Potential protective effect of PPI in COPD.

Associations of an increased incidence of respiratory disease in the presence of gastroesophageal reflux disease (GERD), and improvements of respiratory disease with treatment for GERD, have been reported. Respiratory conditions associated with GERD or its treatment include chronic cough, asthma, and interstitial lung disease. Such associations between chronic obstructive pulmonary disease (COPD) and GERD have not been reported. We chose to retrospectively study the severity of airway obstruction as measured by pulmonary function testing (PFT) in a cohort of COPD patients with respect to the use of proton pump inhibitors (PPI). METHODS: Single-center retrospective analysis of patients with documented obstructive disease by PFT in 2014. A total of 1445 patients were identified as having an obstructive pattern. We selected a cohort of 647 patients who self-reported a diagnosis of COPD and had clinical findings consistent with this diagnosis. We compared patients who had been prescribed PPI (PPI group, n=383) to those who had not (non-PPI group, n=264). Univariate comparisons were by Chi-square analysis for dichotomous variables and two-sided student\u27s t-test for continuous variables. SPSS 20 software was used for statistical analysis. A p value of 0.05 was considered significant. Reported values are mean+/- standard deviation. RESULTS: The PPI group and non-PPI group were not different in terms of gender (PPI group 157/383 females; non-PPI group 127/264 females; p=0.073), body mass index (PPI group 27.9+/-7.4; non-PPI group 26.9+/-6.9; p=0.085), or age (PPI group 68.9+/-10.3; non-PPI group 68.2+/-10.8; p=0.407). The FEV1/FVC for the PPI group was 48.1+/-12.0 compared to the non-PPI group 45.3+/-12.1 (p=0.004). The percent predicted FEV1 for the PPI group was 51.2+/-19.2 compared to 46.7+/-19.0 for the non-PPI group (p=0.003). In a multivariate analysis with a model that included BMI, gender, age, and percent predicted FEV1, only the latter was associated with PPI treatment (p=0.022). CONCLUSIONS: Patients with PPI prescription in our study had less severe airway obstruction than patients who were not prescribed these medications. Multiple reasons for this association could be postulated. Different co-morbidity profiles or insurance coverages could exist between groups. Patients with more severe COPD might take more medications, limiting the availability of medications targeting symptom relief. Finally, PPI use could ameliorate airway obstruction in smoking-related lung disease. Potential mechanisms for a protective effect of PPI in COPD might implicate reduction of gastric acid aspiration, or a primary effect of the medication on lung disease pathophysiology. Further research evaluating PPI use in COPD is warranted

The use in the United States of a baseline high-sensitivity cardiac troponin t value below the level of detection to rule out acute myocardial infarction.

Background: The use of a single baseline high sensitivity cardiac troponin T (hs-cTnT) measurement \u3c level of detection (LoD) to rule-out acute myocardial infarction (AMI) is recommended in the 2015 European Society of Cardiology guidelines. However, this suggestion is mostly based on trials including European populations and using a LoD for hs-cTnT of 5 ng/L. The purpose of this study was to determine if a single baseline hs-cTnT level \u3c 6 ng/L (the FDA approved LoD) could rule-out AMI in a United States (US) Emergency Department (ED) population. Methods: Patients presenting to the ED with any symptoms suspicious for ACS at a single US tertiary care urban center were enrolled. Baseline blood samples were obtained within 60 minutes of a triage ECG. AMI diagnosis was independently adjudicated by a cardiologist and emergency physician using the 3rd Universal Definition and serial troponin I (TnI) levels (Siemens TnI-Ultra) over 3 hours and all clinical data available 30 days post discharge. Results: Of the 569 studied subjects 44 (7.7%) had AMI and all enrolled patients had a baseline blood sample drawn. There were 164 (28.8%) subjects that had a baseline hs-cTnT value \u3c the LoD of 6 ng/L and all were without adjudicated AMI (negative predictive value 100% [95%CI 97.8-100.0], sensitivity 100% [95%CI 92.0-100.0]), irrespective of any ECG abnormalities. There were 30 hemodialysis patients enrolled and all had hs-cTn â%o¥ 6 ng/L at presentation. At 30 days there was 1 non-cardiac death, no cardiac deaths, 1 AMI (0.6%), and no revascularization procedures in those patients with a baseline hs-cTnT \u3c 6 ng/ L. The past medical histories of subjects with a hs-cTnT \u3c 6 ng/L included hypertension 98 (59.8%), diabetes mellitus 26 (15.9%), hypercholesterolemia 48 (29.3%), coronary artery disease 31 (18.9%), prior revascularization procedure 21 (12.8%), myocardial infarction 26 (15.9%), and congestive heart failure 11 (6.7%). Conclusion: A single baseline hs-cTnT level \u3c the US LoD of 6 ng/L can be used to rule-out AMI and identifies a low risk population which may be considered, after appropriate work up for non ACS etiologies as cause for presenting symptoms, for early discharge without further observation and/or cardiac testing. These findings are required to be validated prospectively in further multi-center US trials

The Use in the United States of a Baseline High-Sensitivity Cardiac Troponin T Value Below the Level of Detection to Rule out Acute Myocardial Infarction

Background: The use of a single baseline high sensitivity cardiac troponin T (hs-cTnT) measurement \u3c level of detection (LoD) to rule-out acute myocardial infarction (AMI) is recommended in the 2015 European Society of Cardiology guidelines. However, this suggestion is mostly based on trials including European populations and using a LoD for hs-cTnT of 5 ng/L. The purpose of this study was to determine if a single baseline hs-cTnT level \u3c 6 ng/L (the FDA approved LoD) could rule-out AMI in a United States (US) Emergency Department (ED) population. Methods: Patients presenting to the ED with any symptoms suspicious for ACS at a single US tertiary care urban center were enrolled. Baseline blood samples were obtained within 60 minutes of a triage ECG. AMI diagnosis was independently adjudicated by a cardiologist and emergency physician using the 3rd Universal Definition and serial troponin I (TnI) levels (Siemens TnI-Ultra) over 3 hours and all clinical data available 30 days post discharge. Results: Of the 569 studied subjects 44 (7.7%) had AMI and all enrolled patients had a baseline blood sample drawn. There were 164 (28.8%) subjects that had a baseline hs-cTnT value \u3c the LoD of 6 ng/L and all were without adjudicated AMI (negative predictive value 100% [95%CI 97.8-100.0], sensitivity 100% [95%CI 92.0-100.0]), irrespective of any ECG abnormalities. There were 30 hemodialysis patients enrolled and all had hs-cTn â%o¥ 6 ng/L at presentation. At 30 days there was 1 non-cardiac death, no cardiac deaths, 1 AMI (0.6%), and no revascularization procedures in those patients with a baseline hs-cTnT \u3c 6 ng/ L. The past medical histories of subjects with a hs-cTnT \u3c 6 ng/L included hypertension 98 (59.8%), diabetes mellitus 26 (15.9%), hypercholesterolemia 48 (29.3%), coronary artery disease 31 (18.9%), prior revascularization procedure 21 (12.8%), myocardial infarction 26 (15.9%), and congestive heart failure 11 (6.7%). Conclusion: A single baseline hs-cTnT level \u3c the US LoD of 6 ng/L can be used to rule-out AMI and identifies a low risk population which may be considered, after appropriate work up for non ACS etiologies as cause for presenting symptoms, for early discharge without further observation and/or cardiac testing. These findings are required to be validated prospectively in further multi-center US trials

Rapid evaluation of acute myocardial infarction in a united states population using high sensitivity cardiac troponin T and a European society of cardiology 0/1-hour algorithm guideline.

Background: A baseline and1 hour rule-in/rule-out acute myocardial infarction (AMI) algorithm using high sensitivity cardiac troponin T (hs-cTnT) measurements has been reported and validated in several non United States (US) studies and is recommended in the 2015 European Society of Cardiology (ESC) NSTEMI guidelines. There is no similar approach incorporated in any current US organizational NSTEMI guidelines. The purpose of this study was to apply the ESC baseline and 1 hour algorithm to a US Emergency Department (ED) population presenting with suspected acute coronary syndrome (ACS) to determine its clinical usefulness. Methods: Patients presenting with any symptoms suspicious of ACS at a single US tertiary care urban center were enrolled. Baseline (within 60 minutes of triage ECG) and 60 minute blood samples were obtained for blinded independent hs-cTnT (Roche) measurements. AMI diagnosis was independently adjudicated by 2 physicians after reviewing all available 30 day clinical data and the hospitals serial cardiac troponin I (Siemens) levels over 3 hours in accordance with the 3rd Universal Definition of AMI. Results: Of the 569 enrolled subjects 44 (7.7%) had AMI. Analyzing the baseline and 1 hour ESC algorithm in the 543 patients with these hs-cTnT values available resulted in 312 (57.5%) assigned to the rule-out zone (0 hour \u3c 12 and 1 hour delta \u3c 3 ng/L), 162 (29.8%) to the observation group and 69 (12.7%) to the rule-in zone (0 hour \u3e 52 or 1 hour delta â%o¥ 5 ng/L). The negative predicted value (NPV) and sensitivity for AMI were 99.4% and 95.5% (2 AMIs (0.63%), importantly both type 2, were missed in the rule-out zone while the rule-in zone positive predictive value (PPV) and specificity for AMI were 42.0% and 92.0%. Our results were very similar to those reported in the TRAPID-AMI study (ESC guidelines) for the rule-out zone (NPV and sensitivity 99.1% and 96.7% [7 AMIs (0.05%) were missed) but dissimilar for the rule-in zone (PPV and specificity 77.2% and 96.1%). Conclusion: In our opinion the most important aspect of the ESC baseline and 1 hour recommendations for clinicians is the rapid rule-out of AMI in the large number of ED patients with suspected ACS. For this purpose the rule-out zone of these ESC guidelines, when applied to a US population, has very similar NPVs and sensitivities and so could be used in like fashion. However further multicenter US ED studies are needed to validate our findings

Rapid Evaluation of Acute Myocardial Infarction in a United States Population Using High Sensitivity Cardiac Troponin T and a European Society of Cardiology 0/1-Hour Algorithm Guideline

Background: A baseline and 1 hour rule-in/rule-out acute myocardial infarction (AMI) algorithm using high sensitivity cardiac troponin T (hs-cTnT) measurements has been reported and validated in several non-United States (US) studies and is recommended in the 2015 European Society of Cardiology (ESC) NSTEMI guidelines. There is no similar approach incorporated in any current US organizational NSTEMI guidelines. The purpose of this study was to apply the ESC baseline and 1 hour algorithm to a US Emergency Department (ED) population presenting with suspected acute coronary syndrome (ACS) to determine its clinical usefulness. Methods: Patients presenting with any symptoms suspicious of ACS at a single US tertiary care urban center were enrolled. Baseline (within 60 minutes of triage ECG) and 60 minute blood samples were obtained for blinded independent hs-cTnT (Roche) measurements. AMI diagnosis was independently adjudicated by 2 physicians after reviewing all available 30 day clinical data and the hospitals serial cardiac troponin I (Siemens) levels over 3 hours in accordance with the 3rd Universal Definition of AMI. Results: Of the 569 enrolled subjects 44 (7.7%) had AMI. Analyzing the baseline and 1 hour ESC algorithm in the 543 patients with these hs-cTnT values available resulted in 312 (57.5%) assigned to the rule-out zone (0 hour \u3c 12 and 1 hour delta \u3c 3 ng/L), 162 (29.8%) to the observation group and 69 (12.7%) to the rule-in zone (0 hour \u3e 52 or 1 hour delta â%o¥ 5 ng/L). The negative predicted value (NPV) and sensitivity for AMI were 99.4% and 95.5% (2 AMIs (0.63%), importantly both type 2, were missed in the rule-out zone while the rule-in zone positive predictive value (PPV) and specificity for AMI were 42.0% and 92.0%. Our results were very similar to those reported in the TRAPID-AMI study (ESC guidelines) for the rule-out zone (NPV and sensitivity 99.1% and 96.7% [7 AMIs (0.05%) were missed) but dissimilar for the rule-in zone (PPV and specificity 77.2% and 96.1%). Conclusion: In our opinion the most important aspect of the ESC baseline and 1 hour recommendations for clinicians is the rapid rule-out of AMI in the large number of ED patients with suspected ACS. For this purpose the rule-out zone of these ESC guidelines, when applied to a US population, has very similar NPVs and sensitivities and so could be used in like fashion. However further multicenter US ED studies are needed to validate our findings