Comparison of intravenous urapidil and oral captopril in patients with hypertensive urgencies.
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Administration, Oral↗
Biomedical subjects
M M Hirschl
Publications and source records attributed to M M Hirschl.
[Effects of terazosine and atenolol on serum lipids in essential hypertension].
BACKGROUND: Only a few studies have evaluated the efficacy of alpha-blocking agents in combination with other classes of antihypertensive agents, especially in patients not adequately controlled by monotherapy. As alpha-blockers have an additional beneficial effect on serum lipids, it seems reasonable to use them instead of beta-blockers or diuretics in insufficiently treated hypertensive patients with hyperlipidemia. MATERIALS AND METHODS: All patients with insufficient blood pressure control with either a calcium channel blocker or an ACE inhibitor and evidence of hyperlipidemia (total serum cholesterol > 5.69 mmol/L) were included into an open, randomized and prospective study to evaluate the effects of terazosin and atenolol on lipid profile in hypertensive patients. The patients received either terazosin (n = 26; dose 1 to 10 mg) or atenolol (n = 28; dose 25 to 100 mg). Blood pressure was assessed by 24-hour ambulatory blood pressure measurement and serum lipids were evaluated at the time of inclusion and 12 weeks later. RESULTS: Blood pressure was similar after 12 weeks of treatment (atenolol: 129 (9)/75 (7) mm Hg; terazosin: 128 (11)/75 (9) mm Hg) and total cholesterol was significantly reduced after 12 weeks of treatment (atenolol: Diff 0-12 weeks: 7.29 (1.32) versus 6.62 (1.14 mmol/L, p = 0.006; terazosin: 7.34 (0.93) versus 6.67 (0.85) mmol/L, p = 0.002). In the terazosin group, HDL-cholesterol increased and triglycerides decreased significantly (Diff 0-12 weeks: HDL-chol: 1.55 (0.31) versus 1.63 (0.44) mmol/L, p = 0.04; TG: 1.93 (1.17) versus 1.34 (0.64) mmol/L, p = 0.03). Comparing both groups a significant difference was found with regard to HDL-cholesterol and triglycerides (atenolol versus terazosin: HDL-chol: -0.05 (0.12) versus +0.08 (0.1) mmol/L, p = 0.04; TG: -0.18 (0.61) versus--0.59 (0.6), p = 0.03). CONCLUSIONS: The alpha-blocker terazosin is as effective as atenolol when combined with either an ACE inhibitor or a calcium-channel blocker as a part of a multidrug regimen to achieve sufficient blood pressure control. In addition, terazosin is superior to atenolol with regard to the effect on the lipid profile of hypertensive and hyperlipidemic patients and seems therefore a reasonable alternative to beta-blockers in hypertensive patients with hyperlipidemia.
Adrenergic alpha-Antagonists↗
Different patterns of angioedema in patients with and without angiotensin-converting enzyme inhibitor therapy.
BACKGROUND: There is convincing evidence for a causal relationship between angiotensin converting enzyme inhibitor (ACEI) therapy and angioedema, but the clinical features of the patients remain unclear. The aim of the study was to compare patterns of angioedema in patients under ACEI therapy and those without ACEI therapy. METHODS: One hundred and seventeen consecutive patients with angioedema treated in the emergency department of a 2000-bed tertiary care university hospital were included. A retrospective cohort study was performed, the exposure being ACEI therapy. The pattern of location of angioedema was the primary outcome measure. RESULTS: Of 117 patients with angioedema, 25 (21%) received ACEI therapy. In a multivariate logistic regression model, angioedema of the cheeks, eyelids or nose was independently negatively associated with ACEI therapy [adjusted odds ratio 0.13 (95% confidence interval 0.03 to 0.49), p = 0.003]. Higher age was also significantly associated with ACEI therapy [adjusted odds ratio 1.85 (95% confidence interval 1.23 to 2.80), p = 0.003]. Furthermore, a trend towards an independent negative association between a history of allergies and angioedema under ACEI therapy was seen. CONCLUSION: Patients with angioedema under ACE inhibitor therapy differ significantly from those receiving no ACEI therapy in terms of patterns of angioedema and age. The applicability of this observation as a tool for deciding whether to continue or terminate ACEI therapy requires prospective evaluation.
Age Factors↗
Recalibration of the point-of-care test for CARDIAC T Quantitative with Elecsys Troponin T 3rd generation.
The rapid troponin T assay CARDIAC T Quantitative was recalibrated using Elecsys Troponin T 3rd Generation as a new reference method. This paper presents the method comparisons at six centres using the new reference method. Method comparison between CARDIAC T Quantitative versus Elecsys Troponin T 3rd Generation were performed using 319 samples from patients with acute coronary syndromes. The quality of the CARDIAC T Quantitative was controlled by a daily single determination of CARDIAC Control Troponin T, and for the Elecsys Troponin T 3rd Generation, the Elecsys controls were included in each run. The results for the control materials for the CARDIAC T Quantitative were between 93% and 107% of the target values. The CV ranged from 7% to 16%. From the regression analysis, according to Bablok and Passing (y=1.07x) and the Bland and Altman plot, the bias between CARDIAC T Quantitative and Elecsys Troponin T 3rd Generation is from +6% to +7%. The correlation coefficient is 0.93, and a 3x3 comparison of the clinical efficiency yielded 92% clinical concordance between CARDIAC T Quantitative and Elecsys Troponin T 3rd Generation. In conclusion, CARDIAC T Quantitative was in good agreement with the reference and calibration method Elecsys Troponin T 3rd Generation.
Calibration↗
Clinical application of rapid quantitative determination of cardiac troponin-T in an emergency department setting.
OBJECTIVES: We analysed the clinical use of Troponin-T compared to creatine kinase MB in a non-trauma emergency department setting. BACKGROUND: A newly established single specimen quantitative Troponin T assay allows the clinical application of this parameter. METHODS. Five-hundred Troponin T tests were provided for use by emergency physicians who could combine them with the routine laboratory tests without restriction as to the indication or number of tests per patient. The number of tests per patient, time frame, final diagnosis and additional clinical information gained were recorded. All patients were followed for at least 6 months to verify the diagnosis and to assess the occurrence of cardiac events (nonfatal AMI or cardiac death). The ability of Troponin T and creatine kinase MB tests to predict cardiac events within 6 months were compared. RESULTS: The 500 Troponin T tests were used in 249 patients (median two tests per patient (range 1-5)) within 41 days. The final diagnosis revealed coronary heart disease in 85, non-coronary heart disease in 39, non-cardiac chest pain in 86 and other diagnoses in 39 of the patients. In 14 patients with an elevated creatine kinase MB, myocardial damage could safely be ruled out by a negative Troponin T, in six patients with a normal creatine kinase MB minor myocardial damage could be detected by a positive Troponin T. During follow up 28 cardiac events were recorded. Troponin T had a significantly higher specificity, positive predictive value and proportion of correct prediction for cardiac events within 6 months compared to creatine kinase MB. CONCLUSIONS: Troponin T has proved to be an useful method for diagnosing myocardial damage in routine clinical use in the non-trauma emergency department.
Austria↗
Directional coronary atherectomy: the Vienna experience.
BACKGROUND: Several multicenter trials have shown excellent results for directional coronary atherectomy (DCA) in a selected patient cohort. To prove the applicability of this method in daily clinical routine and a nonselected patient cohort, we analyzed 46 consecutive cases performed at our catheterization lab. METHODS: DCA was performed as a routine procedure in 45 suitable patients. Balloon dilatation or stent implantation postprocedure was accomplished only in case of unsatisfactory results. Quantitative coronary angiography was achieved pre- and postprocedure as well as at 6-month follow-up. RESULTS: Optimal atherectomy < 20% residual stenosis was reached in 24 (52%) of 46 target lesions and a residual stenosis < 50% in 46 (100%) lesions. Procedure-related complications occurred in three (6%) patients (one major complication, death, < 24 hours, 2%; two minor complications, pseudoaneurysm, 4%). The 6-month angiographic follow-up revealed a binary restenosis rate of 29% (n = 11). Ten out of 11 restenotic lesions required revascularization. When patients were stratified in two groups according to their preprocedural minimal lumen diameter (MLD), this parameter proved to be a very strong predictor of outcome. The percentage of restenosis was significantly higher in patients with an MLD > 1.60 mm compared to patients with a smaller MLD (54% vs 19.3%; P < 0.0001). Reference vessel diameter preprocedure did not differ significantly. CONCLUSIONS: Our study demonstrated that DCA is a suitable technique for the daily clinical routine, as the rates of complications and restenosis were similar to that in a highly selective patient cohort. Additionally, our study showed that patient selection should include preprocedural analysis of MLD in order to achieve optimal results. Therefore, atherectomy yielded comparable results to other conventional techniques and may be used instead of or in combination with them.
Aged↗
Impairment of renal function in patients resuscitated from cardiac arrest: frequency, determinants and impact on outcome.
OBJECTIVE: To assess frequency, determinants, and impact on outcome of impaired renal function in cardiac arrest survivors. PATIENTS AND METHODS: In a retrospective analysis 87 patients admitted after cardiac arrest to an emergency department between 1 March 1994 and 31 October 1995 were evaluated; patients were followed until 31 December 1998 or death. Serum creatinine was measured on arrival, 24 hours, 3 and 7 days after cardiac arrest. Impaired renal function was subclassified according to severity differentiating in between cases with an elevation of serum creatinine level > 1.4 mg/dl to 2 mg/dl and > 2 mg/dl. We examined the association between prearrest history and CPR data, collected according to the "Utstein Style", and renal function. RESULTS: Patients were followed for a median of 1199 days (IQR 16 to 1427). Impaired renal function (serum creatinine level > 1.4 mg/dl) was found on admission in 36 patients (41%), at 24 hours in 24 (31%), at 3 days in 13 (19%) and on day seven in 9 patients (16%) respectively. History of congestive heart failure and duration of low flow state (from the beginning of basic and/or advanced life support until restoration of spontaneous circulation) were significantly associated with elevated serum creatinine (> 1.4 mg/dl) at 24 hours after the event. The occurrence of impaired renal function was also more frequent in patients with diabetes mellitus and hypertension, but this did not reach statistical significance. The relative risk for death was 2.8 (95% confidence interval 1.3-5.8) for a serum creatinine level of > 1.4 mg/dl to 2.0 mg/dl and 5.4 (95% confidence interval 2.4-12.1) for values > 2 mg/dl. CONCLUSION: Transient impaired renal function is common in patients surviving cardiac arrest. Congestive heart failure and low flow time are independent predictors for the development of impaired renal function. There is a positive association in between increased serum creatinine levels and risk of death.
Acute Kidney Injury↗
Out-of-hospital diagnosis of cerebral infarction versus intracranial hemorrhage.
OBJECTIVE: To establish a model based on clinical and anamnestic data easily available in the out-of-hospital setting, which facilitates the differential diagnosis between cerebral infarction and intracranial hemorrhage. DESIGN: Retrospective study that simulates a prospective approach. SETTING: Emergency Department of the University Hospital in Vienna, Austria. PATIENTS AND PARTICIPANTS: Data of 224 patients with either intracranial hemorrhage or cerebral infarction were prospectively collected. Uni-and multivariate analysis was performed to identify neurological symptoms and anamnestic data, which were associated with either intracranial hemorrhage or cerebral infarction. MEASUREMENTS AND RESULTS: Unilateral weakness or sensory loss was observed more frequently in patients with infarction compared to hemorrhage (69.8 % vs 11.9 %, P < 0.001). The frequency of patients with impaired level of consciousness was significantly higher in the hemorrhage group compared to the infarction group (59.3 % vs 3.8 %, P < 0.001). A multivariate logistic regression analysis showed that hypertension (OR = 0.31, 95 % CI = 0.12-0.76, P = 0.01), diabetes (OR = 0.17, 95% CI = 0.04-0.68, P = 0.01), and unilateral weakness or sensory loss (OR = 0.10, 95 % CI = 0.04-0.26, P < 0.001) were significantly associated with cerebral infarction. Impaired level of consciousness was significantly related to hemorrhage (OR = 13.41, 95 % CI = 3.92-45.91, P < 0.001). On the basis of the logistic regression analysis, we generated a scoring system for the out-of-hospital diagnosis between infarction and hemorrhage. The values of the score lay between -3 and +3. The probability of infarction increases when the score becomes negative, and the probability for hemorrhage increases when the score becomes positive. CONCLUSION: Our model is a useful guideline for the differential diagnosis between cerebral infarction and intracranial hemorrhage in the out-of-hospital setting, as it is based on easily available clinical and anamnestic parameters.
Aged↗
Hypertension in patients presenting with epistaxis.
STUDY OBJECTIVE: We sought to evaluate whether patients with epistaxis in the emergency department have a higher arterial blood pressure compared with patients with other medical emergencies and to study the association of elevated blood pressure during epistaxis with sustained arterial hypertension. METHODS: In a prospective, cross-sectional, prevalence study we compared arterial blood pressure on admission in the ED in 213 consecutive patients treated for epistaxis with that of 213 sex- and age-matched control subjects. In 33 of those patients with elevated blood pressure during epistaxis, we evaluated the prevalence of sustained arterial hypertension. Main outcome measures were arterial blood pressure during epistaxis and evidence of sustained arterial hypertension, as determined by 24-hour ambulatory blood pressure measurement. RESULTS: Patients with epistaxis had significantly higher blood pressure values compared with those of control patients (systolic blood pressure 161+/-30 versus 144+/-22 mm Hg, P<.001; diastolic blood pressure 84+/-19 versus 75+/-15 mm Hg, P <.001). Of 33 (30%) of 108 patients with elevated blood pressure during epistaxis who were further evaluated, 26 (79%) patients were classified as having sustained arterial hypertension. Nine (27%) patients with sustained arterial hypertension were unaware of a history of hypertension. Patients with sustained arterial hypertension had significantly more episodes of epistaxis compared with patients with elevated blood pressure during epistaxis and no sustained arterial hypertension (mean 5 versus 1; P=.004). CONCLUSION: Patients with epistaxis have a higher blood pressure compared with that of control patients. Twenty-six (79%) of 33 patients with elevated blood pressure during epistaxis had sustained arterial hypertension. Nine (27%) of these patients were unaware of a history of hypertension. Continued management of patients with epistaxis and high blood pressure should include confirmation or exclusion of sustained arterial hypertension by 24-hour ambulatory blood pressure recording.
Aged↗
Accuracy of oscillometric blood pressure measurement according to the relation between cuff size and upper-arm circumference in critically ill patients.
OBJECTIVE: To evaluate the accuracy of oscillometric blood pressure measurement according to the relation between cuff size and upper-arm circumference in critically ill patients. DESIGN: Prospective data collection. SETTING: Emergency department in a 2,000-bed inner city hospital. PATIENTS: Thirty-eight patients categorized into three groups according to their upper-arm circumference (group I: 18-25 cm; group II: 25.1-33 cm; and group III: 33.1-47.5 cm) were enrolled in the study protocol. INTERVENTIONS: In each patient, all three cuff sizes (Hewlett-Packard Cuff 40401 B, C, and D) were used to perform an oscillometric blood pressure measurement at least within 3 mins until ten to 20 measurements for each cuff size were achieved. Invasive mean arterial blood pressure measurement was done by cannulation of the contralateral radial artery with direct transduction of the systemic arterial pressure waveform. The corresponding invasive blood pressure value was obtained at the end of each oscillometric measurement. MEASUREMENT AND MAIN RESULTS: Overall, 1,494 pairs of simultaneous oscillometric and invasive blood pressure measurements were collected in 38 patients (group I, n = 5; group II, n = 23; and group III, n = 10) over a total time of 72.3 hrs. Mean arterial blood pressure ranged from 35 to 165 mm Hg. The overall discrepancy between oscillometric and invasive blood pressure measurement was -6.7+/-9.7 mm Hg (p<.0001), if the recommended cuff size according to the upper-arm circumference was used (539 measurements). Of all the blood pressure measurements, 26.4% (n = 395) had a discrepancy of > or =10 mm Hg and 34.2% (n = 512) exhibited a discrepancy of > or =20 mm Hg. No differences between invasive and noninvasive blood pressure measurements were noted in patients either with or without inotropic support (-6.6 + 7.2 vs. -8.6 + 6.8 mm Hg; not significant). CONCLUSION: The oscillometric blood pressure measurement significantly underestimates arterial blood pressure and exhibits a high number of measurements out of the clinically acceptable range. The relation between cuff size and upper-arm circumference contributes substantially to the inaccuracy of the oscillometric blood pressure measurement. Therefore, oscillometric blood pressure measurement does not achieve adequate accuracy in critically ill patients.
Adolescent↗
Simultaneous comparison of thoracic bioimpedance and arterial pulse waveform-derived cardiac output with thermodilution measurement.
OBJECTIVE: To compare the accuracy and reliability of thoracic electrical bioimpedance (TEB) and the arterial pulse waveform analysis with simultaneous measurement of thermodilution cardiac output (TD-CO) in critically ill patients. DESIGN: Prospective data collection. SETTING: Emergency department and critical care unit in a 2,000-bed inner-city hospital. PATIENTS: A total of 29 critically ill patients requiring invasive hemodynamic monitoring for clinical management were prospectively studied. INTERVENTIONS: Noninvasive cardiac output was simultaneously measured by a TEB device and by analysis of the arterial pulse waveform derived from the finger artery. Invasive cardiac output was determined by the thermodilution technique. MEASUREMENTS AND MAIN RESULTS: A total of 175 corresponding TD-CO and noninvasive hemodynamic measurements were collected in 30-min intervals. They revealed an overall bias of 0.34 L/min/m2 (95% confidence interval, 0.24-0.44 L/min/m2; p < .001) for the arterial pulse waveform analysis and of 0.61 L/min/m2 (95% confidence interval, 0.50-0.72 L/min/m2; p < .001) for the TEB. In 39.4% (n = 69) of all measurements, the discrepancy between arterial pulse waveform analysis and TD-CO was >0.50 L/min/m2. The discrepancies of the arterial pulse waveform analysis correlated positively with the magnitude of the cardiac index (r2 = 0.29; p < .001). In 56.6% (n = 99) of all measurements, the discrepancy between TEB and TD-CO was >0.50 L/min/m2. The magnitude of the discrepancies of the TEB was significantly correlated with age (r2 = 0.17; p = .02). Measurements were in phase in 93.2% of all arterial pulse waveform analysis and in 84.9% of all TEB readings (p < .001). CONCLUSIONS: The arterial pulse waveform analysis exhibits a greater accuracy and reliability as compared with the TEB with regard to overall bias, number of inaccurate readings, and phase lags. The arterial pulse waveform analysis may be useful for the monitoring of hemodynamic changes. However, both methods fail to be a substitute for the TD-CO because of a substantial percentage of inaccurate readings.
Adult↗
G-protein beta3 subunit gene (GNB3) polymorphism 825C-->T in patients with hypertensive crisis.
OBJECTIVE: The polymorphism 825C-->T in exon 10 of the gene GNB3 encoding the beta3 subunit of heterotrimeric guanine nucleotide binding regulatory proteins (G-proteins) results in a splicing variant (GNB3-s) in which the nucleotides 498-620 of exon 9 are deleted. The T allele has been shown to be overrepresented in patients with essential hypertension. Because GNB3-s may support the development of severe elevation of blood pressure, we hypothesized that GNB3 825C-->T may be present more frequently in patients with hypertensive crisis. DESIGN: Case control study. SETTING: Department of Emergency Medicine at the University Hospital of Vienna, Vienna, Austria. PATIENTS: A total of 174 patients admitted to an emergency department for treatment of hypertensive crisis diagnosed as suffering from essential hypertension. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were genotyped for the 825C-->T transition in GNB3. An equal number of age- and gender-matched normotensive, healthy individuals served as the control population. The allele frequency of 825C-->T in the GNB3 gene was 0.310 in patients with hypertensive crisis and 0.342 in the control group. There was no difference in genotype distribution and allele frequency between the patients and the age- and gender-matched control group or between the observed prevalence and the occurrence rate expected from the Hardy-Weinberg principle within each group. CONCLUSIONS: GNB3 825C-->T is not associated with the phenotype of hypertensive crisis in patients suffering from essential hypertension. Furthermore, our data do not support the concept that the 825C-->T transition in the GNB3 gene is associated with essential hypertension.
Adult↗
Increased blood pressure response to the cold pressor test in pregnant women developing pre-eclampsia.
OBJECTIVES: Recent data indicate an increased vascular reactivity due to an overactivity of the sympathetic nervous system in women with pre-eclampsia. We therefore evaluated whether this increased vascular reactivity can be detected prior to the clinical manifestation of preeclampsia by the use of a physiological stimulus. DESIGN: Prospective data collection. SETTING: Clinic of Obstetrics and Gynecology in a 2000 bed tertiary care hospital. PARTICIPANTS: One hundred and twenty-three pregnant women between the 16th to 20th week of gestation. INTERVENTIONS: A cold pressor test was performed by positioning an ice-bag on the forehead of the woman for 3 min. Blood pressure and heart rate were monitored by a continuous, noninvasive blood pressure measurement device during the stimulus and after removal of the icebag. A clinical follow-up was carried out by review of the charts after delivery to identify those women who have developed pre-eclampsia. RESULTS: Ten (8%) out of 123 pregnant women developed pre-eclampsia. During the cold pressor test systolic as well as diastolic blood pressure increased significantly and was more pronounced in women developing pre-eclampsia compared with healthy pregnant women (systolic blood pressure: 14.2 +/- 5.5 versus 8.5 +/- 7.2 mmHg, P= 0.02; diastolic blood pressure: 7.3 +/- 4.9 versus 3.9 +/- 4.7 mmHg, P=0.03). The change in heart rate was similar between both groups (8 +/- 2.6 versus 10.4 +/- 6.4 beats/min, not significant). CONCLUSIONS: An increased vasoconstrictive response to a physiological stimulus is present in women with pre-eclampsia as a sign of an increased vascular reactivity prior to clinical manifestation of the disease. The cold pressor test may be a suitable diagnostic tool to identify women, who will develop pre-eclampsia. However, future studies in larger cohorts are required to establish the final value of this test.
Adult↗
Use of an age-adjusted Doppler E/A ratio in patients with moderate to severe hypertension.
OBJECTIVE: To assess the ratio of early (E) to late atrial (A) mitral Doppler peak flow velocity (Doppler E/A ratio) before and after adjustment for age in patients with moderate to severe hypertension, in whom left ventricular diastolic dysfunction is an early finding. Mitral flow patterns can be used to assess diastolic filling characteristics, and the Doppler E/A ratio is the parameter most commonly used, although it is known to be strongly age dependent. There are no established normal values for this ratio. DESIGN: Retrospective data analysis. SETTING: A 2000-bed tertiary-care teaching hospital. PATIENTS: We studied 190 patients (99 women and 91 men; ages 55 +/- 13 years) with moderate to severe hypertension. INTERVENTIONS: The ratio of early (E) to late atrial (A) mitral Doppler peak flow velocity was measured. As this ratio depends on age, a Z score was calculated to control for this influence. The Z score is the standardized normal deviation of the mean, with a normal value of 0 +/- 2. MAIN OUTCOME MEASURES: Sensitivities and specificities for detecting an age-dependent reduction in Doppler E/A score (Z score less than -2) with a non-age-dependent Doppler E/A ratio (less than 1) were calculated. RESULTS: In 106 of the patients (56%) the Doppler E/A ratio was less than 1.0. Only nine patients (4.7%) had a Z score less than -2. The sensitivity of the Doppler E/A ratio threshold of 1.0 for detecting a Z score less than -2 was 0.89 and the specificity was 0.46. A Z score less than -2 was found only in patients younger than 45 years. CONCLUSIONS: The Doppler E/A ratio was reduced in a large proportion of our patients. However, after correction for age it was decreased in only 4.7% of these patients. The use of a single Doppler E/A ratio threshold value has a weak diagnostic power to detect age-independent changes in mitral flow patterns.
Adult↗
Evaluation of a point-of-care system for quantitative determination of troponin T and myoglobin.
We present the results of a multicenter evaluation of a new point-of-care system (Cardiac Reader) for the quantitative determination of cardiac troponin T (CARDIAC T Quantitative test) and myoglobin (CARDIAC M test) in whole blood samples. The Cardiac Reader is a CCD camera that optically reads the immunochemical test strips. The measuring range is 0.1 to 3 microg/l for CARDIAC T Quantitative and 30 to 700 microg/l for CARDIAC M. Both tests are calibrated by the manufacturer. The reaction times of the tests are 12 or 8 minutes, respectively. Method comparisons were performed with 281 heparinized blood samples from patients with suspected acute coronary syndromes. The results obtained with CARDIAC T Quantitative showed a good agreement compared with cardiac troponin T ELISA (r = 0.89; y = 0.93x + 0.02). The method comparison between CARDIAC M and Tina-quant Myoglobin also showed a good agreement between both assays (r = 0.98; y = 0.92x + 1.6). Test lot-to-lot comparisons yielded differences of 2% and 6% for CARDIAC T Quantitative and of 0 to 11% for CARDIAC M. The within-run imprecision with blood samples and control materials was acceptable for CARDIAC T Quantitative (CV 10 to 15%) and good for CARDIAC M (CV 5 to 10%). The between-instrument CV was below 7% for CARDIACT Quantitative and below 5% for CARDIAC M. The cross-reactivity of CARDIAC T Quantitative with skeletal troponin T was approximately 0.003%. No significant analytical interference was detected for any of the assays in investigations with biotin (up to 100 microg/l), hemoglobin (up to 0.125 mmol/l), hematocrit (26 to 52%), bilirubin (up to 340 micromol/l), triglycerides (up to 5.0 mmol/l), and 18 standard drugs. With the Cardiac Reader reliable quantitative results can be easily obtained for both cardiac markers. The system is, therefore, particularly suitable for use in emergency rooms, coronary care units and small hospitals.
Coronary Disease↗
Analytical and clinical performance of an improved qualitative troponin T rapid test in laboratories and critical care units.
OBJECTIVE: To evaluate the performance of a visual troponin T rapid test in the hands of nontraditionally trained personnel of 2 critical care units in comparison to 3 laboratories. METHODS: Method comparisons of the troponin T rapid test versus cardiac troponin T enzyme-linked immunosorbent assay were performed with 804 samples from 510 patients with suspected acute coronary syndromes. Cross-reactivity with skeletal troponin T was studied up to 5000 microg/L. RESULTS: Laboratories and critical care units obtained comparable results in the analytical cutoff of the test (0.11 and 0. 10 microg/L) and in the diagnostic sensitivities in the detection of acute myocardial infarction (96% and 93% after 8 hours) and of high-risk patients with unstable angina pectoris (100% and 100%). Different percentages of false-positive results (0.2% and 3%) were found, which may reflect different objectives and strategies in these hospital units. The cross-reactivity with skeletal troponin T was less than 0.01%. CONCLUSIONS: The troponin T rapid test gives reliable results not only when used by laboratory personnel experienced in the execution of analytical methods, but also in the hands of nurses and physicians working in clinical units outside the laboratory.
Angina, Unstable↗
[Sublingual nitroglycerin or intravenous enalaprilat in preclinical treatment of hypertensive patients with pulmonary edema].
In a prospectively designed randomized study, we compared the efficacy of sublingual nitroglycerine and intravenous enalaprilat in the out-of-hospital treatment of 46 hypertensive patients with pulmonary edema (defined as rales over both lungs and systolic blood pressure > 200 mm Hg and diastolic blood pressure > 100 mg). The out-of-hospital treatment consists of oxygen (6 Ll/min) via a face mask, furosemide 80 mg i.v., opioids 10 mg s.c., and either sublingual nitroglycerine (n = 23; initial dose: 0.8 mg; repetitive application of 0.8 mg every 10 min until a cumulative dose of 3.2 mg) or intravenous enalaprilat (initial dose: 2.5 mg; repetitive application of 2.5 mg every 30 min until a cumulative dose of 10 mg). The aim of the antihypertensive treatment was a reduction of systolic blood pressure below 160 mm Hg and diastolic blood pressure below 90 mm Hg until admission to the emergency department. In the emergency room, an arterial and venous blood sample was taken to determine the respiratory (pO2, pCO2) and metabolic status (pH value; base-excess; serum lactate) of the patient. Successful antihypertensive treatment was observed in 13/23 (57%) patients of the enalaprilat group and 15/23 (65%) patients of the nitroglycerine group (p = 0.54). Systolic and diastolic blood pressure on admission were similar in both treatment groups (systolic RR: enalaprilat: 179 [31] mm Hg; nitroglycerine: 184 [38] mm Hg; p = 0.59; diastolic RR: enalaprilat: 96 [14] mm Hg; nitroglycerine: 101 [14] mm Hg; p = 0.12). No significant differences were observed between the enalaprilat and the nitroglycerine groups concerning respiratory and metabolic parameters on admission (pO2: 67 [15] vs. 64 [17] mm Hg; p = 0.50; pCO2: 46 [9] vs. 47 [13]; p = 0.75; pH value: 7.27 [0.12] vs. 7.27 [0.09]; p = 0.98; BE: -4.2 [3.7] vs. -5.7 [4.1]; p = 0.23; lactate: 4.2 [3.3] vs. 4.2 [2.7]; p = 0.98). Intravenous enalaprilat did not exhibit any advantage compared to nitroglycerine in terms of blood pressure reduction or respiratory and metabolic parameters on admission to the emergency room. We conclude that enalaprilat is no substitute for nitroglycerine in the out-of-hospital treatment of hypertensive patients with pulmonary edema.
Administration, Sublingual↗
Sustained ventricular tachycardia in the emergency department.
The aim of the study was to evaluate the demographics, haemodynamics, ECG characteristics, underlying disease, tachycardia termination and outcome of patients with sustained ventricular tachycardia (VT). We registered 75 patients presenting with VT (51 male, median age 63) from December 1993 to August 1998 in our emergency department (ED). Seventeen of these patients were haemodynamically unstable (23%), and 58 patients were stable (77%); there was no difference in the tachycardia cycle length (median 320 ms) and QRS width (median 140ms) between the two groups; however, five of the seven patients with polymorphic VT pattern were in the unstable group. Ischaemic heart disease was the underlying disorder in 57 patients (76%). Acute myocardial infarction (AMI) was present in 12 of the 58 stable (21%) compared to 11 of the 17 unstable (65%) patients. In three patients (4%) VT terminated spontaneously, in 34 patients (45%) VT was terminated by first-line intravenous drug therapy, and in 38 patients (51%) including all 17 unstable and 22 stable who failed to respond to the intravenous antiarrhythmic therapy challenge out of 55 patients, VT was terminated by electrical therapy. Within 2 days, 48 patients (64%) were transferred to an open ward, 13 (17%) still needed intensive care, nine (12%) were discharged to home and five (7%) died. Death occurred due to cardiac failure from AMI with extensive anterior wall infarction in three patients, and due to constrictive pericarditis and reocclusion of stented LAD each in one patient. At presentation in the emergency department, the majority of the patients with VT were haemodynamically stable, thus allowing first-line antiarrhythmic drug administration. However, in the course of the disease, half needed electrical therapy for definitive termination of the tachycardia. Therefore, direct current cardioversion must be available in the emergency department. Haemodynamic instability and death occurs significantly more often if VT occurs during the course of AMI.
Aged↗