ObjectivesWe investigated the natural history of patients after a first episode of acute heart failure (FEAHF) requiring emergency department (ED) consultation, focusing on: the frequency of ED visits and hospitalisations, departments admitting patients during the first and subsequent hospitalisations, and factors associated with difficult disease control.We included consecutive patients diagnosed with FEAHF (either with or without previous heart failure diagnosis) in four EDs during 5 months in three different time periods (2009, 2011, 2014). Diagnosis was adjudicated by local principal investigators. The clinical characteristics of the index event were prospectively recorded, and all post-discharge ED visits and hospitalisations [related/unrelated to acute heart failure (AHF)], as well as departments involved in subsequent hospitalisations were retrospectively ascertained. 'Uncontrolled disease' during the first year after FEAHF was considered if patients were attended at ED (≥ 3 times) or hospitalised (≥ 2 times) for AHF or died. Overall, 505 patients with FEAHF were included and followed for a mean of 2.4 years. In-hospital mortality was 7.5%. Among 467 patients discharged alive, 288 died [median survival 3.9 years, 95% confidence interval (CI) 3.5-4.4], 421 (90%) revisited the ED (2342 ED visits; 42.4% requiring hospitalisation, 34.0% AHF-related) and 357 Ò. Miró et al.(77%) were hospitalised (1054 hospitalisations; 94.1% through ED, 51.4% AHF-related). AHF-related hospitalisations were mainly in internal medicine (28.0%), short-stay unit (26.3%), cardiology (20.8%), and geriatrics (14.1%). Only 47.4% of AHF-related hospitalisations were in the same department as the FEAHF, and internal medicine involvement significantly increased with subsequent hospitalisations (P = 0.01). Uncontrolled disease was observed in 31% of patients, which was independently related to age > 80 years [odds ratio (OR) 1.80, 95% CI 1.17-2.77], systolic blood pressure < 110 mmHg at ED arrival (OR 2.61, 95% CI 1. 26-5.38) and anaemia (OR 2.39, 95% CI

P atients with symptoms suggestive of acute myocardial infarction (AMI) account for ≈10% of all emergency department (ED) presentations. 1 The majority of patients are finally found to have diagnoses other than AMI. 2 Thus, the expeditious evaluation of such patients is important because delays in ruling out AMI may interfere with the detection of other underlying diseases. The 0/1 hour (0/1h) algorithm and the 0/3 hour (0/3h) algorithm are both recommended by the European Society of Cardiology with a Class I recommendation for the early rule-out of AMI. 1 The 0/1h algorithm and 0/3h algorithm are completely different protocols. Whereas the 0/1h algorithm uses high-sensitivity cardiac troponin (hs-cTn) concentrations at presentation and absolute changes within the first hour and hence takes optimal advantage of the increased diagnostic accuracy and precision of hs-cTn assays, the 0/3h algorithm uses a fixed threshold protocol based on the 99th percentile at presentation and 3 hours in conjunction with clinical criteria (GRACE [Global Registry of Acute Coronary Events] score <140 and the need to be pain free). It is currently unknown whether 1 algorithm is preferable to the other. The aim of this study was to directly compare safety, quantified by the negative predictive value (NPV) and the negative likelihood ratio (LR) for the presence of AMI, and efficacy, quantified by the proportion of patients triaged toward rule-out in a large diagnostic multicenter study enrolling patients presenting with suspected AMI to the ED (URL: https://www.clinicaltrials.gov. Unique identifier: NCT00470587). The study was carried out according to the principles of the Declaration of Helsinki and approved by the local ethics committees. Written informed consent was obtained from all patients. Patients presenting with ST-segment-elevation MI were excluded. Triage toward rule-out by the 0/1h or the 0/3h algorithm was compared against the final adjudication performed by 2 independent cardiologists using all information, including cardiac imaging and serial hs-cTnT measurements. Analyses were performed with hs-cTnT and hs-cTnI. NPV and efficacy were compared by the McNemar test and Pearson χ 2 test, respectively. The 95% confidence intervals (CIs) were calculated with the Wilson score method without continuity correction. Among 2547 patients eligible for analysis with hs-cTnT, AMI was the final adjudicated diagnosis in 387 patients (15%). The 0/1h algorithm provided safety similar to that of the 0/3h algorithm (NPV, 99.8% [95% CI, 99.4-99.9] and negative LR, 0.01 [95% CI, 0.00-0.03] versus NPV, 99.7% [95% CI, 99.2-99.9] and negative LR, 0.02 [95% CI, 0.00-0.05]) but allowed the rule-out of significantly more patients compared with the 0/3h algorithm (60% versus 44%; P<0.001). Among 2197 patients eligible for analysis with hs-cTnI, AMI was the final diagnosis in 327 patients (15%). The 0/1h algorithm provided higher safety compared with the 0/3h algorithm (NPV, 99.6% [95% CI, 99.1-99.9%] and negative LR, 0.02 [95% CI, 0.01-0.05] versus NP...

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Early standardized clinical judgement for syncope diagnosis in the emergency department. J Intern Med 2021; Background. The diagnosis of cardiac syncope remains a challenge in the emergency department (ED).Objective. Assessing the diagnostic accuracy of the early standardized clinical judgement (ESCJ) including a standardized syncope-specific case report form (CRF) in comparison with a recommended multivariable diagnostic score.Methods. In a prospective international observational multicentre study, diagnostic accuracy for cardiac syncope of ESCJ by the ED physician amongst patients ≥ 40 years presenting with syncope to the ED was directly compared with that of the Evaluation of Guidelines in Syncope Study (EGSYS) diagnostic score. Cardiac syncope was centrally adjudicated independently of the ESCJ or conducted workup by two ED specialists based on all information available up to 1-year follow-up. Secondary aims included direct comparison with high-sensitivity cardiac troponin I (hs-cTnI) and B-type natriuretic peptide (BNP) concentrations and a Lasso regression to identify variables contributing most to ESCJ.Results. Cardiac syncope was adjudicated in 252/ 1494 patients (15.2%). The diagnostic accuracy of ESCJ for cardiac syncope as quantified by the area under the curve (AUC) was 0.87 (95% CI: 0.84-0.89), and higher compared with the EGSYS diagnostic score (0.73 (95% CI: 0.70-0.76)), hs-cTnI (0.77 (95% CI: 0.73-0.80)) and BNP (0.77 (95% CI: 0.74-0.80)), all P < 0.001. Both biomarkers (alone or in combination) on top of the ESCJ significantly improved diagnostic accuracy. Conclusion.ESCJ including a standardized syncopespecific CRF has very high diagnostic accuracy and outperforms the EGSYS score, hs-cTnI and BNP.