The Diagnostic Role of Uric Acid to Creatinine Ratio for the Identification of Patients with Adverse Pulmonary Embolism Outcomes

Background: Uric acid (UA) is the final product of purine metabolism and a marker of oxidative stress that may be involved in the pathophysiology of cardiovascular and thromboembolic disease. The aim of the current study is to investigate the potential value of UA to creatinine ratio (UA/Cr) as a diagnostic tool for the outcome of patients admitted with acute pulmonary embolism (PE) and the correlations with other parameters. Methods: We evaluated 116 patients who were admitted for PE in a respiratory medicine department. PE was confirmed with computed tomography pulmonary angiography. Outcomes evaluated were hospitalization duration, mortality or thrombolysis and a composite endpoint (defined as mortality or thrombolysis). Patients were assessed for PE severity with the PE Severity Index (PESI) and the European Society of Cardiology (ESC) 2019 risk stratification. Results: The median (interquartile range) UA/Cr level was 7.59 (6.3–9.3). UA/Cr was significantly associated with PESI (p < 0.001), simplified PESI (p = 0.019), and ESC 2019 risk stratification (p < 0.001). The area under the curve (AUC) for prediction of 30-day mortality by UA/Cr was 0.793 (95% CI: 0.667–0.918). UA/Cr levels ≥7.64 showed 87% specificity and 94% negative predictive value for mortality. In multivariable analysis UA/Cr was an independent predictor of mortality (HR (95% CI): 1.620 (1.245–2.108), p < 0.001) and composite outcome (HR (95% CI): 1.521 (1.211–1.908), p < 0.001). Patients with elevated UA/Cr levels (≥7.64) had longer hospitalization (median (IQR) 7 (5–11) vs. 6 (5–8) days, p = 0.006)), higher mortality (27.3% vs. 3.2%, p = 0.001) and worse composite endpoint (32.7% vs. 3.4%, p < 0.001). Conclusion: Serum UA/Cr ratio levels at the time of PE diagnosis are associated with disease severity and risk stratification, and may be a useful biomarker for the identification of patients at risk of adverse outcomes.

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SPMSQ for risk stratification of older patients in the emergency department

Zeitschrift für Gerontologie und Geriatrie ◽

10.1007/s00391-019-01626-z ◽

2019 ◽

Vol 52 (S4) ◽

pp. 222-228 ◽

Cited By ~ 1

Author(s):

A. Schönstein ◽

H.-W. Wahl ◽

H. A. Katus ◽

A. Bahrmann

Keyword(s):

Emergency Department ◽

Nursing Home ◽

Risk Stratification ◽

Predictive Validity ◽

Older Patients ◽

Area Under The Curve ◽

Composite Endpoint ◽

Adverse Outcomes ◽

Nursing Home Admission ◽

Initial Contact

Abstract Background Risk stratification of older patients in the emergency department (ED) is seen as a promising and efficient solution for handling the increase in demand for geriatric emergency medicine. Previously, the predictive validity of commonly used tools for risk stratification, such as the identification of seniors at risk (ISAR), have found only limited evidence in German geriatric patient samples. Given that the adverse outcomes in question, such as rehospitalization, nursing home admission and mortality, are substantially associated with cognitive impairment, the potential of the short portable mental status questionnaire (SPMSQ) as a tool for risk stratification of older ED patients was investigated. Objective To estimate the predictive validity of the SPMSQ for a composite endpoint of adverse events (e.g. rehospitalization, nursing home admission and mortality). Method This was a prospective cohort study with 260 patients aged 70 years and above, recruited in a cardiology ED. Patients with a likely life-expectancy below 24 h were excluded. Follow-up examinations were conducted at 1, 3, 6 and 12 month(s) after recruitment. Results The SPMSQ was found to be a significant predictor of adverse outcomes not at 1 month (area under the curve, AUC 0.55, 95% confidence interval, CI 0.46–0.63) but at 3 months (AUC 0.61, 95% CI 0.54–0.68), 6 months (AUC 0.63, 95% CI 0.56–0.70) and 12 months (AUC 0.63, 95% CI 0.56–0.70) after initial contact. Conclusion For longer periods of observation the SPMSQ can be a predictor of a composite endpoint of adverse outcomes even when controlled for a range of confounders. Its characteristics, specifically the low sensitivity, make it unsuitable as an accurate risk stratification tool on its own.

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Measurement of High-Sensitivity Cardiac Troponin in Pulmonary Embolism: Useful Test or a Clinical Distraction

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0039-1698762 ◽

2019 ◽

Vol 45 (08) ◽

pp. 784-792

Author(s):

Giuseppe Lippi ◽

Emmanuel J. Favaloro ◽

Peter Kavsak

Keyword(s):

Pulmonary Embolism ◽

Risk Stratification ◽

Cardiac Troponin ◽

Laboratory Tests ◽

High Sensitivity ◽

Severity Index ◽

Adverse Outcomes ◽

Incremental Value ◽

Risk Patients ◽

Acute Pe

AbstractThe ability to predict death or other unfavorable outcomes after an acute pulmonary embolism (PE) is challenging, with current available risk score models having relatively unsatisfactory prognostic performance in this area. For example, the simplified pulmonary embolism severity index (sPESI), the most frequently used stratification tool, misclassifies a significant percentage of low- and high-risk patients. This gap in care, along with the increasing clinical availability of high-sensitivity cardiac troponin (hs-cTn) laboratory tests and the recent emphasis on detecting myocardial injury, may foster further evaluation of hs-cTn testing in patients with acute PE. Our analysis of the current scientific literature on hs-cTn in patients with acute PE identified that hs-cTn testing may provide valuable information for predicting future adverse outcomes and mortality, independently from baseline clinical risk assessment. Although the risk of an adverse event is indeed higher in patients with higher sPESI scores, cTns retain their prognostic value also in those at low risk, suggesting that a combination of hs-cTn with sPESI may provide an incremental value over assessment of either variable alone. Accordingly, the future development of updated risk stratification models, with the inclusion of laboratory tests such as hs-cTn, may represent an enhanced approach for risk stratification in patients with acute PE. Additional research, however, is needed to verify whether the combination of cTns, specifically as measured with hs-cTn assays, with other biomarkers may further improve the current capacity to efficiently manage patients with acute PE.

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d-Dimer Assessment Improves the Simplified Pulmonary Embolism Severity Index for In-Hospital Risk Stratification in Acute Pulmonary Embolism

Clinical and Applied Thrombosis/Hemostasis ◽

10.1177/1076029618776799 ◽

2018 ◽

Vol 24 (8) ◽

pp. 1340-1346 ◽

Cited By ~ 2

Author(s):

Marta Kozlowska ◽

Magdalena Plywaczewska ◽

Marcin Koc ◽

Szymon Pacho ◽

Anna Wyzgal ◽

...

Keyword(s):

Pulmonary Embolism ◽

Adverse Event ◽

Risk Stratification ◽

Prognostic Value ◽

Acute Pulmonary Embolism ◽

Clinical Course ◽

Area Under The Curve ◽

Severity Index ◽

Net Reclassification Improvement ◽

D Dimer

d-dimer (DD) levels are used in the diagnostic workup of suspected acute pulmonary embolism (APE), but data on DD for early risk stratification in APE are limited. In this post hoc analysis of a prospective observational study of 270 consecutive patients, we aimed to optimize the discriminant capacity of the simplified pulmonary embolism severity index (sPESI), an APE risk assessment score currently used, by combining it with DD for in-hospital adverse event prediction. We found that DD levels were higher in patients with complicated versus benign clinical course 7.2 mg/L (25th-75th percentile: 4.5-27.7 mg/L) versus 5.1 mg/L (25th-75th percentile: 2.1-11.2 mg/L), P = .004. The area under the curve of DD for serious adverse event (SAE) was 0.672, P = .003. d-dimer =1.35 mg/L showed 100% negative predictive value for SAE and identified 11 sPESI ≥1 patients with a benign clinical course, detecting the 1 patient with SAE from sPESI = 0. d-dimer >15 mg/L showed heart rate for SAE 3.04 (95% confidence interval [CI]: 1-9). A stratification model which with sPESI + DD >1.35 mg/L demonstrated improved prognostic value when compared to sPESI alone (net reclassification improvement: 0.085, P = .04). d-dimer have prognostic value, values <1.35 mg/L identify patients with a favorable outcome, improving the prognostic potential of sPESI, while DD >15 mg/L is an independent predictor of SAE.

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A novel H-FABP assay and a fast prognostic score for risk assessment of normotensive pulmonary embolism

Thrombosis and Haemostasis ◽

10.1160/th13-08-0663 ◽

2014 ◽

Vol 111 (05) ◽

pp. 996-1003 ◽

Cited By ~ 35

Author(s):

Merle Tschepe ◽

Valerie Seeber ◽

Isabella Zwiener ◽

Katherina Kuhnert ◽

Katrin Schäfer ◽

...

Keyword(s):

Pulmonary Embolism ◽

Prognostic Score ◽

Multivariable Analysis ◽

Area Under The Curve ◽

Severity Index ◽

Prognostic Information ◽

Fatty Acid Binding ◽

Net Reclassification Improvement ◽

Model C

SummaryWe tested whether heart-type fatty acid binding protein (H-FABP) measured by a fully-automated immunoturbidimetric assay in comparison to ELISA provides additive prognostic value in patients with pulmonary embolism (PE), and validated a fast prognostic score in comparison to the ESC risk prediction model and the simplified Pulmonary Embolism Severity Index (sPESI). We prospectively examined 271 normotensive patients with PE; of those, 20 (7%) had an adverse 30-day outcome. H-FABP levels determined by immunoturbidimetry were higher (median, 5.2 [IQR; 2.7–9.8] ng/ml) than those by ELISA (2.9 [1.1–5.4] ng/ml), but Bland-Altman plot demonstrated a good agreement of both assays. The area under the curve for H-FABP was greater for immunoturbidimetry than for ELISA (0.82 [0.74–0.91] vs 0.78 [0.68–0.89]; P=0.039). H-FABP measured by immunoturbidimetry (but not by ELISA) provided additive prognostic information to other predictors of 30-day outcome (OR, 12.4 [95% CI, 1.6–97.6]; P=0.017). When H-FABP determined by immunoturbidimetry was integrated into a novel prognostic score (H-FABP, Syncope, and Tachycardia; FAST score), the score provided additive prognostic information by multivariable analysis (OR, 14.2 [3.9–51.4]; p<0.001; c-index, 0.86) which were superior to information obtained by the ESC model (c-index, 0.62; net reclassification improvement (NRI), 0.39 [0.21–0.56]; P<0.001) or the sPESI (c-index, 0.68; NRI, 0.24 [0.05–0.43]; P=0.012). In conclusion, determination of H-FABP by immunoturbidimetry provides prognostic information superior to that of ELISA and, if integrated in the FAST score, appears more suitable to identify patients with an adverse 30-day outcome compared to the ESC model and sPESI.

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Predictive value of troponins and simplified pulmonary embolism severity index in patients with normotensive pulmonary embolism

Multidisciplinary Respiratory Medicine ◽

10.4081/mrm.2013.512 ◽

2013 ◽

Vol 8 ◽

Author(s):

Savas Ozsu ◽

Yasin Abul ◽

Asim Orem ◽

Funda Oztuna ◽

Yilmaz Bulbul ◽

...

Keyword(s):

Pulmonary Embolism ◽

Predictive Value ◽

Troponin T ◽

Univariate Analysis ◽

Early Death ◽

Severity Index ◽

Pulmonary Angiography ◽

Adverse Outcomes ◽

End Point ◽

All Cause Mortality

Background: To investigate whether 2 cardiac troponins [conventional troponin-T(cTnT) and high sensitive troponin-T(hsTnT)] combined with simplified pulmonary embolism severity index (sPESI), or either test alone are useful for predicting 30-day mortality and 6 months adverse outcomes in patients with normotensive pulmonary embolism(PE). Methods: The prospective study included 121 consecutive patients with normotensive PE confirmed by computerized tomographic(CT) pulmonary angiography. The primary end point of the study was the 30-day all-cause mortality. The secondary end point included the 180-day all-cause mortality, the nonfatal symptomatic recurrent PE, or the nonfatal major bleeding. Results: Overall, 16 (13.2%) out of 121 patients died during the first month of follow up. The predefined hsTnT cutoff value of 0.014 ng/mL combined with a sPESI ≥1 'point(s) were the most significant predictor for 30-day mortality [OR: 27.6 (95% CI: 3.5–217) in the univariate analysis. Alone, sPESI ≥1 point(s) had the highest negative predictive value for both 30-day all-cause mortality and 6-months adverse outcomes,100% and 91% respectively. Conclusions: The hsTnT assay combined with the sPESI may provide better predictive information than the cTnT assay for early death of PE patients. Low sPESI (0 points) may be used for identifying the outpatient treatment for PE patients and biomarker levels seem to be unnecessary for risk stratification in these patients.

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Low Serum Uric Acid Predicts Risk of a Composite Disease Endpoint

Medicina ◽

10.3390/medicina57040361 ◽

2021 ◽

Vol 57 (4) ◽

pp. 361

Author(s):

Fatma Özpamuk-Karadeniz ◽

Yusuf Karadeniz ◽

Adnan Kaya ◽

Servet Altay ◽

Günay Can ◽

...

Keyword(s):

Logistic Regression ◽

Uric Acid ◽

Serum Uric Acid ◽

Density Lipoprotein ◽

Positive Association ◽

Composite Endpoint ◽

Adverse Outcomes ◽

Inverse Association ◽

Adjusted Logistic Regression ◽

Low Serum

Background and objectives: Mortality may increase in hypouricemia as well as inhyperuricemia. We assessed the predictive value of low serum uric acid (SUA) levels on the risk of overall mortality or a composite endpoint of death and nonfatal events. Materials and Methods: In 1013 community-based middle-aged adults, free of uncontrolled diabetes and coronary heart disease at baseline, the association of sex-specific SUA tertiles with defined outcomes was evaluated prospectively by logistic regression, stratified to gender and presence of type-2 diabetes, using recent criteria. Results: Totally, 43 deaths and additional incident nonfatal events in 157 cases were recorded at a median 3.4 years’ follow-up. Multivariable linear regression disclosed SUA to be significantly associated among non-diabetic individuals positively with creatinine, triglycerides, and body mass index in women further with fasted glucose. In multivariable-adjusted logistic regression analysis, sex-specifically dichotomized baseline uric acid (<5.1 and <4.1 mg/dL vs. higher values) significantly predicted the non-fatal events in the whole sample (relative risk (RR) 1.51 [95% confidence interval (CI) 1.02; 2.26]), as well as in men, while composite endpoint in the whole sample tended to rise (RR 1.38). Compared with the intermediate one, the top and bottom SUA tertiles combined tended to confer mortality risk (RR 2.40 [95% CI 0.89; 6.51]). Adverse outcomes in diabetic women were predicted by tertiles 2 and 3. Conclusions: Inverse association of SUA with adverse outcomes, especially in men, is consistent with the involvement of uric acid mass in autoimmune activation. The positive association of uric acid with adverse outcomes in diabetic women is likely mediated by concomitant high-density lipoprotein dysfunction.

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POS1144 SERUM URIC ACID TO CREATININE RATIO IS ASSOCIATED WITH URINARY URIC ACID EXCRETION IN PATIENTS WITH GOUT

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2021-eular.3497 ◽

2021 ◽

Vol 80 (Suppl 1) ◽

pp. 851.2-851

Author(s):

Z. Zhong ◽

Y. Huang ◽

X. Huang ◽

Q. Huang ◽

Y. Liu ◽

...

Keyword(s):

Uric Acid ◽

Serum Uric Acid ◽

Acid Output ◽

Area Under The Curve ◽

Roc Curves ◽

Binary Logistic Regression Analysis ◽

Creatinine Ratio ◽

Acid Excretion ◽

Complete Collection ◽

Uric Acid Excretion

Background:Underexcretion of uric acid is the dominant mechanism leading to hyperuricemia [1] and the 24-hour urinary uric acid excretion is an important measurement. However, it is inconvenient due to accurate timing and complete collection of the specimen.Objectives:The aim of this study was to investigate the relationship between serum uric acid to creatinine ratio (sUACR) and 24-hour urinary uric acid excretion in gout patients.Methods:A total of 110 gout patients fulfilling 2015 ACR/EULAR classification criteria from Guangdong Second Provincial General Hospital from January 2019 to January 2021 were retrospectively enrolled in this study. Patients were divided into underexcretion group (<3600 μmol/24h) and non-underexcretion group (≥3600 μmol/24h). The correlation between sUACR and 24-hour urinary uric acid excretion was analyzed by the Pearson’s correlations analysis. Receiver operation characteristic (ROC) curves were performed to assess the utility of sUACR for discriminating between underexcretion group and non-underexcretion group. Furthermore, the risk factors of uric acid underexcretion were evaluated using binary logistic regression analysis.Results:sUACR in the underexcretion group was significantly lower than the non-underexcretion group (p=0.0001). Besides, sUACR was positively correlated with 24-hour urinary uric acid excretion (r=0.4833, p<0.0001). Furthermore, ROC suggested that the area under the curve (AUC) of sUACR was 0.728, which was higher that of serum uric acid and creatinine. The optimal cutoff point of sUACR was 5.2312, with a sensitivity and specificity of 71.9% and 67.9%. Logistic analysis results revealed that decreased sUACR (<5.2312) was an independent risk factor of underexcretion of uric acid (OR =5.510, 95% CI: 1.952-15.550, P=0.001).Conclusion:sUACR is lower in gout patients with underexcretion of uric acid and may serve as a useful and convenient marker of assessing underexcretion of uric acid in gout patients.References:[1]Perez-Ruiz F, Calabozo M, Erauskin GG, Ruibal A, Herrero-Beites AM. Renal underexcretion of uric acid is present in patients with apparent high urinary uric acid output. Arthritis Rheum 2002; 47: 610–13.Figure 1.A. Comparison of serum uric acid to creatinine ratio between underexcretion group and non-underexcretion group. B. Correlation between serum uric acid to creatinine ratio and 24h uric acid excretion.Disclosure of Interests:None declared.

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Trends in risk stratification, in-hospital management and mortality of patients with acute pulmonary embolism: an analysis from China pUlmonary thromboembolism REgistry Study (CURES)

European Respiratory Journal ◽

10.1183/13993003.02963-2020 ◽

2021 ◽

pp. 2002963

Author(s):

Zhenguo Zhai ◽

Dingyi Wang ◽

Jieping Lei ◽

Yuanhua Yang ◽

Xiaomao Xu ◽

...

Keyword(s):

Pulmonary Embolism ◽

Risk Stratification ◽

Hospital Mortality ◽

Acute Pulmonary Embolism ◽

Severity Index ◽

Disease Diagnosis ◽

Initial Therapy ◽

European Respiratory Society ◽

Systemic Thrombolysis ◽

All Cause Mortality

BackgroundSimilar trends of management and in-hospital mortality of acute pulmonary embolism (PE) have been reported in European and American populations. However, these tendencies were not clear in Asian countries.ObjectivesWe retrospectively analyzed the trends of risk stratification, management and in-hospital mortality for patients with acute PE through a multicenter registry in China (CURES).MethodsAdult patients with acute symptomatic PE were included between 2009 and 2015. Trends in disease diagnosis, treatment and death in hospital were fully analyzed. Risk stratification was retrospectively classified by hemodynamical status and the simplified Pulmonary Embolism Severity Index (sPESI) score according to the 2014 European Society of Cardiology/European Respiratory Society guidelines.ResultsAmong overall 7438 patients, the proportions with high (hemodynamically instability), intermediate (sPESI≥1) and low (sPESI=0) risk were 4.2%, 67.1% and 28.7%, respectively. Computed tomographic pulmonary angiography was the widely employed diagnostic approach (87.6%) and anticoagulation was the frequently adopted initial therapy (83.7%). Between 2009 and 2015, a significant decline was observed for all-cause mortality (from 3.1% to 1.3%, adjusted Pfor trend=0.0003), with a concomitant reduction in use of initial systemic thrombolysis (from 14.8% to 5.0%, Pfor trend<0.0001). The common predictors for all-cause mortality shared by hemodynamically stable and unstable patients were co-existing cancer, older age, and impaired renal function.ConclusionsThe considerable reduction of mortality over years was accompanied by changes of initial treatment. These findings highlight the importance of risk stratification-guided management throughout the nation.

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Assessment of the CHA2DS2-VASc Score in Predicting Mortality and Adverse Cardiovascular Outcomes of Patients on Hemodialysis

American Journal of Nephrology ◽

10.1159/000508836 ◽

2020 ◽

Vol 51 (8) ◽

pp. 635-640

Author(s):

Miri Schamroth Pravda ◽

Keren Cohen Hagai ◽

Guy Topaz ◽

Nili Schamroth Pravda ◽

Nadeen Makhoul ◽

...

Keyword(s):

Myocardial Infarction ◽

Cardiovascular Risk ◽

Risk Stratification ◽

High Mortality ◽

Medical Center ◽

Composite Endpoint ◽

Chronic Hemodialysis ◽

Adverse Outcomes ◽

First Year ◽

Increased Risk

Background: Patients with end-stage renal disease (ESRD) undergoing chronic hemodialysis are at high mortality and cardiovascular risk. This study was aimed to assess whether the CHA2DS2-VASc score may be used for risk stratification of this population. Methods: Included were patients undergoing chronic hemodialysis at Meir Medical Center. The CHA2DS2-VASc score was calculated for each patient at the initiation of hemodialysis. Patients were classified into 3 groups according to the CHA2DS2-VASc score: 0–3 (low), 4–5 (intermediate), and ≥6 (high). The primary endpoint was the composite of all-cause mortality, myocardial infarction, and stroke during the first year of hemodialysis. Results: Of the 457 patients with ESRD, 181 (40%) had low, 193 (42%) intermediate, and 83 (18%) high CHA2DS2-VASc scores. During the first year of hemodialysis, 109 (23.8%) patients died, 17 (3.7%) had a stroke, and 28 (6.1%) had a myocardial infarction. Compared to patients in the low CHA2DS2-VASc score group, those in the intermediate and high score groups had higher risk for the composite endpoint (OR: 2.6, 95% CI: 1.6–4.2, p < 0.01 and OR: 4.2, 95% CI: 2.3–7.5, p < 0.01, respectively). Each 1-point increase in CHA2DS2-VASc score was associated with a 38% increased risk for the composite endpoint, a 19% increased risk for 1-year myocardial infarction, and a 29% increased risk for 1-year stroke. Conclusions: Patients with ESRD are at an extremely high mortality and cardiovascular risk within the first year of hemodialysis. The CHA2DS2-VASc score was strongly associated with adverse outcomes and may be used for risk stratification of these patients.

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