{
  "abstract": "Introduction Breathlessness is a common presenting symptom in acute medicine 1 2 and frequently prompts cardiology referral. It may arise from cardiopulmonary causes including pulmonary embolism (PE), heart failure (HF) and acute coronary syndrome (ACS). Despite guideline recommendations for risk stratification and biomarker-guided investigation, CT Pulmonary Angiography (CTPA) use is frequent with limited documentation of pre-test probability scoring.3 This audit evaluated adherence to national guidelines presiding the investigation and diagnostic pathways for patients referred to cardiology with dyspnoea.Methods We performed a retrospective audit of adult patients admitted acutely between March - June 2020 with breathlessness as a primary or secondary symptom and referred to cardiology. Electronic patient records reviewed for biomarker testing (D-dimer, NT-proBNP, high-sensitivity troponin I [hs-Tn]), imaging (CTPA, transthoracic echocardiography [TTE]), coronary angiography) and diagnostic yield, benchmarked against Royal College of Radiologists’ (RCR) CTPA standards. 4-9Results Seventy-four patients (median age 67 years; 53% male). Biomarker testing and escalation patterns are summarised in table 1. hs-TnI was measured in 81% of patients, D-dimer in 69% and NT-proBNP in 57%, with frequent abnormal results (elevated D-dimer and NT-proBNP in 86%; hs-TnI in 80%).Escalation to imaging and diagnostic yield are shown in table 2. Among patients with elevated age-adjusted D-dimer, 40/44 patients (91%) underwent CTPA, with PE confirmed in 7/40 (17.5%). PE was identified by CTPA in 2/18 (11.1%) with normal or absent D-dimer. Elevated NT-proBNP prompted TTE in 20/31 patients (81%), identifying left ventricular systolic dysfunction in 10/20 (40%), compared with 6/29 (21%) in those with normal or absent NT-proBNP. Despite frequent hs-TnI elevation, only 15/49 patients (31%), underwent coronary angiography, with percutaneous coronary intervention (PCI) performed in 4/15 (20%); no patients with normal or absent hs-TnI required PCI. (Figure 1)Overlap in biomarker testing was common (figure 2), with 22 patients assessed across all three pathways.Discussion This audit demonstrates marked escalation from elevated D-dimer and NT-proBNP to CTPA and TTE. NT-proBNP-guided echocardiography yielded meaningful diagnostic findings, supporting its role as a pre-test biomarker. CTPA yield in patients with elevated D-dimer met RCR standards but was lower when D-dimer was normal or absent, highlighting opportunities to optimise imaging selection. This represents a selected cohort of cardiology-referred patients, and findings may differ in an unselected dyspnoea population.Conclusion Parallel diagnostic investigations are common in cardiology-referred breathlessness. CTPA utilisation with elevated D-dimer achieved diagnostic yields consistent with national standards. Greater use of sequential, biomarker-guided investigation may optimise diagnostic pathways.Abstract 379 Figure 1Simplified schematic of biomarker + image utilityAbstract 379 Figure 2Overlap of biomarker testing in cardiology-referred patients with dyspnoeaAbstract 379 Table 1Investigation utilization of biomakersAbstract 379 Table 2Diagnostic yield from biomarkers escalation",
  "authors": [
    {
      "affiliations": [
        "Midland Metropolitan University Hospital, Birmingham, United Kingdom"
      ],
      "name": "Rana Kashif Riaz"
    },
    {
      "affiliations": [
        "Midland Metropolitan University Hospital, Birmingham, United Kingdom"
      ],
      "name": "Jishel Mathews"
    },
    {
      "affiliations": [
        "Midland Metropolitan University Hospital, Birmingham, United Kingdom"
      ],
      "name": "Ayesha Kazi"
    },
    {
      "affiliations": [
        "Midland Metropolitan University Hospital, Birmingham, United Kingdom"
      ],
      "name": "Emma Humpage"
    },
    {
      "affiliations": [
        "Midland Metropolitan University Hospital, Birmingham, United Kingdom"
      ],
      "name": "Paranjay Dahiya"
    },
    {
      "affiliations": [
        "Midland Metropolitan University Hospital, Birmingham, United Kingdom"
      ],
      "name": "Tanisha Banerjee"
    },
    {
      "affiliations": [
        "Midland Metropolitan University Hospital, Birmingham, United Kingdom"
      ],
      "name": "Shamim Rahman"
    }
  ],
  "title": "379 Diagnostic investigation strategies in cardiology-referred acute breathlessness",
  "uid": "5293306d-5bf8-5be6-9c7f-51c4417feb4c"
}