-0.724, p<0.001; LA abnormality: AUC = 0.683, CI95% 0.617-0.749, p<0.001), without significant difference between them. Indexed LA area in four-chamber view and indexed area-length volumes also were independent predictors of surrogate markers of stroke.

CONCLUSIONS

Left atrium enlargement is associated with an increased prevalence of surrogate markers of stroke in patients with non-valvular AF. Indexed LA area in four-chamber view and indexed area-length volumes displayed the strongest association.

Can cardiac computed tomography predict cardiovascular events in asymptomatic type-2 diabetics?: results of a long term follow-up

Background

Doubts remain about atherosclerotic disease and risk stratification of asymptomatic type-2 diabetic patients (T2DP). This study aims to evaluate the usefulness of calcium score (CS) and coronary computed tomography (CT) angiography (CTA) to predict fatal and non fatal cardiovascular events (CVEV) in T2DP.

Methods

Eighty-five consecutive T2DP undergoing CT (Phillips Brilliance, 16-slice) with CS and CTA were prospectively enrolled in a transversal case-control study. Patients were followed for 48 months (range 18 - 68) to assess CVEV: cardiovascular death, acute coronary syndrome, revascularisation and stroke. Potential predictors of CVEV were identified. Predictive models based on clinical features, CTA and CS were created and compared.

Results

Performing CT impacted T2DP treatment. Cardiovascular risk was lowered during follow-up but metabolic control remained suboptimal. CVEV occurred in 11.8% T2DP (3.1%/year). CS ≥86.6 was predictor of CVEV over time, with a high negative predictive value, an 80% sensitivity and 74.7% specificity. Although its prognostic value was not independent of the presence/absence of obstructive CAD, adding CS and CTA data to clinical parameters improved the prediction of CVEV: the combined model had the highest AUC (0.888, 95%CI 0.789-0.987, p < 0.001) for the prediction of the study endpoints.

Conclusions

CS showed great value in T2DP risk stratification and its prognostic value was further enhanced by CTA data. Information provided by CT may help predict CVEV in T2DP and potentially improve their outcome.

Evaluation of left atrial deformation to predict left atrial stasis in patients with non-valvular atrial fibrillation - a pilot-study

BACKGROUND

Speckle tracking-derived strain and strain rate are recently available parameters to assess left atrial (LA) deformation. We hypothesized that such new parameters could be of interest to evaluate the risk of LA stasis among patients with atrial fibrillation (AF).

METHODS

Single-centre study enrolling all patients with non-valvular AF lasting longer than 48 hours for whom no therapeutic anticoagulation was given in the preceding 3 weeks and who were assessed through transesophageal and transthoracic echocardiogram during a 6 month time interval. LA deformation was assessed by transthoracic echocardiogram through speckle tracking analysis, whereas LA stasis parameters were sought on transesophageal echocardiogram.

RESULTS

Among the 82 assessed patients, LA appendage thrombi or sludge were found in 16 (19.5%). A moderate positive correlation was found between peak positive strain rate and maximum emptying velocity (r = 0.589; P <0.001) and peak positive strain rate and maximum filling velocity of the LA appendage (r = 0.651; P <0.001). Peak negative strain rate was also found to be associated with both maximum emptying velocity (r = -0.513; P <0.001) and maximum filling velocity of the LAA (r = -0.552; P <0.001). AF duration, peak negative strain rate and time-to-peak positive strain were independent predictors of LAA thrombi or sludge on multivariate analysis logistic regression. The area under the curve for the estimated probabilities using the obtained logistic regression model was 0.89 (95%CI 0.81-0.96; P <0.001).

CONCLUSION

Our findings suggest that LA mechanical dysfunction assessed through speckle tracking may be of interest to predict LA stasis in the setting of AF.

Reduced expression of claudin-2 is associated with high histological grade and metastasis of feline mammary carcinomas

Claudins (CLDNs) are a family of tight junction (TJ) proteins that play an important role in maintaining cell polarity, in controlling paracellular ion flux and in regulating cell proliferation and differentiation. There is a growing body of evidence that associates changes in CLDN expression with the development of human breast cancer. In the present study CLDN-2 expression was examined immunohistochemically in samples of normal feline mammary tissue (n = 5) and mammary carcinomas (n = 52), including metastatic lesions (n = 29). Seventy-seven percent of carcinomas showed reduced CLDN-2 expression compared with that observed in normal mammary gland. Reduced expression of CLDN-2 was significantly associated with a high histological grade of carcinoma (P = 0.011), with 88.6% of grade II/III carcinomas showing decreased expression. Furthermore, CLDN-2 down-regulation was significantly associated with metastatic disease (P = 0.0027), with 93.1% of cases with signs of metastasis showing decreased expression of this protein. CLDN-2 may constitute a molecular marker for identification of a subgroup of feline mammary carcinomas characterized by high histological grade and the development of metastasis.

Mean corpuscular volume and red cell distribution width as predictors of left atrial stasis in patients with non-valvular atrial fibrillation

BACKGROUND

The role of erythrocyte indexes for the prediction of left atrial stasis, assessed by transesophageal echocardiography in patients with non-valvular atrial fibrillation, has not been previously clarified.

METHODS

Single center cross-sectional study comprising 247 consecutive patients admitted to the emergency department due to symptomatic atrial fibrillation and undergoing transesophageal echocardiogram evaluation for exclusion of left atrial appendage thrombus (LAAT) before cardioversion. All patients had a complete blood count performed up to 12 hours prior to the transesophageal echocardiogram. Markers of left atrial stasis were sought: LAAT, dense spontaneous echocardiographic contrast (DSEC) and low flow velocities (LFV) in the left atrial appendage. Erythrocyte indexes' accuracy for detecting transesophageal echocardiogram changes was evaluated through receiver operating curve analysis. Binary logistic multivariate analysis, using solely erythrocyte indexes and in combination with other variables (i.e. CHADS2, CHA2DS2VASc classifications and left ventricle ejection fraction), was used for transesophageal echocardiogram endpoints prediction.

RESULTS

LAAT was found in 8.5%, DSEC in 26.1% and LFV in 12.1%. Mean corpuscular volume and red cell distribution width were independent predictors of LAAT and DSEC. Despite adding incremental predictive value to each other, when clinical risk factors from CHADS2 and CHA2DS2VASc classifications and left ventricle ejection fraction were added to the models, only mean corpuscular volume remained an independent predictor of LAAT and DSEC.

CONCLUSIONS

These findings suggest that mean corpuscular volume and red cell distribution width may be linked to left atrial stasis markers.

Mean platelet volume is associated with the presence of left atrial stasis in patients with non-valvular atrial fibrillation

Background

Mean platelet volume has been associated with stroke in patients with atrial fibrillation. However, its role as a predictor of left atrial stasis, assessed by transesophageal echocardiography, in patients with non-valvular atrial fibrillation has not yet been clarified.

Methods

Single center cross-sectional study comprising 427 patients admitted to the emergency department due to symptomatic atrial fibrillation and undergoing transesophageal echocardiogram evaluation for exclusion of left atrial appendage thrombus before cardioversion. All patients had a complete blood count performed in the 12 hours prior to transesophageal echocardiogram. Markers of left atrial stasis were sought: left atrial appendage thrombus, dense spontaneous echocardiographic contrast and low flow velocities in the left atrial appendage. The presence of at least one of the former markers of left atrial stasis was designated left atrial abnormality. Binary logistic multivariate analysis was used for obtaining models for the prediction of transesophageal echocardiogram endpoints.

Results

Left atrial appendage thrombus was found in 12.2%, dense spontaneous echocardiographic contrast in 29.7%, low flow velocities in 15.3% and left atrial abnormality in 34.2%. Mean platelet volume (exp β = 3.41 p = 0.048) alongside with previous stroke or transient ischemic attack (exp β = 5.35 p = 0.005) and troponin I (exp β = 5.07 p = 0.041) were independent predictors of left atrial appendage thrombus. Mean platelet volume was also incorporated in the predictive models of dense spontaneous echocardiographic contrast, low flow velocities and left atrial abnormality, adding predictive value to clinical, echocardiographic and laboratory variables.

Conclusions

These findings suggest that mean platelet volume may be associated with the presence of markers of left atrial stasis, reinforcing a likely cardioembolic mechanism for its association with stroke in patients with non-valvular atrial fibrillation.

Percutaneous closure of the left atrial appendage for thromboembolic prevention in atrial fibrillation

Atrial fibrillation is a common arrhythmia in clinical practice. It is associated with high morbidity and mortality due to its thromboembolic potential, which makes thromboembolic prevention particularly important. Warfarin has been the first-line therapy for this purpose, but it has various limitations and is often contraindicated or underutilized. The fact that thrombi are frequently located in the left atrial appendage in atrial fibrillation led to the development of percutaneous closure for thromboembolic prevention. This article examines the current evidence on percutaneous closure of the left atrial appendage by reviewing the results of the numerous clinical trials on the technique.

Manchester triage in acute pulmonary embolism: can it unmask the grand impersonator?

BACKGROUND

Acute pulmonary embolism (PE) is associated with high mortality risk. Early diagnosis is difficult because of non-specific clinical presentation and delay in imaging confirmation. Manchester Triage (MT) prioritises patients on the basis of illness severity and potentially recognises those with higher mortality risk. No studies of the role and impact of MT on rapid PE diagnosis and in-hospital mortality (IHM) have been carried out.

OBJECTIVE

To assess the appropriateness of MT in this set of patients presenting acutely to the emergency department (ED), and to determine whether it assists in a rapid diagnosis, acts as a protective triage tool and affects short-term mortality.

METHODS

Single-centre retrospective study of 176 consecutive patients with PE, assessed by MT in the ED between January 2006 and October 2010 (mean age 70.5±15.7 years, 38.6% men). The primary outcome measure was all-cause IHM.

RESULTS

IHM was seen in 30 (17%) patients. More than half of the patients with PE (54%) were classified as target time for first medical observation (MOb) ≤10 min. 73.3% of IHM occurred in this group (p=0.020) with several increased markers of illness severity. MOb ≤10 min was not associated with faster PE imaging confirmation. The average door-to-diagnosis time (PEDx) was 26.8±36.8 h and PEDx >17.0 h was associated with higher IHM (p=0.017). On multivariate analysis, thrombolysis and MOb ≤10 min were included in an IHM predictor model.

CONCLUSION

MT has high sensitivity in identifying patients with PE at risk. Those patients assigned as MOb ≤10 min have increased markers of illness severity and higher IHM. MT acts as a protective system in this challenging set and should be used as a patient's first assessment, aiding the emergency medical team to recognise those in need of urgent assessment and treatment.