A pilot study to develop a prediction instrument for endocarditis in injection drug users admitted with fever.

Am J Emerg Med. 2011 Oct;29(8):894-8

Authors: Rodriguez R, Alter H, Romero KL, Kea B, Chiang W, Fortman J, Marks C, Cheung P, Conti S

Abstract
OBJECTIVE: Seeking to evaluate the feasibility of a prediction instrument for endocarditis in febrile injection drug users (IDUs), we determined (1) the frequency percentage of IDUs admitted with fever diagnosed with endocarditis and (2) whether individual or combinations of emergency department (ED) clinical criteria (patient history, physical examination findings, and laboratory tests) are associated with endocarditis in IDUs admitted to rule out endocarditis.
METHODS: The ED and inpatient charts of all IDUs with a diagnosis of rule out endocarditis admitted at 3 urban hospitals in 2006 were reviewed. Screening performance of individual criteria was determined, and the most sensitive combination of criteria was derived by classification tree analysis.
RESULTS: Of 236 IDUs admitted with fever, 20 (8.5%) were diagnosed with endocarditis. Lack of skin infection, tachycardia, hyponatremia, pneumonia on chest radiograph, history of endocarditis, thrombocytopenia, and heart murmur had the best screening performance. The classification tree-derived best criteria combination of tachycardia, lack of skin infection, and cardiac murmur had a sensitivity of 100% (95% confidence interval, 84%-100%) and negative predictive value of 100% (95% confidence interval, 88%-100%).
CONCLUSIONS: Using ED clinical criteria, a multicenter prospective study to develop an instrument for endocarditis prediction in febrile IDUs is feasible, with an estimated target enrollment of 588 patients.

PMID: 20685064 [PubMed - in process]

Hypertensive heart failure: patient characteristics, treatment, and outcomes.

Am J Emerg Med. 2011 Oct;29(8):855-862

Authors: Peacock F, Amin A, Granger CB, Pollack CV, Levy P, Nowak R, Kleinschmidt K, Varon J, Wyman A, Gore JM,

Abstract
BACKGROUND: Acute heart failure (AHF) is a common, poorly characterized manifestation of hypertensive emergency. We sought to describe characteristics, treatment, and outcomes of patients with severe hypertension complicated by AHF. METHODS AND RESULTS: The observational retrospective Studying the Treatment of Acute hypertension (STAT) registry records data on emergency department and hospitalized patients receiving intravenous therapy for blood pressure (BP) greater than 180/110 mm Hg in 25 US hospitals. A subset of patients with HF was defined as pulmonary edema on chest x-ray (CXR) or an elevated B-type natriuretic peptide level (BNP > 500 or NTproBNP > 900 pg/mL) in patients with creatinine level 2.5 mg/dL or less. Remaining STAT patients, after excluding those with a primary neurologic diagnosis, constitute the non-HF cohort. An adverse composite outcome was defined as mechanical ventilation, intensive care unit (ICU) admission, hospital length of stay more than 1 week, or death within 30 days. Of 1199 patients, 302 (25.2%) had AHF. Acute HF patients and non-AHF patients were similar in age, sex, and overall mortality, but AHF patients were more commonly African American, with a history of HF, diabetes or chronic obstructive pulmonary disease, and prior hypertension admissions. Heart failure patients had higher creatinine and natriuretic peptide levels but lower ejection fraction. They were more likely admitted to the ICU; receive electrocardiograms, bilevel positive airway pressure ventilation, and CXRs; and be readmitted within 90 days. Finally, BP decreases lower than 120 mm Hg within 12 hours were associated with an increased rate of the composite adverse outcome. CONCLUSIONS: Acute HF as a manifestation of hypertensive emergency is common, more likely in African Americans, and requires more clinical resources than patients with non-HF-related severe hypertension. Accurate BP control is critical, as declines less than 120 mm Hg were associated with increased adverse event rates.

PMID: 20825913 [PubMed - as supplied by publisher]