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Overview

The emergency department arguably the most intensive department in the hospital, with the wide variety of diseases and a high demand in rescue and management. Furthermore, the needs of patients in the emergency room compared to the outpatient department are generally more immediate and severe, with conditions such as acute heart failure, acute renal failure and pregnancy related emergencies. As such, nowadays most general hospitals and specialized hospitals in large and medium sized cities have set up emergency rooms with adequately equipped staff to deal patients under this categories.

1. Risk

Cardiovascular disease is the manifestation of both systemic vascular disease and vascular disease relating to the heart. The risk factors are a combination of biological, pathological and psychosocial factors. Examples of such risk factors are smoking, obesity, poor blood viscosity, hypertension and hyperlipidaemia. Having multiple risk factors of substantially increases one’s risk of cardiovascular or cerebrovascular disease.
Common predispositions to acute kidney injury include extensive burns, myocardial infarction hypertension, antihypertensive drugs, renal parenchyma or renal vascular disease related factors such as vasculitis, deep vein thrombosis, glomerulonephritis, interstitial nephritis, sepsis, etc.

2. Clinical Manifestations

Around half of patients with acute myocardial infarctions have symptoms present 1-2 days or 1-2 weeks before onset, the most common being Acute kidney injury usually manifests as decreased urine output, azotemia, fluid balance disorder, hyperkalemia, hyponatremia, and metabolic acidosis.
About half of patients with acute myocardial infarction have prodromal symptoms 1 to 2 days or 1 to 2 weeks before onset. The most common is the increase of crushing chest pain (azotemia), prolonged seizure time, no relief from nitroglycerin, sudden onset of angina related pain.

Investigations and Diagnosis

ReLIA’s Biomarker Guide

1. Hypersensitive Troponin I (hs-cTnI)

Hypersensitive Troponin is an incredibly sensitive and practical biomarker for myocardial injury. With the highest sensitivity and specificity, hs-cTnl can be used as an independent diagnostic indicator for myocardial infarction. Due to its high sensitivity, even small amounts of damage to the myocardium can be detected. As myocardial injury is very strong evidence of myocardial disease, early detection of thus allows for a more rapid diagnosis and treatment.

2. N terminal pro-brain natriuretic peptide (NT-proBNP)

Compared to BNP, NT-proBNP has a longer half life (1-2 hours compared to BNP’s 20 minutes), a higher concentration in blood (15-20 times that of BNP) and is also biologically inactive. It also wont be affected by BNP related drugs. Therefore, NT-proBNP is recognized as a good biochemical marker that reflects cardiac function. It can be used to diagnose symptomatic heart failure, estimate the prognosis of patients with heart failure and acute coronary syndrome and to monitor treatment.

3. D-dimer

D-dimer is a fibrin degradation product present after fibrinolysis. Blood levels of D-dimers increase in disseminated intravascular coagulation, kidney disease, organ transplant rejection and thrombolytic therapy. As long as there is active thrombotic and fibrinolytic activity in the body, levels of D-dimers will rise. For elderly or hospitalized patients, elevated D-dimer levels can be due to abnormal coagulation caused by bacteraemia or other diseases.

4. Neutrophil gelatinase-associated lipocalin (NGAL)

NGAL, especially urinary levels of NGAL, can be used for the early diagnosis of AKI. Note that the 2hour urinary NGAL level is more sensitive and specific compared to serum NGAL. It can also be used in assessing the severity of renal impairment. In patients with delayed renal function, serum NGAL can be used to monitor patient recovery and assess whether hemodialysis is required after transplantation. There is a positive correlation between urinary NGAL levels at 2, 4 and 6 hours after a cardiopulmonary bypass to duration of hospital stay. Finally, urinary NGAL levels predict whether dialysis treatment is required within one week of renal transplant patients and to assess kidney function after 3 months