Myocardial ischemia induces intracellular accumulation of non-glycosylated apolipoprotein J that results in a reduction of circulating glycosylated ApoJ (ApoJ-Glyc). The latter has been suggested to ...be a marker of transient myocardial ischemia.
This proof-of-concept clinical study aimed to assess whether changes in circulating ApoJ-Glyc could detect myocardial ischemia in patients attending the emergency department (ED) with chest pain suggestive of acute coronary syndrome (ACS).
In suspected ACS patients, EDICA (Early Detection of Myocardial Ischemia in Suspected Acute Coronary Syndromes by ApoJ-Glyc a Novel Pathologically based Ischemia Biomarker), a multicentre, international, cohort study assessed changes in 2 glycosylated variants of ApoJ-Glyc, (ApoJ-GlycA2 and ApoJ-GlycA6), in serum samples obtained at ED admission (0 h), and 1 h and 3 h thereafter, blinded to the clinical diagnosis (i.e. STEMI, NSTEMI, unstable angina, non-ischemic).
404 patients were recruited; 291 were given a clinical diagnosis of “non-ischemic” chest pain and 113 were considered to have had an ischemic event. ApoJ-GlycA6 was lower on admission in ischemic compared with “non-ischemic” patients (66 46–90 vs. 73 56–95 μg/ml; P = 0.04). 74% of unstable angina patients (all with undetectable hs-Tn), had ischemic changes in ApoJ-Glyc at 0 h and 89% at 1 h. Initially low ApoJ-Glyc levels in 62 patients requiring coronary revascularization increased significantly after successful percutaneous intervention.
Circulating ApoJ-Glyc concentrations decrease early in ED patients with myocardial ischemia compared with “non-ischemic” patients, even in the absence of troponin elevations. ApoJ-Glyc may be a useful marker of myocardial ischemia in the ED setting.
•ApoJ-Glyc detects reversible myocardial ischemia and the restoration of perfusion.•ApoJ-Glyc is a dynamic marker of transient/reversible myocardial ischemia.•ApoJ-Glyc might complement the diagnostic role of hs-Tn in the Emergency Department.
The objectives were to determine the impact of frailty and disability on 30-day mortality and whether the addition of these variables to HFRSS EFFECT risk score (FBI-EFFECT model) improves the ...short-term mortality predictive capacity of both HFRSS EFFECT and BI-EFFECT models in older patients with acute decompensated heart failure (ADHF) atended in the emergency department. We performed a retrospective analysis of OAK Registry including all consecutive patients ≥65 years old with ADHF attended in 3 Spanish emergency departments over 4 months. FBI-EFFECT model was developed by adjusting probabilities of HFRSS EFFECT risk categories according to the 6 groups (G1: non frail, no or mildly dependent; G2: frail, no or mildly dependent; G3: non frail, moderately dependent; G4: frail, moderately dependent; G5: severely dependent; G6: very severely dependent).We included 596 patients (mean age: 83 SD7; 61.2% females). The 30-day mortality was 11.6% with statistically significant differences in the 6 groups (p < 0.001). After adjusting for HFRSS EFFECT risk categories, we observed a progressive increase in hazard ratios from groups G2 to G6 compared with G1 (reference). FBI-EFFECT had a better prognostic accuracy than did HFRSS EFFECT (log-rank p < 0.001; Net Reclassification Improvement NRI = 0.355; p < 0.001; Integrated Discrimination Improvement IDI = 0.052; p ;< 0.001) and BI-EFFECT (log-rank p = 0.067; NRI = 0.210; p = 0.033; IDI = 0.017; p = 0.026). In conclusion, severe disability and frailty in patients with moderate disability are associated with 30-day mortality in ADHF, providing additional value to HFRSS EFFECT model in predicting short-term prognosis and establishing a care plan.
FUNDAMENTOS // La valoración funcional forma parte de la valoración geriátrica. No se conoce bien cómo se realiza en los servicios de Urgencias
hospitalarios (SUH) y menos aún su valor pronóstico. El ...objetivo de este trabajo fue investigar si la dependencia funcional basal para realizar las actividades
básicas de la vida diaria (ABVD) era un factor pronóstico independiente de muerte tras la visita índice al SUH durante la primera ola pandémica de la
COVID-19 y si tuvo un impacto diferente en pacientes con y sin diagnóstico de COVID-19.
MÉTODOS // Se realizó un estudio observacional retrospectivo de la cohorte EDEN-Covid (Emergency Department and Elder Needs during COVID) formada
por todos los pacientes de edad mayor o igual a 65 años atendidos en 52 SUH españoles, seleccionados por oportunidad durante siete días consecutivos
(del 30 de marzo al 5 de abril de 2020). Se analizaron variables demográficas, clínicas, funcionales, mentales y sociales. La dependencia se categorizó con
el índice de Barthel (IB) en independiente (IB=100), dependencia leve-moderada (100>IB>60) y dependencia grave-total (IB<60), y se evaluó su asociación
cruda y ajustada con la mortalidad a 30, 180 y 365 días mediante modelos de riesgos proporcionales de COX.
RESULTADOS // De 9.770 pacientes incluidos con una media de edad de 79 años, un 51% eran hombres, 6.305 (64,53%) eran independientes, 2.340 (24%)
tenían dependencia leve-moderada y 1.125 (11,5%) dependencia grave-total. El número de fallecidos a 30 días en estos tres grupos fue 500 (7,9%), 521 (22,3%) y 378 (33,6%), respectivamente; a 180 días fue 757 (12%), 725 (30,9%) y 526 (46,8%); y a 365 días 954 (15,1%), 891 (38,1%) y 611 (54,3%). En relación a los pacientes independientes, los riesgos (hazard ratio) ajustados de fallecer a 30 días, asociados a dependencia leve-moderada y grave-total, fueron 1,91 (IC 95%: 1,66-2,19) y 2,51 (2,11-2,98); a 180 días fueron de 1,88 (1,68-2,11) y 2,64 (2,28-3,05); y a 365 días fueron 1,82 (1,64-2,02) y 2,47 (2,17-2,82). Este impacto negativo de la dependenciasobre la mortalidad fue mayor en pacientes diagnosticados de COVID-19 que en los no COVID-19 (p interacción a 30, 180 y 365 días de 0,36, 0,05 y 0,04).
CONCLUSIONES // La dependencia funcional de los pacientes mayores que acuden a SUH españoles durante la primera ola pandémica se asocia a
mortalidad a 30, 180 y 365 días, y este riesgo es significativamente mayor en los pacientes atendidos por COVID-19.
BACKGROUND // Functional assessment is part of geriatric assessment. How it is performed in hospital Emergency Departments (ED) is poorly understood,
let alone its prognostic value. The aim of this paper was to investigate whether baseline disability to perform basic activities of daily living (BADL) was
an independent prognostic factor for death after the index visit to the ED during the first wave of the COVID-19 pandemic and whether it had a different
impact on patients with and without diagnosis of COVID-19.
METHODS // A retrospective observational study of the EDEN-Covid (Emergency Department and Elder Needs during COVID) cohort was carried out, consisting
of all patients aged ≥65 years seen in 52 Spanish EDs selected by chance during 7 consecutive days (30/3/2020 to 5/4/2020). Demographic, clinical, functional,
mental and social variables were analyzed. Dependence was categorized with the Barthel index (BI) as independent (BI=100), mild-moderate dependence
(100>BI>60) and severe-total dependence (BI<60), and their crude and adjusted association was evaluated with mortality at 30, 180 and 365 days using COX
proportional hazards models.
RESULTS // Of 9,770 enrolled patients with a mean age of 79 years, 51% were men, 6,305 (64.53%) were independent, 2,340 (24%) had mild-moderate
dependence, and 1,125 (11.5%) severe-total dependence. The number of deaths at 30 days in these three groups was 500 (7.9%), 521 (22.3%) and 378 (33.6%),
respectively; at 180 days it was 757 (12%), 725 (30.9%) and 526 (46.8%); and at 365 days 954 (15.1%), 891 (38.1%) and 611 (54.3%). In relation to independent
patients, the adjusted risks (hazard ratio) of dying within 30 days associated with mild-moderate and severe-total dependency were 1.91 (95% CI: 1.66-2.19) and
2.51. (2.11-2.98); at 180 days they were 1.88 (1.68-2.11) and 2.64 (2.28-3.05); and at 365 days they were 1.82 (1.64-2.02) and 2.47 (2.17-2.82). This negative impact of dependency on mortality was greater in patients diagnosed with COVID-19 than in non-COVID-19 (p interaction at 30, 180 and 365 days of 0.36, 0.05 and 0.04).
CONCLUSIONS // The functional dependence of older patients who attend Spanish EDs during the first wave of the pandemic is associated with mortality
at 30, 180 and 365 days, and this risk is significantly higher in patients treated for COVID-19.
Physicians in the emergency department (ED) need additional tools to stratify patients with acute heart failure (AHF) according to risk.
To predict mortality using data that are readily available at ...ED admission.
Prospective cohort study.
34 Spanish EDs.
The derivation cohort included 4867 consecutive ED patients admitted during 2009 to 2011. The validation cohort comprised 3229 patients admitted in 2014.
88 candidate risk factors and 30-day mortality.
Thirteen independent risk factors were identified in the derivation cohort and were combined into an overall score, the MEESSI-AHF (Multiple Estimation of risk based on the Emergency department Spanish Score In patients with AHF) score. This score predicted 30-day mortality with excellent discrimination (c-statistic, 0.836) and calibration (Hosmer-Lemeshow P = 0.99) and provided a steep gradient in 30-day mortality across risk groups (<2% for patients in the 2 lowest risk quintiles and 45% in the highest risk decile). These characteristics were confirmed in the validation cohort (c-statistic, 0.828). Multiple sensitivity analyses did not find important amounts of confounding or bias.
The study was confined to a single country. Participating EDs were not selected randomly. Many patients had missing data. Measurement of some risk factors was subjective.
This tool has excellent discrimination and calibration and was validated in a different cohort from the one that was used to develop it. Physicians can consider using this tool to inform clinical decisions as further studies are done to determine whether the tool enhances physician decision making and improves patient outcomes.
Instituto de Salud Carlos III, Spanish Ministry of Health; Fundació La Marató de TV3; and Catalonia Govern.
The objective was to determine the relationship between short-term mortality and intravenous morphine use in ED patients who received a diagnosis of acute heart failure (AHF).
Consecutive patients ...with AHF presenting to 34 Spanish EDs from 2011 to 2014 were eligible for inclusion. The subjects were divided into those with (M) or without IV morphine treatment (WOM) groups during ED stay. The primary outcome was 30-day all-cause mortality, and secondary outcomes were mortality at different intermediate time points, in-hospital mortality, and length of hospital stay. We generated a propensity score to match the M and WOM groups that were 1:1 according to 46 different epidemiological, baseline, clinical, and therapeutic factors. We investigated independent risk factors for 30-day mortality in patients receiving morphine.
We included 6,516 patients (mean age, 81 SD, 10 years; 56% women): 416 (6.4%) in the M and 6,100 (93.6%) in the WOM group. Overall, 635 (9.7%; M, 26.7%; WOM, 8.6%) died by day 30. After propensity score matching, 275 paired patients constituted each group. Patients receiving morphine had a higher 30-day mortality (55 20.0% vs 35 12.7% deaths; hazard ratio, 1.66; 95% CI, 1.09-2.54; P = .017). In patients receiving morphine, death was directly related to glycemia (P = .013) and inversely related to the baseline Barthel index and systolic BP (P = .021) at ED arrival (P = .021). Mortality was increased at every intermediate time point, although the greatest risk was at the shortest time (at 3 days: 22 8.0% vs 7 2.5% deaths; OR, 3.33; 95% CI, 1.40-7.93; P = .014). In-hospital mortality did not increase (39 14.2% vs 26 9.1% deaths; OR, 1.65; 95% CI, 0.97-2.82; P = .083) and LOS did not differ between groups (median interquartile range in M, 8 7; WOM, 8 6; P = .79).
This propensity score-matched analysis suggests that the use of IV morphine in AHF could be associated with increased 30-day mortality.
Abstract only
Introduction:
Reduced serum levels of glycosylated apolipoprotein J (ApoJ-Glyc) have been proposed as a marker for the early detection of myocardial ischemia with a potential prognostic ...value.
Objective:
The EDICA clinical trial assessed the performance of ApoJ-Glyc as a biomarker for the early detection of myocardial ischemia in patients attending the A&E department with chest pain suggestive of acute coronary syndrome (ACS) and investigated -as a secondary pilot objective- its prognostic value.
Methods:
EDICA -a multi-centre, international, diagnostic study (NCT04119882) assessed 404 patients. Based on clinical variables and diagnostic tests, 291 patients were considered to have had a “non-ischemic” event and 113 an “ischemic” event. Blood samples were obtained for the assessment of high-sensitivity troponin and ApoJ-Glyc at admission and at 1h and 3h thereafter. GRACE Risk Score was calculated in all ischemic patients. Patients were followed up for 6 months after presentation and the occurrence of MACE (cardiac death, recovered cardiac arrest, re-infarction, cardiac failure, new admission for ACS after discharge, or unplanned revascularization for cardiac ischemia after discharge) was recorded. ApoJ-Glyc serum levels were analyzed with a novel ELISA targeting a specific glycosylated variant of ApoJ (ApoJ-GlycA2).
Results:
Among the patients in the ischemic group, 8.8% had MACE at 6-months and these showed a 26% mean reduction in ApoJ-GlycA2 levels 3h post-admission compared with levels at presentation. This reduction was not observed in patients without MACE. Patients in the highest GRACE Risk Score tertile (>118 points) showed a progressive decrease in ApoJ-GlycA2 levels after presentation compared with patients in the lower risk tertiles (mean decrease: 41% at 1h, P=0.01 and 35% at 3h, P=0.02 when compared with admission levels).
Conclusions:
A progressive decrease in ApoJ-Glyc levels after A&E admission appears to not only identify patients with ischemic events but also those at higher risk of suffering serious recurrent cardiovascular events at 6-months’ follow-up. Further studies in larger cohorts of patients are warranted to validate the potential role of ApoJ-Glyc in risk stratification in the context of cardiac ischemic events.
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