References

[1] Gümüş T, Yıldırım D, Uçar G. Lung injury and pneumothorax after defibrillation asdemonstrated with computed tomography. Am J Emerg Med 2013;31(6):1003.e1–3.

[2] Vollmann D, Lüthje L, Seegers J, Sohns C, Dorenkamp M, Vafa A, et al. Sternalfracture after elective electrical cardioversion of atrial fibrillation. Clin Res Cardiol2011;100:261–2.

[3] Brinn LB, Moseley JE. Bone changes following electrical injury; case report andreview of literature. Am J Roentgenol Radium Ther Nucl Med 1966;97(3):682–6.

[4] Mahlfeld A, Franke J, Mahlfeld K. Ultrasound diagnosis of sternum fractures.Zentralbl Chir 2001;126:62–4.

The relation between N-terminal pro–B-type natriuretic peptideand heart failure☆

To the Editor,

We read the article “Predictive cutoff point of admission N-terminal pro–B-type natriuretic peptide (NT-proBNP) testing inthe emergency department (ED) for prognosis of patients withacute heart failure (HF)” by Golcuk et al with interest [1]. Theauthors aimed to determine a cutoff level of plasma NT-proBNPthat could successfully predict the short- and long-term prognosisof patients with acute heart failure at the time of admission tothe ED. They concluded that elevated NT-proBNP levels at thetime of admission are a strong and independent predictor of all-cause mortality in patients with acute heart failure at 30 days and1 year after admission.

Although most widely used as a marker of systolic heart failure,elevated NT-proBNP has been reported in patients with diastolicdysfunction [2]. Therefore, it is important to determine diastolic andsystolic function by echocardiography. Performing echocardiographyis also important for measurement of pulmonary artery pressure.Pulmonary arterial hypertension is frequently seen in rheumaticdiseases and NT-proBNP levels may be a result of the increase inpulmonary pressure [3]. On the other hand, high levels of NT-proBNPcan be observed in many cases which increase cardiac output andcardiac stress such as sepsis, cirrhosis, and hyperthyroidism [4]. Incontext, determination of liver test and thyroid hormones profile mayreveal a stronger results in such a study.

Furthermore, renal dysfunction may predict HF and couldestimate the risk of mortality and morbidity for HF [5]. Althoughit is important to measure the creatinine clearance by glomerularfiltration rate (GFR), they had not given information about it. Thereare different methods for GFR measurement in clinical practice.The Cockcroft-Gault equation and the modification of diet in renaldisease (MDRD) are commonly used method for calculating theGFR. However, the Cockcroft-Gault equation may estimate lowerGFR in younger age groups compared with the MDRD formula, butit can measure higher GFR in older individuals compared with theMDRD formula [6].

In conclusion, elevated NT pro-BNPmay strongly predicts all-causemortality and morbidity of patients with HF [7]. However, higher NTpro-BNP may be associated very different conditions and the pivotalroles of those factors evaluate further large-scale prospectiverandomized clinical trials.

Sevket Balta MDSait Demirkol MDUgur Kucuk MDMurat Unlu MD

Zekeriya Arslan MDTurgay Celik MD

☆ There is no conflict of interests.

Department of CardiologyGulhane Medical Academy Ankara

TurkeyE-mail address: drsevketb@gmail.com

http://dx.doi.org/10.1016/j.ajem.2013.07.022

References

[1] Golcuk Y, Golcuk B, Velibey Y, Oray D, Atilla OD, Colak A, et al. Predictive cutoff pointof admission N-terminal pro-B-type natriuretic peptide testing in the ED forprognosis of patients with acute heart failure. Am J Emerg Med. Elsevier Inc.;2013;13–7.

[2] Tschöpe C, Kasner M, Westermann D, Gaub R, Poller WC, Schultheiss H-P. The roleof NT-proBNP in the diagnostics of isolated diastolic dysfunction: correlationwith echocardiographic and invasive measurements. Eur Heart J 2005;26(21):2277–84.

[3] Mirjafari H, Welsh P, Verstappen SMM, Wilson P, Marshall T, Edlin H, et al. N-terminal pro-brain-type natriuretic peptide (NT-pro-BNP) and mortality risk inearly inflammatory polyarthritis: results from the Norfolk Arthritis Registry(NOAR). Ann Rheum Dis 2013. [Epub ahead of print].

[4] Aydogan M, Balta S, Kurt O, Sarlak H, Gumus S, Demirkol S. The reasons ofhigher NT-proBNP depend on very different conditions. Ann Rheum Dis 2013;72(7):e17.

[5] Balta S, Demirkol S, Karaman M. Renal dysfunction may predict new onset heartfailure. Am Heart J. 2013. [Epub ahead of print].

[6] Demirkol S, Balta S, Kucuk U, Karaman M, Kucuk HO, Kurt O. Neutrophil-to-lymphocyte ratio may predict contrast-induced nephropathy. Angiology 2013.

[7] Balta S, Demirkol S, Aydogan M, Celik T. Higher NT-proBNP May be related to verydifferent conditions. J Am Coll Cardiol. 2013; Article in press.

Ramipril and hydrochlorothiazide treatment of hypertensiveurgency in the ED

To the Editor,

Hypertensive urgencies are a frequent cause for consultation at theemergency department (ED). There are multiple approaches totreating this presentation, and we endeavored to assess the safetyand efficacy of an oral treatment with 10 mg of ramipril and 12.5 mgof hydrochlorothiazide to treat hypertensive urgencies (which wedefine as systolic blood pressure of N180mmHg and/or diastolic bloodpressure of N120 mmHg with absence of acute target organ disease inthe ED) [1].

We enrolled 620 patientswith hypertensive urgency prospectivelyand consecutively in our study. The mean age was 61.4 ± 10.7 years,50% of patients weremale, and 80% of the total number of patients haddiagnosis of hypertension. All patients were discharged from the EDwith 10 mg of ramipril and 12.5 mg of hydrochlorothiazide when thesystolic blood pressure was b160 mmHg and/or diastolic bloodpressure was b100 mmHg [2].

There were no adverse events reported; 87% of patients weredischarged after 3±1.2 hours upon arrival at the ED, but 13%of patientswere admitted into the coronary care unit to receive intravenoustreatment [3,4].

We have concluded that 10 mg of ramipril and 12.5 mg of hydro-chlorothiazide can be a safe and effective treatment for hypertensiveurgency in the ED.

Diego Conde MDFlorencia Castro MDMilagros Caro MD

Instituto Cardiovascular de Buenos AiresBuenos Aires 1428, Argentina

E-mail address: drconde@hotmail.com

http://dx.doi.org/10.1016/j.ajem.2013.07.024

1533Correspondence / American Journal of Emergency Medicine 31 (2013) 1525–1534

References

[1] Zampaglione B, Pascale C, Marchisio M, et al. Hypertensive urgencies and emer-gencies. Prevalence and clinical presentation. Hypertension 1996;27:144–7.

[2] Komsuoglu SS, Komsuoglu B, Ozmenoglu M, et al. Oral nifedipine in the treatmentof hypertensive crises in patients with hypertensive encephalopathy. Int J Cardiol1992;34:277–82.

[3] The sixth report of the Joint National Committee on prevention, detection,evaluation, and treatment of high blood pressure. Arch Intern Med 1997;157:2413–46.

[4] Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressurelowering and low dose aspirin in patients with hypertension: principal results ofthe Hypertension Optimal Treatment (HOT) randomized trial. HOT Study Group.Lancet 1998;351:1755–62.

1534 Correspondence / American Journal of Emergency Medicine 31 (2013) 1525–1534