Background:Cardiac troponins are the preferred biomarker to diagnose myocardial injury. Complicating the interpretation of serial troponins in patients with end-stage renal disease, it has been shown that the hemodialysis procedure results in a small but significant decline in high-sensitivity cardiac troponins (hs-cTnT). This raises the possibility that continuous renal replacement therapy (CRRT) might similarly alter cardiac troponin levels and affect their interpretation when cardiac ischemia is being considered.Objective:We sought to determine the effect of CRRT on hs-cTnT levels over time in a group of patients without active myocardial injury.Design:Prospective, observational studySetting:Single tertiary care hospital, Montreal, QuebecPatients:Ten critically ill patients with acute kidney injury (AKI) undergoing CRRT. Cardiac ICU (intensive care unit) patients and acute coronary syndrome patients were excluded from the study. The CRRT prescription was at the discretion of the treating intensivist and relatively high doses were used in this study.Measurements:The hs-cTnT levels were drawn pre-CRRT, within 6 hours of initiation, and approximately every 6 hours thereafter along with routine CRRT blood work.Methods:Changes in hs-cTnT, creatinine, and albumin levels were recorded over the course of CRRT. Mean change in serum analyte concentration and 95% confidence interval was determined for specified time intervals relative to baseline, with paired t tests used to determine statistical significance.Results:Among the 10 patients included in the study, the cause of AKI was primarily acute tubular necrosis from septic shock or hemorrhagic shock. Compared with baseline hs-cTnT levels prior to CRRT initiation, mean hs-cTnT level fell by 42% at 5 to 10 hours post-CRRT initiation, followed by a plateauing of levels for the duration of time on CRRT.Limitations:Single-center study only applicable to hs-cTnT assay.Conclusions:This study demonstrates a significant decrease in hs-cTnT within 5 to 10 hours of CRRT initiation. This suggests that interpretation of cardiac troponin changes during CRRT must take into consideration the timing of dialysis initiation relative to the time of sample collection.
PURPOSE:To determine the use of D-dimers in the diagnostic approach to patients presenting to the emergency department (ED) with suspected venous thromboembolism (VTE). METHODS:We performed a retrospective chart review of all adult patients presenting to the ED of the Jewish General Hospital (Montreal, Canada) between March 23 rd and April 3 rd , 2015 and had a high sensitivity D-dimer requested. Patients evaluated for non-VTE conditions were excluded. For all included patients, we determined if a Wells score prior to D-dimer requisition was recorded. For patients without a documented Wells score, we calculated the Modified Wells score based on data from the ED physician's initial history and physical exam. We determined diagnostic imaging following D-dimer in all patients. RESULTS:Among 141 patients with a D-dimer for VTE assessment, 9 (6.4%) had a documented Wells score, 10 (7.1%) had sufficient data to calculate a score, and 122 (86.5%) had neither a recorded score nor sufficient data. All 9 patients with a documented score had a low/moderate risk score, and the D-dimer was positive in 5 (55.6%) and negative in 4 (44.4%). All 10 patients with a calculated score had a low/moderate risk score, among whom 3 (30%) had a positive D-dimer and 7 (70%) had a negative D-dimer. Among the patients with a recorded or calculated score, diagnostic imaging was performed in none of the patients with a negative D-dimer and in 5 (62.5%) patients with a positive D-dimer. Among the group of patients without a recorded or calculated score, 49 (40.2%) had a positive D-dimer among whom 30 (61.2%) had imaging and 73 (59.8%) had a negative D-dimer among whom 6 (8.2%) had diagnostic imaging. CONCLUSIONS:In our study, only 6% of patients presenting to the ED with suspected VTE had a prediction rule calculated prior to D-dimer requisition. In addition, low/moderate risk score patients with a positive D-dimer did not always undergo diagnostic imaging. Physician use of D-dimers for VTE assessment is not in keeping with guideline recommendations.CLINICAL IMPLICATIONS: Guideline recommendations suggest that the initial assessment for VTE include risk stratification. Low/moderate risk patients should have a D-dimer. A negative result reliably excludes the presence of VTE in this population, eliminating the need for imaging. Elimination of inappropriate imaging would improve resource allocation and reduce patient harm (eg, radiation exposure). Conversely, D-dimers are not indicated in high risk patients. Negative results in this population carry a significant false negative risk. This may lead to patient morbidity/mortality from a missed VTE if imaging is not pursued. Similarly, low/moderate risk patients with a positive D-dimer should undergo imaging to avoid missing a VTE.
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