Patients reaching the emergency department (ED) with symptoms of acute ischemic stroke (AIS) may be affected by a stroke mimics (SMs). A prompt clinical diagnosis could avoid unnecessary thrombolysis. We evaluated a new and rapid approach, the Santa Maria Nuova-Stroke Mimic (SMN-SM) scale, to improve a prompt clinical diagnosis. 340 consecutive patients admitted to the ED with suspected AIS were evaluated. The final diagnosis was: AIS in 267 (78,5%) and SMs in 73 (21,5%) patients. Multivariate logistical analysis showed that the following features – lack of facial paralysis, dizziness, migraine, seizure disorders, blood pressure <150, cognitive impairment, and female sex – were significantly more abundant in patients with SMs than in AIS. To each of these features we assigned a numerical score and we performed a receiver operating characteristic analysis. When the score of the scale was above 8 (cut-point), we obtained a specificity of 93% and a sensitivity of 56% for a SM diagnosis. Thus, the SMN-SM scale seems a rather useful tool to improve SMs diagnosis.

Mild traumatic brain injury (mTBI) is a common cause of admission to the Emergency Department (ED). Many patients are elderly on oral anticoagulant therapy (OAT) at increased risk of immediate and delayed intracranial hemorrhage (ICH). To investigate the frequency of delayed ICH (DICH) in old patients with mTBI in OAT and the occurrence of complications related to the ED stay. In this single-center retrospective study, we recruited all patients in OAT aged 65 and over, admitted for mTBI to the ED of our Hospital in Florence from March 2019 to February 2021. Clinical variables were collected and cranial computed tomography (CT) scans reviewed. The primary outcome was the frequency of DICH occurring within 30 days since the trauma after a first negative CT. Secondary outcomes included need of neurosurgical intervention and death for DICH, and hospital-related complications. Statistical analyses were conducted using IBM SPSS Statistics (version 22). Among 363 enrolled patients, there were 31 acute ICH (8.5

We analysed the clinical features and diagnostic workup of patients presenting with haemoptysis to an Italian teaching hospital to derive an easy-to-use clinical score to guide risk stratification and initial management in the emergency department (ED). We retrospectively reviewed clinical records of consecutive patients with haemoptysis over 1 year. A pre-specified set of variables, including demographic data, vital signs, type of expectorate (pure blood vs. blood-streaked sputum), comorbidities, and diagnostic tests and treatments was originally registered. The primary outcome was a composite of any of the following: death from any cause, invasive or non-invasive ventilation, Intensive Care Unit admission, blood transfusions or invasive haemostatic procedures. We investigated associations between the pre-specified clinical variables and the primary outcome using a logistic regression analysis. Finally, we derived a score (the Florence Haemoptysis Score, FLHASc) giving a proportional weight to each variable according to the Odds Ratios (OR). We included 197 patients with a median age of 60 years. The first radiological study was a plain chest X-ray in 128 patients (65%). For 33 (17%) patients, a chest computer tomography (CT scan) was the first radiological study. The most common diagnosis was lung malignancy (19% of cases). The diagnosis remained undetermined in one-third of patients. The primary outcome was met by 11.2% of the study population. Systolic blood pressure <100 mmHg (OR 9.7), a history of malignancy (OR 3), the expectoration of pure blood (OR 2.8), and more than 2 episodes of haemoptysis in the prior 24 h (OR 2.5) are found as independent predictors of the primary outcome. The FLHASc ranges from 0 to 6 with a prognostic accuracy of 78% (IC 95%, 68–88%). The primary outcome incidence is 2.4% (IC 95%, 0.2–8.2%) in patients with a FLHASc equal to zero (n = 85, 43%) versus 13.4% (IC 95% 7.8–21.1%) in patients with a FLHASc > 0 (p < 0.01). Among patients with a FLHASc equal to zero, a negative chest X-ray study identifies patients who may be safely discharged. Patients who presented to the ED with haemoptysis experience a heterogeneous management. We derive a simple clinical prognostic score that may rationalize their diagnostic workup.

Background: Clinical variables including hypertension could be linked with major bleeding events and death beyond vitamin K antagonist (warfarin) or direct oral anti-coagulants (DOACs) treatment strategy. Methods: Subgroup analysis of major bleeding (primary endpoint) associated with clinical variables, site of bleeding, ongoing antithrombotics, reversal treatment or blood transfusion, outcomes (secondary endpoints) was performed in patients with bleeding events submitted to hard 5:1 propensity-score matching for hypertension. Results: Enrolled patients were 2,792 (mean age, 65.6 ± 19.9 years) during 2-year survey including 166,000 visits, of 200,000 inhabitants catchment area; 8,239 patients received warfarin and 3,797 DOACs. Hypertension account for 1,077 (39%) patients; major bleeding for 474 (17%); death for 29 (1%), and 72 (3%) on 1-month and 1-year, respectively. Hypertension, age, glucose, cancer, ischemic vascular disease, and CHA2D2VASc score were more likely to link with major bleeding. On multivariate analysis, only age (odds ratio [OR], 1.02; P < 0.001), CHA2DS2VASc score ≥ 2 (OR, 2.14; P = 0.001), and glucose (OR, 1.01; P = 0.005) were predictors of major bleeding. Kaplan–Meier analysis demonstrated patients with hypertension as compared with patients without showed 60% versus 20% death on 1-month (P < 0.001). Warfarin compared with DOACs was more likely to present with major bleeding (0.7% versus 0.2%; OR, 2.8; P = 0.005). Receiver operator characteristics analysis showed high value (0.61) of age and glucose over creatinine and systolic arterial pressure (P = NS). Conclusions: Four in 10 patients with major bleeding showed hypertension; of these 8 in 10 will die within 1 month. Warfarin compared with DOACs was more likely to present with major bleeding.

Background: Death of patients presenting with bleeding events to the Emergency Department still represent a major problem. We sought to analyze clinical characteristics associated with worse outcomes including short- and long-term death, beyond antithombotic treatment strategy. Methods: Patients presenting with any bleeding events during 2016-2017 years were enrolled. Clinical parameters, site of bleeding, major bleeding, ongoing anti-thrombotic treatment strategy and death were collected. Hard 5: 1 propensity score matching was performed to adjust dead patients in baseline characteristics. Endpoints were one-month and one-year death. Results: Out of 166,000 visits to the Emergency Department, 3.050 patients (1.8%) were enrolled and eventually 429 were analyzed after propensity. Overall, anticoagulants or antiplatelets were given to 234(54%). Major bleeding account for 111(26%) patients, without differences between those taking anticoagulants or antiplatelets versus others. Death at one-month and one-year was 26(6%) and 72(17%), respectively. Independent predictors of one-month death were major bleeding (Odds Ratio, OR 26, p < 0.001), female gender (OR 7, p < 0.001) and white blood cells (OR 1.2, p = 0.01); of one-year were major bleeding (OR 7, p < 0.001), age (OR 1.1, p < 0.001) and female gender (OR 2.3, p = 0.043). Of note, death rate of gastrointestinal and intracranial bleeding where higher than others (p < 0.001). Overall mortality was approximately 40% on one-month; 60% in older patients and 80% in female gender with CHA(2)D(2)VASC-score >= 2. Receiver operator characteristics analysis showed larger areas for major bleeding and age (0.75 and 0.72, respectively) over others; p < 0.05 on C-statistic. Conclusions: In patients with bleeding events, death rate was driven by major bleeding on short-term and older age on long-term. Among dead patients mortality was approximately 40% on one-month; 60% in older patients, and 80% in female gender. (C) 2017 Elsevier Inc. All rights reserved.

Chest pain (CP) is a worldwide frequent cause of visits to the Emergency Department with eventually <15% of patients recognized as having myocardial ischaemia. Exercise tolerance test (ex-ECG) is a valuable first-line testing to implement prognostication but sensitivity is poor (50%) when compared to exercise myocardial perfusion imaging (92%) with single-photon emission computed-tomography (ex-SPECT) [ 1 Amsterdam E.A. Kirk J.D. Bluemke D.A. Diercks D. Farkouh M.E. Garvey J.L. Kontos M.C. McCord J. Miller T.D. Morise A. Newby L.K. Ruberg F.L. Scordo K.A. Thompson P.D. Testing of low-risk patients presenting to the emergency department with chest pain a scientific statement from the American Heart Association. Circulation. 2010; 122: 1756-1776 Crossref PubMed Scopus (468) Google Scholar , 2 Sechtem U. Achenbach S. Andreotti F. Budaj A. Bugiardini R. Crea F. Cuisset T. Di Mario C. Ferreira J.R. Gersh B.J. Gitt A.K. Hulot J.S. Marx N. Opie L.H. Pfisterer M. Prescott E. Ruschitzka F. Sabate M. Senior R. Taggart D.P. van der Wall E.E. Vrints C.J.M. Knuuti J. Valgimigli M. Bueno H. Claeys M.J. Donner-Banzhoff N. Erol C. Frank H. Funck-Brentano C. Gaemperli O. Gonzalez-Juanatey J.R. Hamilos M. Hasdai D. Husted S. James S.K. Kervinen K. Kolh P. Kristensen S.D. Lancellotti P. Maggioni A.P. Piepoli M.F. Pries A.R. Romeo F. Ryden L. Simoons M.L. Sirnes P.A. Steg P.G. Timmis A. Wijns W. Windecker S. Yildirir A. Zamorano J.L. 2013 ESC guidelines on the management of stable coronary artery disease. Eur. Heart J. 2013; 34: 2949-3003 Crossref PubMed Scopus (3722) Google Scholar ]. We sought to evaluate if any special subset of intermediate-risk CP patients were more likely to receive benefit from nuclear scan strategy.

BACKGROUND:The novel analysis of high-frequency QRS components (HFQRS-analysis) has been proposed in patients with chest pain (CP) and normal electrocardiography (ECG) referred for exercise tolerance test (ex-ECG). The aim of the study was to compare the diagnostic value of ex-ECG with ex-HFQRS-analysis.METHODS:Patients with CP and normal ECG, troponin, and echocardiography were considered. All patients underwent ex-ECG for conventional ST-segment-analysis and ex-HFQRS-analysis. A decrease ≥ 50% of the HFQRS signal intensity recorded in at least 2 contiguous leads was considered an index of ischemia, as ST-segment depression ≥ 2 mm or ≥ 1 mm and CP on ex-ECG. Exclusion criteria were: QRS duration ≥ 120 ms and inability to exercise. End-point: The composite of coronary stenosis ≥ 70% or acute coronary syndrome, revascularization, cardiovascular death at 3-month follow-up.RESULTS:Three-hundred thirty-seven patients were enrolled (age 60 ± 15 years). The percent-age of age-adjusted maximal predicted heart rate was 89 ± 10 beat per minute and the maximal systolic blood pressure was 169 ± 23 mm Hg. Nineteen patients achieved the end-point. In multivariate analysis, both ex-ECG and ex-HFQRS were predictors of the end-point. The ex-HFQRS-analysis showed higher sensitivity (63% vs. 26%; p < 0.05), lower specificity (68% vs. 95%; p < 0.001), and comparable negative predictive value (97% vs. 96%; p = 0.502) when compared to ex-ECG-analysis. Receiver operator characteristics analysis showed the incremental diagnostic value of HFQRS (area: 0.655, 95% CI 0.60-0.71) over conventional ex-ECG (0.608, CI 0.55-0.66) and CP score (0.530, CI 0.48-0.59), however without statistical significance in pairwise comparison by C-statistic.CONCLUSIONS:In patients with CP submitted to ex-ECG, the novel ex-HFQRS-analysis shows a valuable incremental diagnostic value over ST-segment-analysis.

Background: The novel exercise computer-assisted high-frequency QRS analysis (HF/QRS) has demonstrated improved sensitivity and specificity over the conventional ST/electrocardiogram-segment analysis (ST/ECG) in the detection of myocardial ischemia. The aim of the present study was to compare the diagnostic value of the validated exercise echocardiography (ex-Echo) with the novel exercise ECG (ex-ECG) including HF/QRS and ST/ECG analysis.Methods: A prospective cohort study was conducted in the emergency department of a tertiary care teaching Hospital. Patients with chest pain (CP), normal resting ECGs, troponins, and echocardiography, labeled as "intermediate- risk" for adverse coronary events, underwent the novel ex-ECG and ex-Echo. An ST-segment depression of at least 2 mV or at least 1 mV when associated with CP was considered as an index of ischemia, as well as a decrease of at least 50% in HF/QRS intensity, or new wall motion abnormalities on ex-Echo. Exclusion criteria were QRS duration of at least 120 milliseconds, poor echo-acoustic window, and inability to exercise. Patients were followed up to 3 months. The end point was the composite of coronary stenoses of 50% or greater at angiography or acute coronary syndrome, revascularization, and cardiovascular death on the 3-month follow-up.Results: Of 188 patients enrolled, 18 achieved the end point. The novel ex-ECG and ex-Echo showed comparable negative predictive value (97% vs 96%; P= . 930); however, sensitivity was 83% vs 61%, respectively (P = .612), and specificity was 64% vs 92%, respectively,(P = .026). The areas on receiver operating characteristic analysis were comparable (ex-ECG: 0.734 [ 95% confidence interval, or CI, 0.62-0.85] vs ex-Echo: 0.767 [CI, 0.63-0.91]; C statistic, P = .167). On multivariate analysis, both ex-ECG (hazard ratio, 5; CI, 1-20; P = .017) and ex-Echo (HR, 12; CI, 4-40; P < .001) were predictors of the end point.Conclusions: In intermediate-risk CP patients, the novel ex-ECG including HF/QRS added to ST/ECG analysis was a valuable diagnostic tool and might be proposed to avoid additional imaging. However, the novel test needs additional study before it can be recommended as a replacement for current techniques. (C) 2014 Elsevier Inc. All rights reserved.

Background: The novel analysis of high-frequency QRS components (HF/QRS) has been proposed in patients with chest pain (CP) referred for exercise tolerance test (ex-ECG). We sought to evaluate the prognostic role of exercise high-frequency QRS-analysis (ex-HF/QRS) in patients with recent-onset stable CP, in the emergency setting.Methods: Patients with CP underwent ex-ECG. A decrease greater than or equal to 50% of the signal of HF/QRS intensity was considered as index of ischemia as ST-segment depression greater than or equal to 2 mm or greater than or equal to 1 mm associated with CP. Exclusion criteria were QRS duration greater than or equal to 120 milliseconds and inability to exercise. Baseline characteristics were adjusted with the propensity score matching specifying nearest-neighbor matching in cardiovascular risk factors and risk scores. The primary end point was the composite of coronary stenosis greater than or equal to 70% or acute coronary syndrome, revascularization, and cardiac death on the 6-month follow-up.Results: Of 589 patients, 22 achieved the end point. On the univariate analysis, known cardiovascular disease, GRACE score, and ex-HF/QRS were predictors of the end point. On the multivariate analysis, only ex-HF/QRS was predictor of the end point (odd ratio, 28; 95% confidence interval [CI], 6-120; P < .001). Overall, the ex-HF/QRS when compared to ex-ECG showed higher sensitivity (91% vs 27%; P = .02), lower specificity (74% vs 86%; P = .09), and comparable negative predictive value (99% vs 97%; P = .78). Receiver operating characteristic curve analysis showed the larger area of ex-HF/QRS (0.83; 95% CI, 0.75-0.90) over ex-ECG (0.57; CI, 0.44-0.70) and GRACE score (0.65; CI, 0.54-0.76); P < .03 on C-statistic. Women showed the largest area (0.89; CI, 0.83-0.95; P < .03) vs the other clinical data.Conclusions: In patients with CP, the novel ex-HF/QRS analysis has a valuable incremental prognostic role over ex-ECG, especially in women. (C) 2015 Elsevier Inc. All rights reserved.

Hypertension and atrial fibrillation (AFib) frequently coexist in clinical practice. However, it is unclear whether this association per se or in combination with coronary artery disease (CAD) is a predictor of adverse outcomes.The aim of this study is to recognize and treat CAD in patients with hypertension and AFib.Patients with long-standing hypertension and recent-onset AFib (lasting ≤48 hours) were enrolled and managed with standard care regardless of the presence of troponin elevations (e-TnI) (group 1, n=636, 2010-2011 years) or managed with tailored-care including echocardiography and stress testing when presenting with e-TnI (group 2, n=663, 2012-2013 years).The composite of ischemic vascular events including stroke, acute coronary syndrome, revascularization, and death at the 6-month follow-up.Out of 1299 patients enrolled, those with e-TnI (56 and 57 in groups 2 and 1, respectively, P=0.768) were more likely to admit in group 2 vs. group 1 (21 vs. 32, respectively, P=0.060), and less likely to undergo stress testing in group 2 vs. group 1 (15 vs. 1, respectively, P<0.001). Twenty-one patients in group 2 were admitted with positive stress testing (n=9) or high e-TnI (n=12; 1.04±1.98 ng/mL); conversely 35 were discharged with negative stress testing (n=6) or very-low e-TnI (n=29; 0.27±0.22 ng/mL). Finally, 7 patients vs. 1, in groups 2 and 1, respectively, underwent revascularization (P=0.032), and 3 vs. 12 reached the endpoint (P=0.024). On multivariate analysis, e-TnI, known CAD and age were predictors of the endpoint.In patients with hypertension, AFib, and e-TnI, tailored-care inclusive of echocardiography and stress testing succeeded in recognizing and treating CAD avoiding adverse events without increase in admissions.

BACKGROUND Hypertension and atrial fibrillation (AFib) frequently coexist in clinical practice. However, it is unclear whether this association per se or in combination with coronary artery disease (CAD) is a predictor of adverse outcomes. AIM The aim of this study is to recognize and treat CAD in patients with hypertension and AFib. METHODS Patients with long-standing hypertension and recent-onset AFib (lasting ≤48 hours) were enrolled and managed with standard care regardless of the presence of troponin elevations (e-TnI) (group 1, n=636, 2010-2011 years) or managed with tailored-care including echocardiography and stress testing when presenting with e-TnI (group 2, n=663, 2012-2013 years). ENDPOINT The composite of ischemic vascular events including stroke, acute coronary syndrome, revascularization, and death at the 6-month follow-up. RESULTS Out of 1299 patients enrolled, those with e-TnI (56 and 57 in groups 2 and 1, respectively, P=0.768) were more likely to admit in group 2 vs. group 1 (21 vs. 32, respectively, P=0.060), and less likely to undergo stress testing in group 2 vs. group 1 (15 vs. 1, respectively, P<0.001). Twenty-one patients in group 2 were admitted with positive stress testing (n=9) or high e-TnI (n=12; 1.04±1.98 ng/mL); conversely 35 were discharged with negative stress testing (n=6) or very-low e-TnI (n=29; 0.27±0.22 ng/mL). Finally, 7 patients vs. 1, in groups 2 and 1, respectively, underwent revascularization (P=0.032), and 3 vs. 12 reached the endpoint (P=0.024). On multivariate analysis, e-TnI, known CAD and age were predictors of the endpoint. CONCLUSIONS In patients with hypertension, AFib, and e-TnI, tailored-care inclusive of echocardiography and stress testing succeeded in recognizing and treating CAD avoiding adverse events without increase in admissions.

OBJECTIVES:The aim of this study was to identify a reliable tool for the early prognostic stratification of septic patients admitted to the emergency department-high dependency unit (ED-HDU), a clinical setting providing a subintensive level of care; we also estimated the cost saving associated with HDU stay compared with ICU stay. MATERIALS AND METHODS:Mortality in Emergency Department Sepsis (MEDS), Acute Physiology Age Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), Sequential Organ Failure Assessment (SOFA) score (SOFA-T0) and the Charlson index were calculated at ED admission. SOFA score was also calculated after 24 h (SOFA-T1). The primary outcome was 28 days mortality. RESULTS:We admitted 140 patients with severe sepsis or septic shock in our ED-HDU from June 2008 to December 2010; 135 were included in the study. One month's mortality was 29%. SOFA-T1 was significantly higher in patients who needed an ICU admission (7.5±3.8 vs. 5.3±3.0, P=0.048); it also showed the best mortality prediction ability (area under the curve 0.80, 95% confidence interval 0.70-0.91), compared with MEDS, SAPS, and APACHE score. Troponin and procalcitonin evaluated at ED admission and after 24 h did not show significant differences according to prognosis; patients with lactate more than 2 showed a higher mortality (40 vs. 22%, P=0.034). In a regression analysis adjusted for age, lactate value, and the Charlson index, SOFA-T1 (RR 1.551, 95% confidence interval 1.204-1.998, P<0.001) maintained an independent prognostic value for 28 days mortality. During the 267 days of stay at the ED-HDU, the total saving was &OV0556;460 041, compared with the cost of the same period in the ICU. CONCLUSION:SOFA score is a feasible and accurate tool for an early risk stratification of septic patients admitted to the ED-HDU.