Douleur thoracique aux urgences : utilisation adéquate des scores diagnostiques

Résumé La douleur thoracique est un motif très fréquent de consultation aux urgences. Le diagnostic différentiel est large et regroupe diverses étiologies parmi lesquelles les syndromes coronariens aigus (SCA) qui sont à l’avantplan. L’exclusion d’un SCA demeure une priorité absolue pour l’urgentiste au vu de la morbidité et de la mortalité qui lui sont associées. Afin d’aider le praticien dans sa démarche diagnostique, plusieurs algorithmes ont été élaborés pour exclure et diagnostiquer efficacement un SCA. Ceux-ci intègrent des données cliniques, électrocardiographiques et le dosage de la troponine. Leur utilisation est relativement simple et a été validée dans plusieurs essais cliniques. Ils permettent d’écarter le diagnostic de SCA chez une proportion significative de patients, avec une marge d’erreur très faible. Le score HEART se montre supérieur aux autres scores existants, et son application en salle d’urgences permet d’orienter de manière adéquate la démarche diagnostique, afin de réduire les investigations complémentaires et d’accélérer la prise en charge. Afin d’exclure un SCA sans recourir au dosage de la troponine, la règle CARE a été proposée récemment avec des résultats prometteurs. Issue directement du score HEART, elle permet d’écarter très rapidement le diagnostic de SCA puisqu’elle se passe de dosage biologique tout en gardant un profil de sécurité semblable

Do Not Throw Out the Baby With the Bathwater

International audienc

How to Combat Over-Testing for Patients Suspected of Pulmonary Embolism: A Narrative Review

The diagnosis of PE remains difficult in 2023 because the signs and symptoms are not sensible nor specific. The consequences of potential diagnostic errors can be dramatic, whether by default or by excess. Furthermore, the achievement of a simple diagnostic strategy, based on clinical probability assessment, D-dimer measurement and computed tomography pulmonary angiography (CTPA) leads to a new challenge for PE diagnosis: over-testing. Indeed, since the 2000s, the wide availability of CTPA resulted in a major increase in investigations with a mod I confirm erate increase in PE diagnosis, without any notable improvement in patient outcomes. Quite the contrary, the complications of anticoagulation for PE increased significantly, and the long-term consequences of imaging diagnostic radiation is an important concern, especially the risk of breast cancer for young women. As a result, several strategies have been proposed to fight over-testing. They are mostly based on defining a subgroup of patients for whom no specific exam should be required to rule-out PE and adjusting the D-dimer cutoff to allow the exclusion of PE without performing CTPA. This narrative review presents the advantages and limitations of these different strategies as well as the perspective in PE diagnosis

Diagnosis of Pulmonary Embolism during Pregnancy

Although rare, pulmonary embolism (PE) remains one of the most common causes of severe maternal morbidity and mortality during pregnancy. Among pregnant women with suspected PE, the prevalence of confirmed disease is far lower than in the general population, reflecting the fear of missing the diagnosis and a low threshold to suspect PE in this setting. Two prospective management outcome trials have recently assessed two different diagnostic algorithms based on the assessment of clinical probability, D-dimer, venous compression ultrasonography of the lower limbs (CUS), and computed tomography pulmonary angiography (CTPA). Both demonstrated the safety of such strategies to exclude PE, with a very low failure rate defined as the rate of subsequent 3-month venous thromboembolism in women left untreated after a negative work-up. These studies were also the first to prospectively demonstrate the safety of negative D-dimer associated with a clinical prediction rule to exclude PE without any chest imaging. Pregnant women are known to be a subgroup at particularly high risk of inappropriate diagnostic management, so the implementation of such validated diagnostic strategies in clinical practice should represent a high priority goal

Validation of risk assessment models predicting venous thromboembolism in acutely ill medical inpatients: a cohort study.

BACKGROUND As hospital-acquired venous thromboembolism (VTE) represents a frequent cause of preventable deaths in medical inpatients, identifying at risk patients requiring thromboprophylaxis is critical. We aimed to externally assess the Caprini, IMPROVE and Padua VTE risk scores and to compare their performance to advanced age as a stand-alone predictor. METHODS We performed a retrospective analysis of patients prospectively enrolled in the PREVENU trial. Patients aged 40-years and older, hospitalised for at least 2-days on a medical ward were consecutively enrolled and followed for three months. Critical ill patients were not recruited. Patients diagnosed with VTE within 48-hours from admission, or receiving full dose anticoagulant treatment or who underwent surgery were excluded. All suspected VTE and deaths occurring during the three-month follow-up were adjudicated by an independent committee. The three scores were retrospectively assessed. Body mass index, needed for the Padua and Caprini scores were missing in 44% of patients. RESULTS Among 14,910 eligible patients, 14,660 were evaluable, of which 1.8% experienced symptomatic VTE or sudden unexplained death during the three-month follow-up. The area under the receiver operating characteristic curves (AUC) were 0.60 (95%CI 0.57-0.63), 0.63 (95%CI 0.60-0.66) and 0.64 (95%CI 0.61-0.67) for Caprini, IMPROVE and Padua scores, respectively. None of these scores performed significantly better than advanced age as a single predictor (AUC 0.61, 95%CI 0.58-0.64). CONCLUSION In our study, Caprini, IMPROVE and Padua VTE risk scores have poor discriminative ability to identify not-critically ill medical inpatients at risk of VTE, and do not perform better than a risk evaluation based on patient's age alone

Outpatient management of pulmonary embolism

Despite clear potential benefits of outpatient care, most patients suffering from pulmonary embolism (PE) are currently hospitalized due to the fear of possible adverse events. Nevertheless, some teams have increased or envisage to increase outpatient treatment or early discharge. We performed a narrative systematic review of studies published on this topic. We identified three meta-analyses and 23 studies, which involved 3671 patients managed at home (n = 3036) or discharged early (n = 535). Two main different approaches were applied to select patients eligible for outpatient in recent prospective studies, one based on a list of pragmatic criteria as the HESTIA rule, the other adding severity criteria (i.e. risk of death) as the Pulmonary Embolism Severity Criteria (PESI) or simplified PESI. In all these studies, a specific follow-up was performed for patients managed at home involving a dedicated team. The overall early (i.e. between 1 to 3 months) complication rate was low, < 2% for thromboembolic recurrences or major bleedings and < 3% for deaths with no evidence in favour of one selection strategy or another. Outpatient management appears to be feasible and safe for many patients with PE. In the coming years, outpatient treatment may be considered as the first line management for hemodynamically stable PE patients, subject to the respect of simple eligibility criteria and on the condition that a specific procedure for outpatient care is developed in advance

Adaptation of ED design layout during the COVID-19 pandemic: a national cross-sectional survey

International audienceBACKGROUND: The aim was to describe the organisational changes in French EDs in response to the COVID-19 pandemic with regard to architectural constraints and compare with the recommendations of the various bodies concerning the structural adjustments to be made in this context. METHODS: As part of this cross-sectional study, all heads of emergency services or their deputies were contacted to complete an electronic survey. This was a standardised online questionnaire consisting of four parts: characteristics of the responding centre, creation of the COVID-19 zone and activation of the hospital’s emergency operations plan, flow and circulation of patients and, finally, staff management. Each centre was classified according to its workload related to COVID-19 and its size (university hospital centre, high-capacity hospital centre and low-capacity hospital centre). The main endpoint was the frequency of implementation of international guidelines for ED organisation. RESULTS: Between 11 May and 20 June 2020, 57 French EDs completed the online questionnaire and were included in the analysis. Twenty-eight EDs were able to separate patient flows into two zones: high and low viral density (n=28/57, 49.1%). Of the centres included, 52.6% set up a specific triage area for patients with suspected COVID-19 (n=30/57). Whereas, in 15 of the EDs (26.3%), the architecture made it impossible to increase the surface area of the ED. CONCLUSION: All EDs have adapted, but many of the changes recommended for the organisation of ED could not be implemented. ED architecture constrains adaptive capacities in the context of COVID-19

Les modèles de risque de maladie thromboembolique veineuse acquise chez les patients hospitalisés en secteur médical

IntroductionLa maladie thromboembolique veineuse (MTEV) acquise à l’hôpital représente une part importante de morbi-mortalité évitable chez les patients hospitalisés en secteur médical. D’un autre côté, la thromboprophylaxie anticoagulante expose les patients à un risque hémorragique et majore les dépenses de santé. L’identification des patients hospitalisés à risque de MTEV est en cela cruciale. L’objectif de cette étude est d’évaluer de manière externe, les performances de 3&nbsp;modèles de risque (score de Padua, Carpini et Improve) et de les comparer aux performances de l’âge pris isolément.Patients et méthodesIl s’agit d’une étude rétrospective sur une base de patients inclus prospectivement dans une étude randomisée en cluster sans intervention directe sur le patient. Les patients de plus de 40&nbsp;ans, hospitalisé depuis les urgences en secteur médical plus de 48&nbsp;h ont consécutivement été inclus et suivi à 3&nbsp;mois. Les patients chez qui un diagnostic de MTEV avait été porté dans les 48&nbsp;premières heures d’hospitalisation, ou ayant reçu un traitement anticoagulant pour une raison autre que la MTEV, ou encore ayant subi une chirurgie sous anesthésie générale ont été exclus. Les modèles de risques ont été calculés à posteriori. La réduction de mobilité a été déduite de la durée d’hospitalisation moins un jour. Le critère de jugement principal était la survenue d’un épisode thrombotique veineux symptomatique ou le décès brutal inexpliqué adjudiqué à 3&nbsp;mois.RésultatsParmi les 14&nbsp;910&nbsp;patient éligibles, 14&nbsp;659 (98,3) étaient évaluables. 263 (1,8&nbsp;%) ont présenté une MTEV symptomatique ou un décès brutal inexpliqué. Les aires sous la courbe ROC étaient respectivement 0,60 [0,57–0,63], 0,62 [0,58–0,64] et 0,62 [0,59–0,65] pour les scores Caprini, Improve et Padua. Aucun de ces modèles n’a montré de performances supérieures à l’âge pris isolément (AUC 0,61 [0,58–0,64]). Ces résultats étaient similaires ne considérant que les évènements symptomatiques non fatals&nbsp;: (0,62 [0,58–0,66], 0,62 [0,58–0,66], 0,63 [0,59–0,67] et 0,58 [0,54–0,62])&nbsp;; ou dans le sous-groupe de patients ne recevant pas de thromboprophylaxie anticoagulante&nbsp;: 0,62 [0,58–0,67], 0,64 [0,60–0,68], 0,64 [0,59–0,68] et 0,66 [0,62–0,70] pour le score Caprini, Improve, Padua et l’âge, respectivement.ConclusionLes scores de Padua, Caprini et Improve ont des capacités de discrimination faible vis-à-vis de la MTEV acquise à l’hôpital, similaire à une évaluation se basant uniquement sur l’âge. Les meilleurs modèles de risque sont nécessaires.</p

Efficacy of HEAR and HEART score to rule out major adverse cardiac events in patients presenting to the emergency department with chest pain: study protocol of the eCARE stepped-wedge randomised control trial.

INTRODUCTION: Current guidelines for patients presenting to the emergency department (ED) with chest pain without ST-segment elevation myocardial infarction (STEMI) on ECG are based on serial troponin measurements. A clinical tool able to identify very low-risk patients who could forgo a troponin test and low-risk patients requiring only one troponin measurement would be of great interest. To do so, the HEAR and HEART score, standing for history, ECG, age, risk factors±troponin were prospectively assessed, but not combined and implemented in clinical practice. The objective of the eCARE study is to assess the impact of implementing a diagnostic strategy based on a HEAR score <2 or a HEART score <4 (HEAR-T strategy) to rule out non-STEMI without or with a single troponin measurement in patients presenting to the ED with chest pain without obvious diagnosis after physical examination and an ECG. METHODS AND ANALYSIS: Stepped-wedge cluster-randomised control trial in 10 EDs. Patients with non-traumatic chest pain and no formal diagnosis were included and followed for 30 days. In the interventional phase, the doctor will be asked not to perform a troponin test to look for an acute coronary if the HEAR score is <2 and not to perform an additional troponin test if the HEAR score is ≥2 and HEART score is <4. The main endpoint is the non-inferiority of the rates of major adverse cardiac events occurring between a patient's discharge and the 30-day follow-up against current recommended guidelines. ETHICS AND DISSEMINATION: The study was approved by an institutional review board for all participating centres. If successful, the eCARE study will cover a gap in the evidence, proving that it is safe and efficient to rule out the hypothesis of an acute myocardial infarction in some selected very low-risk patients or based on a single troponin measurement in some low-risk patients. TRIAL REGISTRATION NUMBER: NCT04157790

Venous thromboembolism risk stratification for patients with lower limb trauma and cast or brace immobilization.

Thromboprophylaxis for patients with non-surgical isolated lower-limb trauma requiring immobilization is a matter of debate. Our aim was to develop and validate a clinical risk- stratification model based on Trauma, Immobilization and Patients' characteristics (the TIP score). The TIP score criteria and the cut-off were selected by a consensus of international experts (n = 27) using the Delphi method. Retrospective validation was performed in a population-based case-control study (MEGA study). The potential score's impact in anticoagulant treatment was assessed in a prospective single-center observational cohort study. After four successive rounds, 30 items constituting the TIP score were selected: thirteen items for trauma, three for immobilization and 14 for patient characteristics were selected, each rated on a scale of 1 to 3. In the validation database, the TIP score had an AUC of 0·77 (95% CI 0.70 to 0.85). Using the cut-off proposed by the experts (≥5) and assuming a prevalence of 1·8%, the TIP scores had a sensitivity, specificity and negative predictive values of 89·9%, 30·7% and 99·4% respectively. In the prospective cohort, 84·2% (165/196) of all the patients concerned who presented at the emergency department had a low VTE risk not requiring thromboprophylaxis according to their TIP scores. The 3-month rate of symptomatic VTE was 1/196 [95% CI 0.1-2.8] this patient was in the sub-group TIP score ≥5. For patients with non-surgical lower-limb trauma and orthopedic immobilization, the TIP score allows an individual VTE risk-assessment and shows promising results in guiding thromboprophylaxis