screening for blunt cerebrovascular injuries is cost-effective: cothren cc, moore ee, ray, ce, et...

e OUTCOMES IN PATIENTS ADMITTED FOR CHESTPAIN WITH RENAL FAILURE AND TROPONIN I EL-EVATIONS. Kontos, MC, Garg R, Anderson FP, et al. AmHeart J 2005;150:676–80.

This prospective study was designed to determine the sig-nificance in troponin I (Tn I) elevations in patients admitted forpossible myocardial ischemia in the face of renal failure. Therewere 3774 consecutive patients admitted for exclusion of myo-cardial infarction without ST segment elevation who underwentserial testing for CK and CK-MB at 0, 3, 6, and 8 h, and Tn Ilevels at 0 and 8 h. If TN I levels were elevated, Tn I levelswere redrawn every 6 to 8 h to determine a peak 24-h level foruse in the analysis. Renal function was assessed in all patientsusing the Cockroft-Gault formula. Patients were then dividedinto three groups: those with normal creatinine clearance(CrCl) (defined as � 60 [n � 2690]), those with moderate renalinsufficiency (defined as a CrCl of 30–59 [n � 755]), and thosewith severe renal insufficiency (defined as a CrCl � 30 [n �329]). Results were compared using standard bivariate statisti-cal testing, and multivariable logistic regression analysis wasused to determine independent predictors of mortality for thethree different study groups. Troponin I elevations were presentin 17% of all patients (13% in the normal group; 19% in themoderate renal insufficiency group; and 26% in the severe renalinsufficiency group). The average Tn I levels per group were0.9 � 0.2 mg/dL, 1.4 � 0.4 mg/dL, and 5.5 � 4.0 mg/dL,respectively. One year all-cause mortality increased as level ofrenal insufficiency increased and as Tn I increased (Tn I pos-itive vs. Tn I negative: normal, 9% vs. 5%; moderate renalinsufficiency, 21% vs. 14%; and severe renal insufficiency,52% vs. 26%; [p � 0.001]). The authors identified Tn I as themost important independent predictor of mortality across thethree groups, and coronary angiography was performed signif-icantly less frequently in patients with renal failure whether ornot Tn I levels were abnormal. The authors concluded that TnI levels are an appropriate and important predictor of increasemortality in patients with and without renal insufficiency.

[Cliff Rice, MD,

Denver Health Medical Center, Denver, CO]

Comment: Troponin I elevations should be interpreted sim-ilarly in patients with and without renal failure.

e SCREENING FOR BLUNT CEREBROVASCULARINJURIES IS COST-EFFECTIVE. Cothren CC, Moore EE,Ray CE, et al. Am J Surg 2005;190:845–9.

This study was designed to determine the role of angio-graphic screening for blunt cerebrovascular injury (BCVI) in ahigh-risk trauma population, the yield of screening, and itsoverall cost-effectiveness. During an 8½ year period, 15,767patients with blunt trauma were admitted to the study facility.Patients meeting screening criteria for BCVI (defined as pa-tients with arterial hemorrhage, neck bruit, expanding neckhematoma, focal neurological deficit, neurological examinationincongruous with head computed tomography [CT] findings,stroke on secondary CT scan, high energy transfer mechanismwith LeForte II or III fractures, or specific cervical spinefractures) and who are candidates for antithrombolytic therapyreceived a four-vessel cerebrovascular angiographic study.Twenty-one patients presented with signs or symptoms ofneurological ischemia before screening and were not includedin the study. A total of 727 asymptomatic patients met screen-ing criteria and received angiographic studies. Of these, BCVIwas present in 244 (34%). Of the 244 patients with identifiedBCVI, 187 received anithrombotic therapy (heparin – 117;antiplatelet agents – 59; or low molecular weight heparin – 11).There were 48 patients who did not receive antithrombotictherapy secondary to contraindications or subtherapeutic treat-ment. In the group who received adequate treatment withantithrombotic therapies, only one (0.5%) patient had an isch-emic neurologic event compared to 10 (21%) patients in thegroup who received inadequate therapy. The authors estimatedthey averted ischemic neurological events in 32 asymptomaticpatients who received appropriate antithrombotic therapy. Pa-tients with BCVI-related neurological events had a statisticallyhigher percentage of being discharged to a rehabilitation facil-ity (50% vs. 77%), a higher percentage of requiring rehabili-tation for BCVI-related stroke (0% vs. 55%), and a higherstroke-related mortality rate (0% vs. 21% for carotid arteryinjury, and 0% vs. 17% for vertebral artery injury) than thosewithout neurological events. The authors conclude that screen-ing protocols are cost-effective and high risk patients should beroutinely screened for BCVI.

[Cliff Rice, MD,

Denver Health Medical Center, Denver, CO]

Comment: Screening for blunt cerebrovascular injury inhigh-risk patients early in their course seems to be high yield,beneficial to patients found to have BCVI who receive properantithrombotic therapy, and cost effective. More studies need tobe performed to determine the most effective antithrombotictherapy in BCVI patients.

The Journal of Emergency Medicine 127